Author: Ameen Marashi, MD

History

Documentation of age, floaters location, duration, shape, and quantity more than as floaters are high risk of retinal break which can be in the form of spiderwebs or hairs, visual field defects in the form of a curtain, and photopsia, ^[1] which looks like lightning arc more noticed in head and eye movement . Which is a sign of increased risk of retinal break.

Myopia ^[2] or ocular history of ocular trauma ^[3] or surgery, such as retinal detachment surgery, cataract extraction ^[4], refractive, lens extraction surgery ^[5], YAG laser capsulotomy, or intravitreal injection ^[6], should be documented as these are high risk factors along with Family history of previous retinal detachment or genetic disorders such as Stickler syndrome should be recorded ^[7].

Ocular Examination

A list of ocular examination should set

1) Confrontation visual field examination

2) Best-corrected visual acuity (BCVA) for near and far is an essential step that can perform by a trained optometrist or certified ophthalmologist to document the visual impairment. Most floaters will cause reduced in contrast sensitivity rather than drop of vision.

3) A slit-lamp examination done with a thorough exam of clarity and regularity of the cornea and conjunctival abnormality such injection of conjunctival vessels should be documented, and any other inflammations of the conjunctiva or eyelids documented, along with iris exam and crystalline lens exam to rule out cataract or intraocular lens (IOL) to document the position and clarity of the posterior capsule, it integrity wither it ruptured during cataract extraction or YAG laser capsulotomy was done.

4) Anterior hyaloid examination with retro illumination using slit-lamp microscopy to rule out tobacco dust (pigmented cells which are larger than blood cells) and differentiate it from blood, and inflammatory cells. As presence of heme or RPE cells pose an increased risk of a retinal break.

5) Intra Ocular Pressure (IOP) documentation is essential as high IOP may be associated with pathological myopia and patients with glaucoma history; Note when high IOP spotted a corrected IOP documented after central corneal thickness measurement

6) Bilateral dilated fundus exam is an essential and detailed examination of the optic disc, macula, posterior pole, a mid-peripheral and peripheral retinal exam with specialized indirect wide-field lenses using slit-lamp biomicroscopy using wide-field lenses and indirect ophthalmoscopy with scleral indentation ^[8] to document the following:

A. Core and posterior cortical of the vitreous searching for pigmented, blood, and inflammatory cells along with the presence of Weiss ring.

B. Documenting the extent of posterior vitreous detachment and syneresis if possible.

C. Posterior pole examination to rule out the presence of a macular hole, vitreomacular traction, or epiretinal membrane.

D. Peripheral and mid-peripheral retinal exam to rule out lattice degeneration, tufts, degenerative schisis, retinal breaks, retinal dialysis, and vascular avulsion.

E. When examining peripheral retinal breaks, it is essential to document if there is vitreous traction and if the break has atrophic edges, as it is important to distinguish retinal breaks caused by PVD from preexisting retinal breaks.

F. When examining lattice degeneration, the presence of atrophic holes, retinal tears, and vitreous traction should be documented.

G. Vitreous hemorrhage has a direct relation with the risk of retinal detachment. ^[9] Therefore, in the case of vitreous hemorrhage precluding a complete fundus examination, a headrest in 45 degrees and exam repeated weekly to locate the source of bleeding. As it could be vascular avulsion or/and retinal break which at least one break, in two-thirds of cases, is found, especially in the upper temporal quadrant in 88% of cases and may include more than one break ^[10].

H. Documentation of any retinal detachment or subclinical retinal detachments that has size more than one disc and don’t extend more than two discs posterior to the equator are documented as subclinical retinal detachments.

Diagnostic tests

Fundus images

Usually not enough to rule out retinal breaks; however, wide-field fundus imagining techniques such as OPTOS can provide wide-field viewing images up to 200 degrees. OPTOS is suitable for patients that can’t be dilated or have miosis and in cases of telemedicine, but it should never replace clinical examination.

Wide viewing images may document the presence of peripheral retinal pathologies such as retinal breaks, lattice, and subclinical retinal detachment. They can help to monitor the progression of retinal breaks or subclinical retinal detachment to clinical retinal detachment or changes in the retina associated with lattice degeneration as the formation of retinal breaks on the posterior edge of the lattice or elsewhere.

Optical Coherence Tomography (OCT)

OCT may help to document the presence of vitreomacular traction, macular hole or epiretinal membrane and help to study the areas of PVD and it stages ^[11] using volumetric OCT as the presence of vitreous separation perifoveal with vitreous adhesion on the surface which is classified as stage one, where stage two shows complete separation from the macula where extensive vitreous separation with the adhesion of the vitreous on the optic disc is stage three as stage four is a complete posterior vitreous detachment.

Currently, some OCT machines may provide wide-field OCT cross-sections, which are very helpful in diagnosing retinal breaks with or without vitreous traction.

B-scan

It is excellent to study the PVD extension and vitreous syneresis along that B-scan can diagnose the presence of retinal detachment and retinal breaks, especially in cases with no clear media such as cataract or vitreous hemorrhage ^[12].

B-scan can differentiate the retinal detachment from PVD as the former may exhibit whiplash movement with one free edge, and the other attached to the optic disc with increased high reflectivity membrane like in the vitreous cavity and induce high A-scan spikes and not disappear in low gains where the latter may have a washing machine movement and with no attachments in cases of complete PVD and disappears in low gain and usually don’t cause A-scan spikes.

Managing patients with PVD, lattice degeneration, and retinal breaks

Treatment options

Laser photocoagulation

Laser photocoagulation can create rapid chorioretinal adhesion and then scar to seal the retinal break, so none of the liquified vitreous will go under the retina and create subretinal fluids.

The laser can be applied under local anesthesia using slit-lamp microscopy or indirect ophthalmoscopy, usually a spot size between 200 and 500 μm with a power enough to induce desired retinal burn with duration 0.1 to 0.2 seconds.

Three rows of confluent gray to white laser applications (forming a zone 500 to 1000 μm wide) should be applied around the break or lattice degeneration. However, it is essential to apply laser anterior to retinal break after applying the laser to posterior and lateral edges to prevent extension of the break, and in cases of retinal dialysis, the anterior horns of dialysis should be lasered.

Usually, the chorioretinal adhesion happens faster than cryotherapy, ^[13] so it is advisable to have headrest when there are subretinal fluids for days.

Complications are rare as the laser may induce corneal burns, iatrogenic retinal holes, or hemorrhages in cases where increased power is used.

Cryotherapy

Cryotherapy used to treat anterior retinal breaks or vitreoretinal traction located anteriorly and retinal breaks associated with subretinal fluids.

Usually applied after subconjunctival anesthesia, cryotherapy is done trans-conjunctively while moving the eye to the meridian where the break is located. Then the application of cryotherapy is done while observing retinal whitening on an indirect ophthalmoscope after freezing effect, and then the probe is moved to an adjacent location to apply cryotherapy around the large breaks where the center of the break shouldn’t be treated to avoid RPE dispersion. In contrast, a small hole or breaks can be treated with one cryo application. It is essential to treat the anterior to the retinal break after treating the posterior and lateral edges, in some cases where posterior breaks needed to be treated, a conjunctival incision is needed.

Cryotherapy may not induce chorioretinal adhesion as fast as the laser does, and it makes it take five days to do; therefore, a head positioning and movement restrictions are important to post cryotherapy in some cases.

Complications of cryotherapy may fail to induce chorioretinal adhesion along with the increased risk of macular pucker in the case where the center of retinal break is treated.

Scleral buckle

A scleral buckle is done in cases of subclinical retinal detachments with an increased risk of developing clinical retinal detachment.

A scleral buckle is done under general anesthesia by doing 360 degrees peritomy and applying cryotherapy to all area between Ora Serrata and vitreous base and all areas of vitreoretinal tractions, and then a 2.5-4.00 mm silicon band is placed and fixing it by silk suture in each quadrant, a radial band can be placed as well if needed.

Treatment plan

In the case of symptomatic PVD with no peripheral retinal pathologies

These cases don't require any prophylactic treatment only followed within four weeks, then every two months, then every six to twelve months.

In the case of symptomatic PVD with vitreous hemorrhage but no retinal breaks

These cases don’t require any prophylactic treatment and only followed every week using B-scan to rule out retinal breaks or retinal detachment. ^[14] When the hemorrhage is resolved, then a thorough peripheral retinal exam is conducted to rule out any peripheral retinal breaks.

In the case of symptomatic PVD with vitreous hemorrhage with retinal breaks

- These cases may progress to retinal detachment and need intervention to seal retinal breaks either with the laser if the fundus view permits laser photocoagulation application or cryotherapy if the fundus view doesn’t permit laser application after accurately determining the location of retinal tear using B-scan.

- In cases complicated with retinal detachment or non-resolved vitreous hemorrhage within seven days and can’t be treated with cryotherapy or laser photocoagulation, then pars-plana vitrectomy is indicated ^[15].

In the case of acute symptomatic retinal breaks with persistent vitreoretinal traction

- Horseshoe-shaped, traumatic, or giant tears require prompt treatment (within 72 hrs) with laser photocoagulation or cryotherapy if the location of tear can’t be reached by laser. Those types of symptomatic tears (especially if located superiorly) may progress to clinical retinal detachment if not treated up to 55% of cases. ^[16] The Patient is followed every week, then every four weeks, then every three months and then six months and then annually.

- Retinal dialysis requires prompt treatment with laser photocoagulation or cryotherapy with treating the posterior and lateral edges along with the horns of the dialysis and then followed every week, then every four weeks, then every three months and then six months and then annually.

- Operculated or rounded tears may not always progress to retinal detachment, treatment required in high-risk patients such as pseudophakic and fellow eye had a retinal detachment or family history of retinal detachment. The patient is followed up every two to four weeks and then every three months then every six months then annually.

In the case of asymptomatic retinal breaks not associated persistent vitreoretinal traction

- Horseshoe-shaped, may not progress to retinal detachment, treatment is required in non-atrophic tears ^[17] and high-risk patients such as pseudophakic ^[18], the fellow eye had a retinal detachment ^[19] or family history of retinal detachment and followed up every two to four weeks and then every three months then every six months then annually for horseshoe-shaped tears.

- Giant tears require prompt treatment ^[20], especially in cases where a fellow eye had a retinal detachment with laser photocoagulation or cryotherapy if the location of tear can’t be reached by laser. The patient is followed up every week, then every four weeks, then every three months and then six months and then annually.

- Operculated or rounded tears may not always progress to retinal detachment and follow up every one month then every three months, then every six months, then annually. Treatment rarely recommended, but atrophic holes followed every year.

In the case of lattice degeneration

- In asymptomatic cases with or without atrophic holes, no treatment is required ^[21] only follow up annually.

- In cases that fellow eye suffered from retinal detachment, treatment is considered for pseudophakic cases ^[19] or phakic cases with poor surgical outcome in the fellow eye, the patient can’t recognize retinal detachment or/and vitreous hemorrhage symptoms and patients cannot follow up or live in areas with poor ophthalmic care. Prophylactic treatment of lattice degeneration may have low value due to retinal tears may not necessarily develop from lattice degeneration ^[17], follow up is every six to twelve months.

- In cases of lattice degeneration presented with symptomatic retinal horseshoe-shaped tear requires prompt treatment with laser photocoagulation or cryotherapy if the location of the tear can’t be reached by laser. The patient is followed up every week, then every month, then every three months, then every six months then annually.

- In cases of subclinical retinal detachment treated with laser demarcation (from Ora to Ora) or scleral buckle when progressing to clinical retinal detachment.

In cases of cystic tufts or degenerative retinoschisis

Usually, prophylactic treatment is not required and may only be considered in cases of degenerative retinoschisis with retinal breaks in the outer retinal layer and other eye is suffering from retinal detachment due to the outer retinal layer breaks.

Special cases

Myopic eyes are at risk of development of retinal detachment ^[22] but treated prophylactically in symptomatic retinal breaks, where treatment of asymptomatic retinal breaks is still controversial, but lattice degeneration is not an indication for prophylactic treatment, and 360-degree prophylactic laser therapy without the presence of retinal break before cataract surgery is not indicated.

YAG capsulotomy may increase the risk of retinal detachment up to four-folds ^[23], especially in myopic patients. Therefore, any symptomatic retinal breaks or asymptomatic retinal breaks and lattice degeneration associated with fellow eye had retinal detachment require prophylactic treatment ^[24].

Cataract surgery in cases presented with lattice degeneration with or without atrophic holes doesn’t require prophylactic treatment unless the other eye suffered from retinal detachment, while horseshoe-shaped retinal tear is prophylactically treated.

It is essential to know that patients are not presented with PVD ^[25] before surgery is at a higher risk of developing symptomatic retinal breaks and retinal detachment than those already presented with PVD. In contrast, patients who had complicated cataract surgery such as posterior capsular rupture and vitreous loss ^[26], especially in myopic patients, are at risk of developing symptomatic retinal breaks and retinal detachment; therefore, this complication should be managed with anterior vitrectomy.

Posterior segment surgery though a lot of reports advocating to do 360-degree prophylactic laser therapy, especially in cases before silicone oil removal, none of these reports are strong enough.

Floaters may cause visual disturbance, but treatment indicated only when floater is big enough to cause visual morbidity after six months of presentation and can be treated with YAG laser, especially single (Weiss ring) to few floaters located in the med vitreous) or vitrectomy, but the latter yield better results and more patient satisfaction. However, the treatment decision should be made after ruling out secondary factors such as vitreous hemorrhage, post complicated surgery and uveitis.

Flow chart summarizes the approach and management of posterior vitreous hemorrhage

Follow up and prognosis

- When following up, patients with PVD, changes in visual acuity, along with other symptoms, are documented ^[27], keep in mind that 10% of all cases of PVD may develop retinal breaks and most likely located in the upper quadrants.

- Slit-lamp examination of anterior hyaloid pigmented cells and syneresis ^[28] are documented, then the peripheral retinal exam to document any changes since the last visit. In cases treated with laser (full adhesion occurs within one week) or cryotherapy (full adhesion occurs within three weeks), assessing the chorioretinal scar within two weeks and retreatment required. In contrast, the chorioretinal scar is not adequately surrounding the retinal break or if there is subretinal fluid extending beyond the edges of the chorioretinal scar. ^[29] Patients should avoid strenuous physical activity until an adequate chorioretinal adhesion occurs.

- Despite the successful treatment, additional retinal breaks up to 13% in three months and 21% within two years may form in the long term; therefore, it is essential to follow up the patient for a long time, especially those who underwent cataract surgery ^[30].

- Patients who have opaque media should be followed up with B-scan until fundus view permits; then, the physician should switch to the clinical retinal exam.

- Patients should be educated for the importance of reporting any new visual symptoms such as increased floaters, visual field defects, and visual loss. Patients undergoing refractive surgery to treat myopia should know that they are still at risk of developing retinal breaks or/and retinal detachment in the future.

-If a patient presents PVD and has a vitreoretinal tuft, there is an increased risk of retinal break formation. Therefore, these patients must be closely monitored for retinal break formation.

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These guidelines were reviewed and updated in December 2022