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Symptoms, practitioner experience determine when to monitor, refer retinal disease
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Peripheral retinal disease can present itself in a variety of forms and may be accompanied by any number of symptoms that will influence an optometrist’s decision to either monitor the condition or refer the patient for consultation or treatment. The practitioner’s comfort level, as well as the patient’s, will also influence the way a patient’s condition is handled, said Kevin Alexander, OD, PhD, dean of the Michigan College of Optometry at Ferris State University.
“My recommendations for referring and for monitoring on your own vary from practitioner to practitioner,” Dr. Alexander said. “It depends on one’s own comfort level in examining the peripheral retina and one’s experience in monitoring these problems. It also depends, to a certain degree, on the patient. If the patient is going to worry about it, it may be best to refer to ease the patient’s anxiety.”
Dr. Alexander and two other practitioners discussed with Primary Care Optometry News the most contemporary thinking regarding monitoring and referring when the OD is confronted with lattice degeneration, retinoschisis and retinal holes. While these forms of retinal disease are relatively common and innocuous when asymptomatic, things can change dramatically when certain symptoms and risk factors come into play, they say.
Lattice degeneration
--- Monitor: Pigmented lattice degeneration without associated holes in an asymptomatic myopic patient.
This condition is a fairly common finding and may be monitored on an annual basis, said Mark Dunbar, OD, of the Ophthalmology Referral Center at the Bascom Palmer Eye Institute. “The risk of developing complications from lattice degeneration is probably less than 1%,” Dr. Dunbar said. “Typically, I educate patients about the signs and symptoms of developing a retinal tear or detachment, which includes flashes and floaters, a curtain or shadow coming over their vision and so on. If they develop symptoms, we bring them in, but usually we see them no more than once a year.”
Because the condition can create a weakened area in the retina that potentially may lead to retinal detachment, Dr. Alexander said, certain risk factors must be taken into consideration, such as a family history of retinal detachment or a patient with a high degree of myopia. “An eye with high myopia would tend to detach more easily than other eyes,” he said. “Then, you have to look at the lesion itself and see if there is any fluid under the edge of the lattice or if the surrounding retina looks attached and stable. If there are no risk factors, you can just monitor these lesions.”
Other factors, such as location of the lattice and the status of the other eye, also affect the decision to pursue treatment, said Samuel R. Pesin, MD, vitreoretinal specialist with Retina Vitreous Associates in Toledo, Ohio. “If a patient has had a detached retina in one eye, then I would be more apt to treat the other eye prophylactically,” he said. “Because lattice is a risk factor for a detached retina, as are retinal holes, I might be more inclined to treat the fellow eye than just observe.
“Another issue to consider is a patient’s occupation,” he continued. “If the patient is prone to trauma, such as a boxer, I am more likely to treat that eye prophylactically, too. If a patient is going to have cataract surgery soon, certain types of holes or lattice may be treated before the surgery. These are issues that should be carefully evaluated before the final recommendation for treatment is made.”
A patient who experiences flashes or floaters should also be seen for a dilated peripheral retinal exam within a day or two, then return 1 to 4 weeks later for another dilated assessment, Dr. Pesin said.
Retinoschisis
This condition, a separation of the inner and outer layers of the retina, is less common than lattice degeneration. It also does not typically progress into a retinal detachment, Dr. Dunbar said. If schisis is found in one eye, he advises examining the other eye and checking for inner and outer wall breaks.
“By and large, they are bilateral,” he said. “One retinal specialist said that if you don’t see it in the second eye, you’re not looking hard enough. Outer wall breaks typically have rolled edges, while inner wall breaks don’t. Inner wall breaks are very difficult to see, and they can go on to develop combined schisis detachments. If you just see a pure retinal schisis without a retinal detachment component, it’s best to follow it closely until you’ve proven to yourself that it’s not going to change. I would probably follow it 6 months or a year.”
When retinoschisis proceeds closer to the macula, said Drs. Alexander and Pesin, it may warrant treatment. “It’s rare that schisis ever causes a problem. If it does, it could be related to some encroachment of the schisis cavity more posteriorly, and that could result in worsening side vision,” Dr. Pesin said. “Even that we don’t treat, but when it starts encroaching on the macula, we’re forced to discuss surgical options.”
Again, said Dr. Alexander, whether or not to refer also depends on practitioners’ level of comfort and familiarity with the condition. “If you see an elevation of the retina, some practitioners would be content to refer the patient to a retinal specialist or another optometrist who is comfortable looking at such conditions,” he said.
“Holes can develop with retinoschisis. Inner holes next to the vitreous generally aren’t particularly troublesome, but outer layer holes will often lead to a detached retina,” Dr. Alexander continued. “That can sometimes be difficult to ascertain, because it’s not always easy to see these things, and it’s not terribly common. If you’re comfortable looking at peripheral retinal disease and have seen a fair amount of retinoschisis, there is no reason why you can’t evaluate and follow this, whether you’re an optometrist or an ophthalmologist.”
Atrophic retinal holes
--- Retinal hole with surrounding pigmentation: This was found during a routine dilated eye exam. The patient was asymptomatic.
Because retinal holes are fairly common occurrences, particularly with high myopes and older patients, monitoring is often all that is necessary because the holes tend to self-seal, Dr. Alexander said. “When you examine them carefully, you can see a line of pigment around the edge that sort of seals it,” he said. “If it doesn’t, the potential is there for fluid from the vitreous and the area in front of the retina to get into the hole and cause a little detachment. That isn’t as common as a retinal tear, but it can happen.”
When the hole develops a cuff of fluid, he said, scleral depression should be employed to properly evaluate the condition. “Many of these lesions can be seen with the indirect ophthalmoscope, but you can’t really evaluate the extent of it or the severity of it without doing scleral depression,” he noted.
Size and location of the hole may also play a role in the decision to refer, Dr. Dunbar said. “If you have a hole that is big and superior in the retina, you may want to watch it,” he said. “It’s better to bring it in sooner rather than later. If you haven’t seen many, you may want to look at it at 1 month, at 3 months, at 6 months and at a year.”
Otherwise, Dr. Alexander said, most retinal holes do not require treatment. “We used to treat them all the time 20 years ago, but not anymore. We’ve found that the incidence of retinal detachment is very low,” he said. “I would simply examine these patients, advise them of the signs and symptoms of retinal detachment and follow up on an annual basis.”
Keep current on retinal exams
Keeping up to date on retinal examinations is vital, Dr. Pesin said. “I would like to stress the importance of the dilated retinal evaluation,” he said. “Doctors should adhere to a schedule of at least yearly retinal dilated examinations. And if there’s any question about visual acuity that can’t be answered by anterior segment findings, then dilated retinal examination is basically mandatory.”
As a practitioner’s experience in examining peripheral retinal disease increases, the comfort level grows and conditions become easier to recognize and differentiate from one another, Dr. Alexander said. “The issue isn’t seeing the disease; it is being comfortable evaluating it and knowing what you’re seeing through your clinical experience,” he said. “It is no crime to refer something like this out for confirmation or a consult.”
For Your Information:
- Kevin Alexander, OD, PhD, is dean of the Michigan College of Optometry at Ferris State University. He may be reached at 1310 Cramer Circle, PEN 405, Big Rapids, MI 49307; (231) 591-3706; fax: (231) 591-2394. Dr. Alexander has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Mark Dunbar, OD, is director of optometric services at the Bascom Palmer Institute, University of Miami School of Medicine. He may be reached there at 900 NW 17th St., Miami, FL 33136; (305) 526-8884; fax: (305) 326-6113. Dr. Dunbar has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Samuel R. Pesin, MD, is a vitreoretinal specialist with Retina Vitreous Associates and an associate clinical professor in the department of ophthalmology at the Medical College of Ohio. He may be reached at Retina Vitreous Associates, 2213 Cherry St., Toledo, OH 43608; (419) 251-4367; fax: (419) 251-6751. Dr. Pesin has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.