What is the first line of treatment for a retinal hole causing a scotoma in a highly myopic person?

Treatment of Retinal Hole with Scotoma in Highly Myopic Patients

Prompt treatment with laser photocoagulation is recommended for peripheral retinal holes causing scotoma in highly myopic patients to prevent progression to retinal detachment. 1

Diagnostic Approach

• Comprehensive dilated fundus examination with scleral depression is essential to identify and characterize the retinal hole 1
• Optical Coherence Tomography (OCT) provides high-resolution imaging to confirm the presence and extent of the retinal hole 1
• B-scan ultrasonography may be used if media opacity prevents clear visualization 1
• Visual field testing to map the scotoma and correlate with the anatomical defect 1

Treatment Algorithm

First-line Treatment

1. Laser photocoagulation for peripheral retinal holes with scotoma (if located away from functionally critical areas) 1
   • Creates a chorioretinal adhesion around the hole
   • Prevents progression to retinal detachment
   • Most effective when performed promptly after diagnosis

Alternative Treatments (Based on Location and Complexity)

1. For macular holes:

   • Vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade 1
   • Success rate approximately 90% for macular holes less than 400 μm 1

2. For retinal detachment associated with macular hole:

   • Pars plana vitrectomy with silicone oil or heavy silicone oil (densiron) tamponade 2
   • Macular buckling may be considered in cases with posterior staphyloma 3

Follow-up Protocol

• Initial follow-up at 1-2 weeks post-treatment 1
• Second follow-up at 2-6 weeks to assess chorioretinal scar formation 4
• Long-term follow-up every 3-6 months thereafter 1
• If the tear and accompanying subretinal fluid are not completely surrounded by the chorioretinal scar at follow-up, additional treatment should be administered 4

Patient Education

• Instruct patients to report new symptoms immediately (flashes, floaters, visual field loss, decreased acuity) 4, 1
• Educate on symptoms of retinal detachment requiring immediate attention 1
• Inform about the 5-14% risk of developing additional breaks during long-term follow-up 4
• Emphasize the 10-15% risk of developing holes in the fellow eye 1

Important Considerations

• Untreated retinal holes can progress to retinal detachment, which occurs in 2-8% of highly myopic eyes 1
• The risk of retinal detachment increases cumulatively over time in highly myopic patients 1
• Treatment should be performed promptly after diagnosis to prevent progression 1
• Even with adequate treatment, additional examinations are important as 5-14% of patients will develop additional breaks during long-term follow-up 4

Caution

• Highly myopic patients remain at risk for retinal complications even after refractive surgery to reduce myopia 4
• Regular monitoring of both eyes is necessary due to the risk of bilateral involvement 1