Question.
I have recently heard a talk by Dr GW Aylward on the role of laser/cryo for prophylaxis of RD. According to him, in Moorfields they use laser only for HST with AP traction.
They prefer and advice such prophylaxis for no other condition and his views on sticker’s prophylaxis are clear.
He says that laser would create strong site of adhesion and later in life, when vitreous would under go liquefaction, area of new breaks are seen at the edges of the laser area. He also commented that NNH (no of patients till u avoid a single case of rdwith prophylaxis) for laser prophylaxis is way to low.
For grt with contralateral woop or lattices , high myopes and even in patients with contralateral RD … His opinion is same I e no to prophylaxis
Can we discuss In this grey zone
Reply:
This is what Dr Byers has been teaching for decades. They do not advise active intervention even in fellow eyes unless evidence of traction is present.
Though personally I agree with most of what Dr Bill says, in the practical scenario, there are some other considerations.
1. It is not always possible to judge traction accurately.
2. I treat lattice in eyes about to undergo LASIK (my most common indication) without any evidence of traction. Reason is not LASIK, but that high myopes have a several times higher risk of RD and if needed, the RD surgery will compromise the refractive results significantly. Risk benefit ratio is not against laser barrage.
3. Eyes about to undergo cataract surgery or YAG caps – the risk of RD is much higher than normal population. So I treat in the absence of traction.
4. Leaving fellow eyes untreated may go against you in a court of law in today’s time.
5. The kind of follow up of patients that Drs Norman Byers and Bill Aylward have is unreasonable in most practices in our country.
6. The kind of understanding and preparedness to accept an RD as a rare event without blaming the doctor who already identified predisposing pathology but did not treat due to NNT calculations may be feasible under the NHS system patients that Dr Bill Aylward would encounter. The system would stand behind their doctors in such an event. Most of us do not have that luxury.
Preferred practice for DR
.The International Council of Ophthalmology guidelines for DR which has the following statements as advice for DME as per the resource setting -low ,intermediate or high. Wonder if anyone has any objections to these or any additions or deletions to the following statements about DME in those guidelines? All opinions would be a real learning resource about what is to be followed at the grassroots and would constitute a “preferred practice” as an additional guide
(Ref:http://www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare.pdf )
I quote as follows …
“a. Resource-Rich Settings
i. Optimize medical treatment: Improve glycemic control if HbA1c > 7.5% as well as associated systemic hypertension or dyslipidemia.
ii. Mild or moderate DME without center involvement (e.g., circinate HE ring threatening the center of the macula or when no vision loss has occurred in spite of center involvement): Consider focal laser to leaking microaneurysms. No treatment is applied to lesions closer than 300 μm from the center of the macula.
iii. Severe DME with center involvement and associated vision loss*: intravitreal anti- VEGF treatment (e.g., with ranibizumab [Lucentis] 0.3 or 0.5mg, bevacizumab [Avastin] 1.25mg, or Aflibercept [Eylea]) 2mg therapy).
Consideration should be given to monthly injections followed by treatment interruption and re-initiation based on visual stability and OCT. Patients should be monitored almost monthly with OCT to consider the need for treatment. Typically, the number of injections is 8 the first year, 2 or 3 during the second year, and 1 to 2 during the third year. Persistent retinal thickening and leaking points: consider laser treatment after 24 weeks.
Treatment with intravitreal triamcinolone may be considered, especially in pseudophakic eyes. . Injections are given 4 mm behind the limbus in the inferotemporal quadrant under topical anesthesia using a sterile technique.
iv. DME associated with proliferative DR: combined intravitreal anti-VEGF therapy and PRP should be considered.
v. Vitreomacular traction or epiretinal membrane on OCT: pars plana vitrectomy may be indicated.
b. Intermediate or Low-Resource Settings
i. Generally similar to above. Focal laser is preferred if intravitreal injection of anti-VEGF agents are not available. Bevacizumab (Avastin) is an appropriate alternative to raniziumab (Lucentis) or aflicercept (Eyelea).
Laser can be applied earlier to areas of persistent retinal thickening in eyes unresponsive to anti- VEGF treatment.”
Operated patients at our Howrah surgical training facility
