When to refer/treat operculated holes?

[goldsummer]

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Hi, I'm a future PCP, still in residency. Had a patient recently with an operculated hole in left eye with no subretinal fluid findings.

This was my first time coming across this condition, I was looking it up, and I feel like how to manage them was pretty vague. I would like to pick your brain so I can explain more in depth to any future patients that come my way.

If I come across a patient with an operculated hole, when do I refer? Always? Only if symptomatic? Only if fluid is noted?

And how do you determine if you will surgically treat these holes? What are the options for treatment?


Thanks

 

[Slide]

When you say PCP, do you mean FM/IM, etc? If so, first I’m impressed you actually know what they are and that you saw one. Anyway, if the above is true, you should always immediately (not urgently though) refer to an ophthalmologist, preferably retina. Reason being so is that the patient needs a good dilated, scleral depressed exam to make sure there’s nothing else going on.

As a comprehensive ophthalmologist? I would still say refer always unless there is little access to retina, for the same reason above. I always laser if I see a cuff of fluid or if symptomatic. If the patient has multiple tears or risk factors (myopic, previously broken bag during phaco, Sticklers/Marfan, history of contra lateral RD/tear, etc.), I laser. If it’s chronic and there’s lots of pigmentation in the abscence of the above risk factors, I may choose to observe.

 

[Fascia Lata]

I too was wondering what you mean by PCP. As operculated holes are typically a peripheral retina finding, I just find it hard to believe that a non-ophthalmologist can actually see that, and also determine absence/presence of subretinal fluid!! Even us, non-retina specialist ophthalmologists, find peripheral retinal exams often difficult.

I am sure you mean something else by PCP.

 

[airplanes]

Is it possible OP saw an Ophthalmology report for their patient and noticed operculated hole as a diagnosis and just wanted to learn more/further their knowledge?

 

[Dusn]

An asymptomatic operculate hole with no subretinal fluid does not need to be treated.

By “operculated” they mean that a small piece of retina has completely torn off. This is actually a good thing because there is no longer traction on the rest of the retina that could cause the rest of the retina to detach.

 

[goldsummer]

Is it possible OP saw an Ophthalmology report for their patient and noticed operculated hole as a diagnosis and just wanted to learn more/further their knowledge?

Correct... Except it was an optometry report. Patient had just come in after a routine eye exam and had the report. Had not heard of it and wanted to learn more so I know whens best to refer and can tell patients more information about it next time and risks/benefits of treatment procedures.

 

[goldsummer]

An asymptomatic operculate hole with no subretinal fluid does not need to be treated.

By “operculated” they mean that a small piece of retina has completely torn off. This is actually a good thing because there is no longer traction on the rest of the retina that could cause the rest of the retina to detach.

I see... Does that mean no need to refer to ophthalmology for a more complete exam if its operculated with no fluid? Or refer, but they will not need treatment?

 

[goldsummer]

When you say PCP, do you mean FM/IM, etc? If so, first I’m impressed you actually know what they are and that you saw one. Anyway, if the above is true, you should always immediately (not urgently though) refer to an ophthalmologist, preferably retina. Reason being so is that the patient needs a good dilated, scleral depressed exam to make sure there’s nothing else going on.

As a comprehensive ophthalmologist? I would still say refer always unless there is little access to retina, for the same reason above. I always laser if I see a cuff of fluid or if symptomatic. If the patient has multiple tears or risk factors (myopic, previously broken bag during phaco, Sticklers/Marfan, history of contra lateral RD/tear, etc.), I laser. If it’s chronic and there’s lots of pigmentation in the abscence of the above risk factors, I may choose to observe.

Thanks for your input! 🙂

 

[dantt]

Correct... Except it was an optometry report. Patient had just come in after a routine eye exam and had the report. Had not heard of it and wanted to learn more so I know whens best to refer and can tell patients more information about it next time and risks/benefits of treatment procedures.

I would expect if the hole were diagnosed by an optometrist to defer the decision for referral to the optometrist. PCPs should in general not be making those kind of referrals unless a patient required those referrals for insurance purposes. I always defer specific discussion of the risks and benefits of surgery to the doctor performing surgery.

 

[MstaKing10]

An asymptomatic operculate hole with no subretinal fluid does not need to be treated.

By “operculated” they mean that a small piece of retina has completely torn off. This is actually a good thing because there is no longer traction on the rest of the retina that could cause the rest of the retina to detach.

Mostly agree with you, though I have fixed 3 retinal detachments that resulted from asypmotatic operculated or atrophic holes that then developed acute retinal detachments. Selection bias be damned, I usually treat all holes as I sleep better at night. But in theory you are 100% right

 

[Slide]

Mostly agree with you, though I have fixed 3 retinal detachments that resulted from asypmotatic operculated or atrophic holes that then developed acute retinal detachments. Selection bias be damned, I usually treat all holes as I sleep better at night. But in theory you are 100% right

Damn right; though I don't treat atrophic breaks routinely, if I have a bad suspicion that the eye may take a turn for the worse, I go ahead and laser too. I've had a few patients where lasering a previous operculated break allowed me to perform a pneumatic later on when a detachment developed in another area.