What's up, Doc? For small retinal holes, the risk of complications is very small
Q: I had a routine eye exam by my ophthalmologist, and she found I had an atrophic retinal hole in the outside part of my eye. She said not to worry about it and we would just follow it for now. But I’m a bit nervous. Please give me more information about this condition.
A: Although the eye is a pretty complex organ, considering the basics will be enough for today’s column. For us to see, light must be focused by the lens at the front of the eye through the clear gel-like fluid (called vitreous humor) in the eyeball so it can land on the "picture screen"-like retina. The retina is attached to an underlying support structure that holds it firmly in place, acting like the theatre wall that supports a movie screen to hold it flat. After the focused light falls onto the retina, the retina’s light-sensitive cells trigger nerve signals that are sent to the brain, enabling us to see.
Idiopathic (spontaneously occurring without a specific identified cause) atrophic retinal holes are pretty common, occurring in up to 5% of the population. They are usually small, peripheral (outside the macula, which is the center part of the retina, responsible for the keenest aspect of our vision) and do not affect vision; they are typically identified on a routine exam as yours was. There is no known way to prevent these from occurring.
Although it is not clear what causes retinal holes, one possibility is that some disruption of the blood supply causes the affected area to degenerate (atrophy, hence the name atrophic retinal holes). Almost half the time atrophic retinal holes are associated with some amount of lattice degeneration, a condition where a part of the retina (usually a peripheral part) becomes thin.
For small atrophic retinal holes that have no symptoms, have no fluid noted "leaking" into them, and when there is no history of retinal detachment (RD, as discussed below) in the other eye, the risk of complications is very small, and no treatment is typically indicated. Instead, the patient is followed clinically to surveil for any changes. Retinal holes that are larger and occur in the macula, are horseshoe-shaped or flapped, or small atrophic holes with the risk factors just noted, may have an increased risk of RD. They should be evaluated for possible prophylactic treatment (to prevent detachment), similar to the treatment of RD discussed below.
RD occurs when the retina is pulled from its underlying support structure; for example, by vitreous humor leaking underneath it to push it away or from contracting vitreous humor (it contracts as we age) "grabbing" it and pulling it away. Either of these could cause it to detach.
If RD occurs, the patient’s vision will usually acutely change. Early visual symptoms of RD may include experiencing flashing lights, the onset of significant and acute floaters (floaters are "debris" in the vitreous humor, and although they may be a normal part of aging the acute onset of many of them, sometimes described as a housefly acutely popping into the vision in one eye, raises a red flag), smoky/blurry vision and/or a curtain-like loss of vision (as the retina peels away).
Most untreated cases of RD will lead to vision loss. Thankfully, there are many possible treatments for this condition and over 90% of RDs can be successfully treated, especially if the condition is addressed early.
Treatment for RD aims at re-anchoring the retina to its supporting structures. This can be done with laser treatments (kind of like welding the retina back in place) or cryopexy (freezing a small area to create a scar to re-anchor it). Injecting air or another gas into the eye (so the bubble can push the retina back into place) is required in some patients. Sometimes surgery is needed to remove and replace the vitreous humor, and sometimes the surgeon sews a "belt" around the back of the eye to "squish" it, bringing the retina back into contact with the eye’s support structure (scleral buckling).
RD is a medical emergency. Because prompt treatment can prevent vision loss, anyone developing symptoms of RD should seek medical care immediately. However, an incidental finding of an asymptomatic small peripheral atrophic retinal hole typically has a good prognosis, and hence the recommendation may be to clinically follow these to surveil for any changes or the development of any concerning features.
Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.
This article originally appeared on MetroWest Daily News: Dr. Jeff Hersh examines atrophic retinal holes, impact on vision
