It’s hard to make an asymptomatic patient better. 

When patients present with a macula-off retinal detachment, an acute central retinal vein occlusion or a central sub-retinal hemorrhage due to neovascular age-related macular degeneration, the need for intervention is obvious from both the patient and physician perspectives. 

However, many pathologies in our realm involve patients who aren’t acutely symptomatic. These clinical scenarios demand a more nuanced discussion with patients about management options, including observation, and the specific risks and benefits of each. 

The most obvious of these we’ve discussed for the last many years involves patients with severe non-proliferative diabetic retinopathy without diabetic macular edema. Accumulating prospective data indicate that earlier initiation with anti-VEGF pharmacotherapy yields tangible benefit, on average, for this population. Nevertheless, there are numerous arguments supported with data on both sides of this theoretical debate, and the ultimate decision to initiate therapy must continue to be an individualized approach, highly dependent on the specific clinical circumstances of each patient. 

A more thorough understanding of which patients may benefit the most from earlier interventions may assist our decision-making, and artificial intelligence systems, as Dr. Grayson Armstrong discusses on page 30, continue to hold great promise for improved prognostication. 

Retinal breaks are another clinical scenario we all encounter regularly. Drs. Jonathan Russel, Bill Smiddy and Harry Flynn beautifully summarize excellent clinical pearls related to their management on page 34. While we can all agree that acute, symptomatic retinal tears should be treated, many breaks and other retinal pathologies such as lattice degeneration can fall into the gray zone of management.  

A few years ago, my parents came to visit and I decided to examine my Dad’s retinas. He had a few drusen consistent with his demographic and some mild vascular changes consistent with his age. On peripheral exam of his left eye, I found a superior, horseshoe retinal tear at the vitreous base with obvious residual vitreous traction, a small cuff of subretinal fluid and no pigmentation. He was asymptomatic. What would you do? 

I laser demarcated the break and referred him to a friend of mine for follow-up in California. To this day, my Dad jokes about how I “blinded” him with my laser despite him being asymptomatic before and after the laser. I then remind him that I may have saved him from needing a vitrectomy. He then typically wins the debate by saying at least he could have gotten rid of his floaters.

Even though Benjamin Franklin was probably right when he said an ounce of prevention is worth a pound of cure, context is everything. Be careful with asymptomatic patients! RS