Retinal Detachment MD: Prevention of retinal detachment by Laser Cerclage for high risk eyes, Marfans, Sticklers, & more

Bob Morris, MD & Doug Witherspoon, MD
Callahan Eye Foundation Hospital

Indirect Ophthalmoscope
Laser Cerclage

Myopia or nearsightedness is frequently discovered in childhood when objects in the distance appear blurred without optical correction.

Peripheral retinal lattice degeneration with small hole

Marfan's Syndrome dislocated lens

Characteristics of Marfan's Syndrome similiar in appearance to 16th President of the US, Abraham Lincoln--Tall, particularly long arms and legs, with long slender fingers and toes

Prevention of Retinal Detachment
Prophylaxis Indirect Ophthalmoscope (IDO) Laser Cerclage

High risk eyes are candidates for preventative treatment.
Our fourteen years of experience with IDO Laser Cerclage indicates that it is highly effective in preventing retinal detachment in high-risk eyes. Eyes known to have a substantial risk for retinal detachment include the fellow eye or second eye of someone who has experienced retinal detachment in the other eye. Any one who has had cataract surgery has a modestly increased risk of retinal detachment over someone who hasn't and their risk increases slightly if they have had a secondary laser procedure known as YAG capsulotomy, to improve vision. Extremely nearsighted (myopic) eyes and eyes with lattice degeneration are also conditions which increase the risk of retinal detachment.

Marfan's syndrome is a condition associated with cataracts and high myopia complicated by subluxation of the lens (the lens moves off center, disrupting vision). Lens removal for this problem is curative but adds another risk factor to an eye already at risk of retinal detachment. Stickler's syndrome is a dominantly inherited condition in which retinal detachment commonly occurs in young adult life often in both eyes.

Evolution of prophylaxis laser retina treatment
Laser surgery in ophthalmology revolutionized the treatment of many eye conditions from the cornea to the retina in the last quarter of the 20th century. The indirect ophthalmoscope (IDO) method of laser delivery became available in the 1990s finally providing the retina surgeon with the ideal surgical instrument to apply laser treatment to the peripheral retina to prevent retinal detachment. Before the IDO laser delivery, prophylaxis laser photocoagulation against retinal detachment was only possible by the slitlamp method of delivery. The slitlamp delivery system was limited and the results of the procedure were not effective in the long term. Unlike the slitlamp delivery instrument, the IDO laser instrument allowed the surgeon a wide field of view into the far periphery, excellent depth perception, no glare and the ability of the surgeon to indent the eye for maximum view. These IDO features let the surgeon place laser treatment in the peripheral area of retina where an estimated 95% retinal breaks which cause retinal detachment occur. Our experience is that proper IDO Laser Cerclage nearly eliminates future tear occurrence in the areas of treatment. Treatment to the peripheral area of the retina is advantageous for the patient subjectively because visual function in the peripheral retina is low, rarely noticed.

The typical approach carried out today--only treating visible areas of retinal pathology (focal prophylaxis laser photocoagulation) in high risk eyes. Focal laser prophylaxis does prevent retinal detachment from the specific area treated but has been disappointing in preventing retinal detachment. Because new tears can develop in the untreated peripheral areas of focally treated high risk eyes and often lead to retinal detachment.

IDO Laser Cerclage
IDO Laser Cerclage is an outpatient procedure that may be performed either in the office setting or in an outpatient surgery site. It can be done with a local anesthetic block or under brief general anesthesia. The surgery is short, taking no more than 20 to 30 minutes for the actual laser treatment. Patients wear a patch to cover and protect the eye from injury while the eye remains numb; about 5 hours. Discomfort after the surgery is usually mild and most often is relieved with over the counter non-asprin analgesics. The day following surgery patients may resume normal daily activities. (see post-op laser care instructions)

Laser photocoagulation produces a titrated amount of heat in specific layers of tissue treated. In the areas of the retina where the laser is applied the retina tissue bonds to the underlying pigment tissue that absorbs the light, causing the layers to bond together and forging a strong resistance against vitreous traction and subsequent tears. IDO Laser Cerclage is applied in the peripheral retina, the area of the retina most prone to retinal breaks and the area of the retina least important to daily visual function. Very few people actually perceive visual change.

After about two months when the retinal adhesions have had a chance to form the retinal surgeon will want to evaluate the adequacy of treatment. Because the tissue in different individuals may respond differently, "touch up" spots of treatment in some areas might be considered. Most often the original treatment is sufficient.

The complications associated with laser cerclage documented in the scientific literature include the above modest loss of side vision, a loss of pupilary function in the treated eye and the formation of macular pucker. In our experience these complications are rare.