October 17, 2022
Authored by: Danielle Strauss, MD
CC: A 27 year-old woman was referred for evaluation of lattice in both eyes. She had no visual complaints.
She had a strong family history of retinal detachments (father, uncle) and wanted to be checked by a retinal specialist. She was also a marathon runner and had the NYC marathon coming up.
Pt reported a history of myopia, wearing glasses since she was 7 years old.
Her last DFE was many years ago.
Past ocular history: no surgical history, no history of glaucoma.
BCVA cc: 20/20 OD, 20/20 OS
IOP: 16 OD, 16 OS
DFE: see imaging below
Widefield color fundus photo of the right eye shows peripheral lattice degeneration with atrophic holes.
Here is a closer look at the lattice with an atrophic hole
Widefield photo of the left eye showed an inferotemporal retinal detachment due to open atrophic holes. There are patches of lattice outside of the detachment, also with open atrophic holes.
SD-OCT of the macula in both eyes was unremarkable.
27 yo woman with
Lattice degeneration is a common finding of the peripheral retina and can be seen commonly in myopes. Generally, lattice degeneration can simply be observed, with annual scleral depressed DFE recommended annually. Even lattice with atrophic holes may be observed. However, in some instances, we elect to prophylactically treat lattice with laser retinopexy in the following circumstances: 1) the patient is symptomatic for flashes and floaters in an eye with lattice, 2) the patient has open atrophic holes that have subretinal fluid accumulation, 3) there is vitreal traction over the lattice 4) the lattice has an associated horseshoe tear. If atrophic holes begin to develop subretinal fluid, if left untreated and not monitored appropriately, patients may go on to slowly develop retinal detachments. Patients may be asymptomatic or may complain of a scotoma in the vision. If the detachment is localized or anterior to the equator, it may be amenable to barricade with laser. However, if the fluid extends posterior to the equator, generally, surgical repair is planned.
In this case, the patient was asymptomatic. However, given the extent of the subretinal fluid, its posterior location in the inferior macula, and the strong family history of retinal detachments, we elected to proceed with surgical repair.
We planned a scleral buckling procedure for the patient’s left eye, and laser retinopexy of the patient’s lattice degeneration in the right eye.
The scleral buckling procedure has existed for decades and remains an important method for the primary repair of RDs. In young myopic patients, scleral buckling procedure is often preferred over pars plana vitrectomy for primary repair. Young myopes generally do not have an existing posterior vitreal detachment, and are phakic with clear lenses which makes scleral buckling a better choice.
The scleral buckle is made of inert silicone and is placed around the globe under the rectus muscles. It is sutured into place in the oblique quadrants with permanent sutures.The goal of scleral buckling is to inwardly indent the eye wall, which brings the retinal pigment epithelium back to the neurosensory retina. The breaks are treated with cryotherapy to seal them. Buckles may be segmental and placed in certain quadrants of the eye, or they may be encircling. When an encircling band is chosen, the indentation of the globe will cause an axial elongation and a myopic shift post-operatively.
The patient underwent an uncomplicated encircling scleral buckle procedure, with drainage of the subretinal fluid, and injection of a small gas bubble at the end of the surgery.
Here is a post-operative widefield photo of the left eye.
2 months post-operatively, we can appreciate that the retinal detachment has resolved, and the retina is sitting flat on the buckle. The areas of prior lattice and atrophic holes are scarred from the cryotherapy.
Lattice in the right eye is treated with laser photocoagulation.
3 months post-op, the patient returned to her OD for a new refraction, and was 20/20 with correction. She went on to run the NYC marathon in November.