The ratings of importance to the care process (A, B, C) and the ratings for strength of evidence (I, II, III) are defined at the end of the "Major Recommendations" field.
Diagnosis
The initial evaluation of a patient with risk factors or symptoms includes all features of the comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to posterior vitreous detachment (PVD), retinal breaks, and lattice degeneration.
History
- Symptoms of PVD [A:I]
- Family history [A:II]
- Prior eye trauma, including surgery [A:II]
- Myopia [A:II]
- History of cataract surgery [A:II]
Examination
- Examination of the vitreous [A:III] for detachment, pigmented cells, hemorrhage, and condensation
- Peripheral fundus examination with scleral depression [A:III]
There are no symptoms that can reliably distinguish PVD with an associated retinal break from PVD without an associated retinal break; therefore, a peripheral retinal examination is required. [A:III] The preferred method of evaluating peripheral vitreoretinal pathology is with indirect ophthalmoscopy combined with scleral depression.
Diagnostic Tests
If it is impossible to evaluate the peripheral retina, B-scan ultrasonography should be performed to search for retinal tears or detachment and for other causes of vitreous hemorrhage. [A:II]
Treatment
The table below summarizes recommendations for management.
| Type of Lesion |
Treatment |
| Acute symptomatic horseshoe tears |
Treat promptly [A:II] |
| Acute symptomatic operculated tears |
Treatment may not be necessary [A:III] |
| Traumatic retinal breaks |
Usually treated [A:III] |
| Asymptomatic horseshoe tears |
Usually can be followed without treatment [A:III] |
| Asymptomatic operculated tears |
Treatment is rarely recommended [A:III] |
| Asymptomatic atrophic round holes |
Treatment is rarely recommended [A:III] |
| Asymptomatic lattice degeneration without holes |
Not treated unless PVD causes a horseshoe tear [A:III] |
| Asymptomatic lattice degeneration with holes |
Usually does not require treatment [A:III] |
| Asymptomatic dialyses |
No consensus on treatment and insufficient evidence to guide management |
| Fellow eyes with atrophic holes, lattice degeneration, or asymptomatic horseshoe tears |
No consensus on treatment and insufficient evidence to guide management |
Treatment of peripheral horseshoe tears should be extended well into the vitreous base, even to the ora serrata. [A:II] The surgeon should inform the patient of the relative risks, benefits, and alternatives to surgery. [A:III] The surgeon has the responsibility for formulating a postoperative care plan and should inform the patient of these arrangements. [A:III]
Follow-up
The guidelines in the table below are for routine follow-up in the absence of additional symptoms. Patients with no positive findings at the initial examination should be seen at the intervals recommended in the Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern (PPP). [A:III] All patients with risk factors should be advised to contact their ophthalmologist promptly if new symptoms such as flashes, floaters, peripheral visual field loss, or decreased visual acuity develop. [A:II]
| Type of Lesion |
Follow-up Interval |
| Symptomatic PVD with no retinal break |
Depending on symptoms, risk factors, and amount of vitreous traction, patients should be followed in 1 to 6 weeks |
| Acute symptomatic horseshoe tears |
1 to 2 weeks after treatment, then 4 to 6 weeks, then 3 to 6 months, then annually |
| Acute symptomatic operculated tears |
2 to 4 weeks, then 1 to 3 months, then 6 to 12 months, then annually |
| Traumatic retinal breaks |
7 to 14 days after treatment, then 4 to 6 weeks, then 3 to 6 months, then annually |
| Asymptomatic horseshoe tears |
1 to 4 weeks, then 2 to 4 months, then 6 to 12 months, then annually |
| Asymptomatic operculated tears |
2 to 4 weeks, then 1 to 3 months, then 6 to 12 months, then annually |
| Asymptomatic atrophic round holes |
Annually |
| Asymptomatic lattice degeneration without holes |
Annually |
| Asymptomatic lattice degeneration with holes |
Annually |
| Asymptomatic dialyses |
If untreated, 1 month, then 3 months, then 6 months, then every 6 months
If treated, 1 to 2 weeks after treatment, then 4 to 6 weeks, then 3 to 6 months, then annually |
| Fellow eyes with atrophic holes, lattice degeneration, or asymptomatic horseshoe tears |
Every 6 to 12 months |
History
- Visual symptoms [A:I]
- Interval history of eye trauma, including intraocular surgery [A:I]
Examination
- Measurement of visual acuity [A:III]
- Evaluation of the status of the vitreous, with attention to the presence of pigment or syneresis [A:II]
- Examination of the peripheral fundus with scleral depression [A:II]
- B-scan ultrasonography if the media is opaque [A:II]
Provider
It is essential that ancillary clinical personnel be familiar with the symptoms of PVD and retinal detachment so that symptomatic patients can gain prompt access to the health care system. [A:II]
Patients with symptoms of possible or suspected PVD or retinal detachment and related disorders should be examined promptly by an ophthalmologist skilled in binocular indirect ophthalmoscopy and supplementary techniques. [A:III] Patients with retinal breaks or detachments should be treated by an ophthalmologist with experience in the management of these conditions. [A:III]
Counseling/Referral
Patients at high risk of developing retinal detachment should also be educated about the symptoms of PVD and retinal detachment as well as about the value of periodic follow-up examinations.[A:II]
All patients at increased risk of retinal detachment should be instructed to notify their ophthalmologist promptly if they have a significant change in symptoms, such as a significant increase in floaters, loss of visual field, or decrease in visual acuity. [A:III]
Definitions:
Ratings of Importance to Care Process
Level A, most important
Level B, moderately important
Level C, relevant but not critical
Ratings of Strength of Evidence
- Level I includes evidence obtained from at least one properly conducted, well-designed randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
- Level II includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies, preferably from more than one center
- Multiple-time series with or without the intervention
- Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization
- Expert opinion (e.g., Preferred Practice Pattern panel consensus)
