Introduction

Giant retinal tear by definition is a retinal tear of more than 90° circumferential extent.¹ Since the posterior vitreous is detached, the vitreous gel is adherent to the anterior flap. Hence, the posterior flap has a tendency to fold over. In contrast, in a giant retinal dialysis the retina is either torn at the ora serrata or there is a break in ciliary epithelium, with the vitreous being adherent to the posterior retina.² Thus, the posterior flap does not have the tendency to fold over, since it is supported by the vitreous gel.

The management of fresh giant retinal tear is an emergency. The delay in surgical intervention could lead to significant proliferative vitreoretinopathy (PVR) changes jeopardizing reattachment of the retina and eventual visual gain. Before the introduction of perfluorocarbon liquids by Stanley Chang,³ the management of giant retinal tears was challenging and resulted in limited success. The present day management of giant retinal tear is reasonably straightforward, with predictably good success rate.

Etiology

Most giant retinal tears are idiopathic in origin with males being at higher risk. Traumatic giant retinal tears are commonly located in the upper nasal and lower temporal quadrants and are again commoner in males. In a population-based study in the UK, Ang et al. have reported an annual incidence of 0.091 patients per 100 000 population.⁴ Most of the cases were idiopathic (54.8%) and males predominated (71.7%).⁴

The association with high myopia is well established.⁵ Of all retinal detachments in Marfan syndrome, 11.3% have been reportedly caused by giant retinal tears.⁶ Retinal detachment, especially due to giant retinal tear has been identified as an important complication of Stickler syndrome.⁷ Other diseases associated with occurrence of giant retinal tear include the Ehlers–Danlos syndrome,⁸ lens coloboma,⁹ and aniridia.¹⁰

Pathogenesis

Schepens first described the important role played by the vitreous in giant retinal tear. Central vitreous liquefaction is associated with condensation in the peripheral vitreous base that leads to traction on the peripheral retina.¹ As traction progresses, it is evident clinically as spreading “white-without-pressure.” Later, transvitreal contraction of the cortical gel occurs, tearing the retina along the vitreous base in a zipper fashion. Occasionally, multiple horseshoe-shaped tears may form along the posterior vitreous base and coalesce to form a giant retinal tear. Radial extensions (horns) can occur at the two ends of the giant retinal tear. Eyes with radial extension invariably have some amount of vitreous hemorrhage since the tears cut across larger blood vessels posteriorly.

A giant retinal tear nearing 180° in circumferential extent has a tendency to fold over. The size of the giant retinal tear also has an effect on the amount of retinal pigment epithelium that gains access to the vitreous cavity, thus increasing the risk of PVR. Giant retinal tear occurring after penetrating injuries has high risk of PVR while giant dialysis tends to progress very slowly.

History of management of giant retinal tear

The management of giant retinal tear can be divided conveniently into pre- and post-perfluorocarbon liquids (PFCL) eras. Most techniques used in the pre-PFCL era are of historic importance. However, a brief mention of these techniques is relevant in the overall understanding of the management of giant retinal tear. The primary problem faced by the surgeon was the gravity-driven tendency of the flap of the retinal tear to fold and fall back. Scleral buckles have been done for smaller extent of the tears (around 90°). A relatively shallow, but broad buckle was aimed at, so that the tendency for the flap to slip back is reduced and the inevitable central sagging of the flap is accommodated on the broad buckle.¹⁷ Attempts were also made to rotate the patient and to reposition the retinal flap with the help of an air bubble.¹⁸ Vitreoretinal surgery helped mobilize the inverted flaps of large giant retinal tears but the surgeon still faced difficulty in unrolling the same and fixing it in position. One strategy was to divide the giant retinal tear into smaller segments by pinning the edge of the tear down to the RPE/choroid complex using retinal tacks^19,20 or sutures.²¹ This enabled routine fluid–air exchange to fix the retina without slippage of the retinal flap. Another technique involved fluid–air exchange in prone position. After a vitrectomy (and sometimes placement of buckle), the sclerotomies were closed and the patient was turned prone. Without contaminating the operative field, fluid–air exchange was then performed, with the air injection being done in front of the optic disc and fluid being evacuated from the anterior chamber.²² The air progressively attached the retina posteroanteriorly. The patient is repositioned in the supine position and internal tamponading agent was injected – gas or silicone oil as the case may be. Among all these techniques, perhaps the best attachment of the retina with no folds or slippage was seen with prone fluid–air exchange following vitrectomy. With the use of PFCLs, the surgery has become much simpler.

Preoperative evaluation and planning

A thorough evaluation of both the anterior and posterior segments is important to plan the surgery properly. Corneal and lens status must be noted. Perforating injury-related retinal detachments with vitreous incarceration and giant retinal tear can have associated corneal problems such as generalized haze due to edema, opacity, Descemet’s membrane folds, etc. The lens could be subluxated due to the blunt trauma and could be also cataractous.

Pseudophakic eyes can also have specific problems. The intraocular lens (IOL) could be tilted or subluxed (especially in eyes that had capsular dehiscence and vitreous disturbance during cataract surgery). Deposits on the IOL and posterior capsule opacification can interfere with surgery. A decision as to the need to remove the IOL should be taken based on this evaluation. There is however no justification to remove a well-placed IOL.

The intraocular pressure (IOP) could be low, normal or high. A low to very low IOP is seen in relatively recent giant retinal tears and often associated with choroidal detachment. One may chose to treat such cases with a course of systemic steroids for a few (3–5) days before performing the surgery. High intraocular pressure is rare at the time of presentation with acute giant retinal tear even in eyes with preexisting glaucoma. However, eyes with traumatic dialysis can have persistent high pressures despite the presence of retinal detachment. Following reattachment of the retina, one should anticipate an acute rise in intraocular pressure. Hence, arrangements for frequent IOP monitoring must be in place. It is only rarely that a glaucoma surgery needs to be combined with the retinal reattachment surgery.

The posterior vitreous will be found to be detached in cases of giant retinal tear, unlike in dialysis. In eyes that had blunt injury, the vitreous base can be avulsed and is seen as a rope-like structure near the pars plana. In eyes with perforating injury or following cataract surgery misadventure, the vitreous could be incarcerated in the wound and is seen as a transvitreal membrane. The giant tear or dialysis is seen usually in the opposite quadrant.¹¹

The extent of retinal detachment can vary. A dialysis can be associated with chronic partial detachments of the retina with high water marks, while giant retinal tear is usually associated with a more rapidly spreading retinal detachment. Eyes with around 90° tears are characterized by sagging of the center of the tear posteriorly but do not show inversion of flap. However, if the two ends of the giant retinal tear trail significantly posteriorly (horns), the retinal flap that is enclosed in between, can fold back. Retinal tears that are nearing 180° circumferentially will show a tendency to fold back. The inverted flap can sometimes obscure the disc (Fig. 109.1). The edge of the tear usually is scrolled inwards despite lack of obvious PVR elsewhere. The pars plana epithelium can be detached in the area of tear and sometimes beyond, due to the vitreous base traction. The anterior flap of the retina can harbor lattice degeneration. Additional horseshoe tears can be seen in other quadrants near the posterior vitreous base. A macular hole can coexist – especially in eyes that are highly myopic or where the giant retinal tear is a result of blunt injury. Significant pigment dispersal is seen in the vitreous cavity and pigment is often seen adherent to the surface of the retina. A traumatic dialysis is often associated with evidence of damage to the RPE and choroid at the site of the ora serrata.

Fig. 109.1 Fundus photograph showing inferotemporal giant retinal tear with inverted flap that is obscuring the optic disc. Note the bare choroid/RPE inferiorly.

Ultrasonographic diagnosis of giant retinal tear

In eyes with opaque media, giant retinal tear can be suspected on ultrasonography.²³ A suggestive feature is a discontinuity noticed anteriorly in the retinal echo and extending more than one quadrant. Double linear echo would be seen near the disc due to the close proximity of the two layers of the retina; one representing the flap of the giant retinal tear and hence discontinuous with the globe contour and the other representing the detached retina and hence continuous with the globe contour (Fig. 109.2).

Fig. 109.2 Ultrasonography in an eye with giant retinal tear. Note double linear echo close to the optic disc – the inner layer is discontinuous while the outer layer is continuous with the globe contour.

Vitreous surgery

In the current scenario, most cases of giant retinal tear would be managed by a vitreoretinal approach.

Role of an encircling band along with vitreoretinal surgery

Many surgeons feel comfortable placing an encircling band even in eyes undergoing vitreoretinal (VR) surgery.²⁴ An encircling band is expected to support the vitreous base and reduce the risk of redetachment taking place from the quadrants where there is no retinal tear. However, there are reports that the success rate of surgery for fresh giant retinal tear is not reduced by not placing the buckle.²⁵ In addition, minimally invasive vitreous surgery is possible if one is not placing the buckle.²⁶ The trick is in the use of wide-angle system of visualization and a radical vitreous base removal. In the presence of some degree of PVR, placement of encircling band is desirable.

Lens management

The options for lens management are: (1) leave it untouched; (2) lensectomy and leaving the eye aphakic; (3) lens removal and keeping the posterior capsule intact for future IOL placement; and (4) lens removal and IOL placement at the same time. The exact approach would depend on the individual case and the surgeon’s choice and the ability to be reasonably sure of the power of the IOL to be implanted. In general, IOL placement would be avoided in eyes with severe PVR. In fresh giant retinal tears, IOL placement is possible, especially if a buckle is not being placed. Guidance from previous refractive status and fellow eye measurements would be needed to calculate the IOL power. In eyes with gross subluxation of the lens, scleral fixation of IOL is an option, but is best deferred to a later date. In eyes where silicone oil is being used as a tamponading agent, one can leave the eye aphakic at the first sitting and implant the IOL at the time of silicone oil removal.

Management of intraocular lens

A well-positioned IOL is not an issue in the management of giant retinal tear. However, IOL can be associated with problems such as deposits of pigment and inflammatory precipitates on the IOL surface, posterior capsule opacification, tilt and displacement of IOL (especially if the cataract surgery had been eventful). As long as the visualization is not hampered, the IOL need not be disturbed. Simple maneuvers such as creating an opening in the posterior capsule or gently scrapping the precipitates on the IOL surface under viscoelastic fill of the anterior chamber, can greatly improve the visualization. Silicone IOLs can be associated with problems when silicone oil is injected, especially if there is posterior capsule opening. The oil tends to stick to the posterior exposed surface of the IOL and at the time of silicone oil removal, a film of oil remains permanently adherent to the IOL surface. This, however, is not an absolute indication to remove the IOL.

Explanting the IOL is best done through a scleral tunnel rather than a clear corneal wound. With scleral entry, there is much better maintenance of corneal clarity during the subsequent vitreoretinal surgery. A scleral wound is also less prone to leak, even when the eye is distorted, e.g., during scleral indentation.

Visualization

With the advent of wide-angle viewing systems, the management of giant retinal tear has considerably improved. It is a tremendous advantage to be able to visualize the periphery without losing view of the posterior pole – especially while exchanging the perfluorocarbon liquid with gas or silicone oil. The Lander lens system even with prism lenses would be a poor substitute. However, a Lander lens would be useful for internal limiting membrane (ILM) peeling, if there is an associated macular hole.

Handheld illumination and 3-port vitrectomy will suffice in cases of fresh giant retinal tear. In badly traumatized eyes with giant retinal tear (especially when the tear is 360°), and in eyes with severe PVR, bimanual surgery would be required. The choice is between using a combined instrument such as an illuminated pic or making a fourth sclerotomy and placing a chandelier light pipe.

Vitrectomy

Vitreous removal is perhaps the easiest of the steps in giant retinal tear surgery. With a total posterior vitreous detachment that is most often associated with a giant retinal tear, all the vitreous lies anteriorly and can be easily removed. In fresh giant retinal tear, the flap tends to be mobile and care should be exercised to prevent accidental unnecessary nibbling of the flap. While placing the infusion cannula, one should be aware that some of the eyes with profuse hypotony can have significant ciliochoroidal edema/detachment. Placement of 6 mm infusion cannula can reduce the risk of suprachoroidal infusion, but the surgeon must ensure that the tip is seen inside the vitreous cavity before switching on the infusion. If the cannula tip is not seen, a MVR blade introduced from one of the upper sclerotomies can be used to cut the tissue overlying the tip of the infusion cannula. A loose pars plana epithelium can also drape round the infusion cannula but can be easily removed with the cutter.

In eyes with vitreous in the anterior segment wound and a giant retinal tear, the first step would be to excise the incarcerated vitreous and allow the retina to fall back before performing the rest of the vitrectomy.

Radical excision of the vitreous base

The vitreous base is debulked to the maximum extent possible. However, to be able to perform this step adequately, the posterior pole and the retinal flap should be kept down with a bubble of perfluorocarbon liquid. Otherwise the retinal flap will keep getting sucked into the port, even while working in the opposite quadrant. Even in phakic eyes, a good amount of debulking is possible without lens sacrifice, by having the assistant indent the sclera.

Mobilizing the retina and management of anterior retinal flap

The anterior retinal flap to which the vitreous is adherent should be excised as much as possible. If the same is left behind, it can get fibrosed and also exert traction on the ciliary body. As mentioned above, the edge of the giant retinal tear tends to scroll in and this does not necessarily indicate fibrosis along the edge. However, if the edge is stiff, one can excise the same. Inspection of the retina should include the assessment of PVR and the location of the fibrosis – pre- and subretinal. In fresh cases of giant retinal tear, the retina will be freely mobile and the inverted flap can be lifted up with the intraocular instruments. Despite the absence of frank PVR, one very often sees pigment deposition on the surface of the retina, especially inferiorly. The pigment clumps can be relatively adherent to the surface of the retina and could indicate early attempts at proliferation. One may have to use fine instruments, such as a membrane scratcher (rake), to remove these immature membranes. Loose pigment can be removed with a brush needle. Meticulous removal of such immature membranes can reduce the risk of recurrent retinal detachment.

Eyes with PVR

In eyes with PVR, the anatomy is varied depending on the severity. Some description on the pathoanatomy has been given in the section on preoperative evaluation. In general, the posterior pole is cleared first, a bubble of perfluorocarbon liquid is placed to stabilize the posterior pole and then the rest of the dissection is carried out. A combination of spatula, scratcher, and forceps is needed. As one proceeds with the dissection, more membranes become evident, especially when placing the retina on stretch with additional perfluorocarbon liquid. Injecting too much perfluorocarbon liquid in the initial stages without adequate relief of posterior traction, will result in the bubble finding its way into the subretinal space. The subretinal PFCL may need to be removed before further dissection. Subretinal fibrosis is identifiable once most of the preretinal traction is relieved. In the presence of giant retinal tear, removal of the subretinal membranes should not be difficult. The ease of attaining complete relief of traction depends on the severity of the PVR. Anterior circumferential traction usually needs bimanual dissection, while keeping the posterior pole down with perfluorocarbon liquids.

In eyes presenting with a 360° giant retina tear and PVR, picking up the membranes with forceps can be difficult, since the retina does not offer any resistance and moves with the forceps. Only with bimanual surgery can the dissection be done. Appearances can be deceptive and what looks like an apparently inoperable bunched up retina lying in the posterior pole can open up to reveal a relatively healthy posterior retina. Delay in performing surgery after penetrating injury greatly increases the risk of the retina becoming contracted and inoperable.

Conversion to a 360° tear

If peripheral traction relief is not adequate, it is best to excise the peripheral retina along with the fibrosis, rather than trying to compromise, by placing a buckle underneath an area of unrelieved peripheral traction. Converting a giant tear to a 360° tear does not worsen the prognosis.

While excising the peripheral retina, it may be worthwhile to leave behind tags of attachment to the ora, until the PFCL is placed up to the arcade. Then the residual tags can be cut to convert it into a 360° tear. This may permit proper orientation of the macula. In view of the extreme distortion of the retina due to the PVR, there can be a tendency for the macula to be shifted to abnormal locations, necessitating manipulation of the retina under the PFCL. On occasion, areas of residual traction are identified after reattaching the retina with PFCL. Some of these membranes can be removed under PFCL. If not, one should not hesitate to remove the PFCL to facilitate removal of the newly identified membranes and then reinject the PFCL. The edge of the giant retinal tear can be folded under the PFCL. As long as there is no fibrosis, these edges are easily smoothed with the help of a spatula. A silicone brush can also be used to stroke the edge into position. Fibrosed edges must be excised.

Perfluorocarbon liquids

Several properties make these liquids well suited for vitreoretinal surgery: the specific gravity (greater than water); transparency (can see and treat the retina underneath); low viscosity (easy to inject and easy to remove); excellent tamponading effect (good retinal flattening); and a refractive index that is different from the infusion fluid (visible interface). PFCLs are useful at several stages of the surgery. (1) During membrane dissection to stabilize the posterior pole; (2) for facilitating internal limiting membrane removal around macular hole in detached retina; (3) for reattachment of the mobilized retina without fear of posterior slippage; (4) for medium-term tamponade.

Injection of PFCL

Wide-field visualization is very useful in this step. The initial bubble of PFCL is injected over the optic disc to unfurl the folded retina. Further injection is made into the main bubble to prevent formation of multiple bubbles. Forceful injection should be avoided since the jet of the liquid can tear through the retina and can even cause choroidal bleed. The PFCL bubble is injected till it flattens the edge of the giant retinal tear. One should be cognizant of the fact that there is subretinal fluid anterior to the bubble in the areas where the retina is not torn from the ora serrata.

In eyes with a 360° retinal tear and some intrinsic contracture of the retina, injection of the PFCL may not result immediately in a smoothly-attached retina. There will be a tendency for the retina to form circumferentially oriented folds around the disc. If the contracture is not severe, the folds can be smoothed with help of a blunt instrument – used to massage the retina gently. A flat retinal spatula, a knob spatula or even the tip of the vitreous cutter can be used for this purpose. In eyes with severe retinal contracture, there will be a tendency for the PFCL bubble to roll off the retina leaving it bunched up around the disc. At this stage, one may have to accept the inability to reattach the retina.

Retinopexy

Endolaser is the preferred modality of retinopexy. By tilting the eye to the same side, the edge of the giant retinal tear can be kept entirely under PFCL, thus facilitating the application of the laser along its edge. In general, about 3–4 rows of burns are applied along the margin. It is best to treat 360°, including the peripheral retina, beyond the area of the giant retinal tear.²⁷

The peripheral retina outside the giant tear will still have subretinal fluid anterior to the PFCL bubble and this would make it difficult at this stage of surgery to produce burns to the ora serrata in this area. Treatment of this anterior retina is easier done once the PFCL is exchanged with silicone oil or gas and the residual anterior subretinal fluid is removed. In phakic eyes, anterior treatment is done with laser delivery by indirect ophthalmoscope (LIO). Only very rarely is cryopexy resorted to.

Internal tamponade

The choice of internal tamponade is between long-acting gases such as 12–14% C₃F₈ or silicone oil. SF₆ and air are not suited, in view of the large extent of the tear and the need for extended period of support.

PFCL–air exchange

This is the step when slippage of the retinal flap can occur if not done with extreme care. The edge of the tear should be dried frequently before removing the main PFCL bubble. In view of the relatively rapid sequence of events (unlike with silicone oil), fluid pockets may be trapped anteriorly and then be pushed under the retina as the PFCL is removed – leading to retinal slippage in the quadrant of the tear. Depending on the extent of the tear and the amount of residual subretinal fluid, the extent of slippage varies. Retinal slippage is characterized by circumferentially oriented folds. The macula can be involved in the fold with temporal tears. Attempts at drying the edge of the tear at this stage do not usually succeed, since the air keeps the fluid trapped posteriorly. Some surgeons suggest leaving behind some vitreous fluid and then positioning the patient prone to permit postoperative smoothing of the folds. Posterior retinotomy is not a great idea. It is perhaps best to reinject the PFCL and perform the exchange with gas more carefully or opt for silicone oil.

PFCL–silicone oil exchange

Directly exchanging PFCL with silicone oil has the least chance of retinal slippage. One should understand the fluid dynamics during this process to obtain the best results with least complications.

1. As the silicone oil is being injected, it forms initially a circular bubble. Once it contacts the central part of the upper meniscus of the PFCL, further injection tends to flatten the anterior surface of the PFCL bubble, thus spreading it over a larger surface of the retina.

2. The balanced salt solution will slowly be pushed into a circumferential ring all round, sandwiched between the oil and PFCL. One should not forget the rim of subretinal fluid that is trapped anterior to the PFCL in the area outside the giant retinal tear (Fig. 109.3).

3. Balanced salt solution (BSS), subretinal fluid, as well as PFCL can be easily sucked with both active and passive suction devices. Silicone oil will tend to block the suction device. Hence, while injecting silicone oil, a sudden rise in IOP can occur if the suction port is located within the silicone oil bubble. Failure to notice the raising IOP can result in some unpleasant consequences such as: (a) the edge of retinal flap getting sucked into the port of the suction device; (b) snapping of corneal sutures in eyes with recently repaired corneal wounds; (c) iris prolapse through a gaping scleral or corneal wound that has been made for IOL explantation.

4. Intermittent injection of silicone oil coupled with careful positioning of the suction tip at the edge of the giant retinal tear and just beyond the PFCL bubble margin will result in slow evacuation of the circumferential ring of balanced salt solution. Even the fluid located in the opposite quadrant will find its way to the site of suction and the subretinal space becomes totally dry. It is easy to distinguish between the residual fluid and silicone oil by the ease with which it finds its way into the suction port. Once all the fluid is removed, the PFCL bubble can be removed. Intermittently one can go back to the edge of the giant retinal tear to make sure that it is dry. Slow injection of the silicone oil will permit controlled removal of the PFCL and the end point is clearly visualized.

5. If the suction port is blocked with silicone oil, the IOP will rapidly rise as evidenced by appearance of central retinal artery pulsations and rapidly developing corneal edema. If the suction port is now shifted to the PFCL bubble, the block reopens as the PFCL washes the silicone oil out and one can clearly see the perfusion returning.

Fig. 109.3 The concept of circumferential ring of fluid trapped between silicone oil and perfluorocarbon liquid (PFCL). Unless this fluid is completely removed before removing the PFCL, slippage of the giant retinal tear flap can occur.

Figures 109.4 and 109.5 show pre- and postoperative photographs of a case of giant retinal tear. Note the postoperative photograph shows early PVR inferiorly.

Fig. 109.4 Preoperative photograph of an eye with 180° giant tear and folded flap.

Fig. 109.5 Postoperative photograph of the eye in Figure 109.4 showing attached retina and early proliferative retinopathy inferiorly. Note the reflexes due to silicone oil.

Results

In the pre-vitrectomy era, Schepens and Freeman could achieve successful reattachment only in two out of 14 eyes.³² Machemer reported a final success rate of 43% following vitrectomy with prone fluid–gas exchange and use of SF₆ gas, although intraoperative success was achieved in 12 of the 14 cases.³³ Aylward et al. reported a success rate of 89% in traumatic giant retinal tears using vitrectomy and silicone oil tamponade.³⁴ Batman et al. reported no difference in success rate between silicone oil and long-acting gas tamponade.³⁵

The routine use of encirclage continues to be debated, with Goezinne et al. reporting higher failure rate in the absence of encirclage,²⁴ while Kreiger and Lewis²⁵ (11 eyes) and Hoffman and Sorr³⁶ (six eyes) reported success without buckle. Loewenstein et al. compared perfluoroperhydrophenanthrene and perfluoro-octane and found no statistically significant difference between the two groups.³⁷ The overall success was 71.7% and 78.3%, respectively in the two groups. But the authors found greater incidence of retained perfluorophenanthrene compared with perfluoro-octane. This was attributed to perfluorophenanthrene’s greater specific gravity, lesser vapor pressure and less prominent interface with balance salt solution. Al-Khairi et al. analyzed the prognostic factors associated with surgical results and identified phakic/clear lens at presentation, unfolded flap of the giant retinal tear, absence of postoperative cataract, and absence of postoperative PVR to be associated with better than 20/200 vision.³⁸ They also found that placement of encircling band and use of silicone oil tamponade were associated with higher anatomical reattachment with one procedure.

Management of fellow eye

In a study of the natural history of the fellow eyes, Freeman reported a 14% incidence of giant retinal tear and 36% incidence of other retinal tears.^8,39 High-risk fellow eyes include high myopia, eyes with progressively increasing white without pressure areas with sharp posterior margin and increased vitreous condensation and patients with Wagner–Stickler syndrome. In a series of 204 patients with Type 1 Stickler syndrome, Ang et al. reported a risk reduction from 73% to 6.5% by performing prophylactic 360° cryopexy posterior to the ora serrata. Posterior lesions were not treated in this study.⁷ Wolfensberger et al. have reported a series of 48 eyes with giant retinal tear where the fellow eye was prophylactically treated with 360° cryopexy.⁴⁰ They found an 8% (four eyes) incidence of retinal breaks (three with retinal detachment) over an 84-month follow-up period, where one patient had giant retinal tear posterior to the treated area. Based on their data, the authors believe that there is justification for prophylactic treatment.

While Freeman advocated prophylactic buckling along with cryopexy,³⁹ most surgeons have resorted to only cryopexy or laser photocoagulation without scleral buckling.^38,40,41 Laser has the advantage of being an outpatient procedure and can be spaced over two or more sittings in an attempt to reduce the inflammation caused by the treatment.

Despite these publications, one has to remember that there is still no consensus on: (1) the need for prophylaxis; (2) modality of treatment (cryopexy or laser); (3) where to treat (ora or equator); and (4) what to treat (visible lattice degenerations/visible areas of white without pressure or just 360° treatment). In a review of literature on interventions for prevention of giant retinal tear in the fellow eye, Ang et al. did not find conclusive evidence to support or refute the value of prophylaxis.⁴² In Stickler syndrome however, the evidence is more strongly in favor of offering prophylaxis for the fellow eye.⁷