• American Academy of Ophthalmology Retina/Vitreous Panel, Preferred Practice Patterns Committee. Posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2008. 20 p. [74 references]

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current, each is valid for 5 years from the "approved by" date unless superseded by a revision.

The ratings of importance to the care process (A-C) and the ratings for strength of evidence (I-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 (American Academy of Ophthalmology Preferred Practice Patterns Committee, 2005), with particular attention to those aspects relevant to posterior vitreous detachment (PVD), retinal breaks, and lattice degeneration.

History

A patient history should include the following elements:

• Symptoms of PVD (Boldrey, 1983; Brod et al., 1991; Tasman, 1968; Dayan et al., 1996; Byer, 1994) [A:I]
• Family history (Snead et al, 1994; Brown et al., 1995) [A:II]
• Prior eye trauma (Cooling, 1986) [A:III]
• Myopia (The Eye Disease Case-Control Study Group, 1993; Austin et al., 1990) [A:II]
• History of ocular surgery, including refractive lens exchange and cataract surgery (Javitt et al., 1992; Tielsch et al., 1996; Rowe et al., 1999; Norregaard et al., 1996; Javitt et al., 1991; Kraff & Sanders, 1990) [A:II]

Examination

The eye examination should include the following elements:

• Examination of the vitreous for hemorrhage, detachment, and pigmented cells (Boldrey, 1983; Brod et al., 1991; Tasman, 1968; Dayan et al., 1996; Byer, 1994; Boldrey, 1997; Coffee et al., 2007) [A:II]
• Peripheral fundus examination with scleral depression (Brockhurst, 1956) [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 (Brockhurst, 1956). [A:III] The preferred method of evaluating peripheral vitreoretinal pathology is with indirect ophthalmoscopy combined with scleral depression (Natkunarajah, Goldsmith, & Goble, 2003). [A:III]

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 (DiBernardo, Blodi, & Byrne, 1992). [A:II]

Treatment

The table below summarizes recommendations for management.

Table: Management Options

PVD, posterior vitreous detachment

*There is insufficient evidence to recommend prophylaxis of asymptomatic retinal breaks for patients undergoing cataract surgery.

The surgeon should inform the patient of the relative risks, benefits, and alternatives to surgery (American Academy of Ophthalmology, "Pretreatment Assessment," 2006; American Academy of Ophthalmology, "An Ophthalmologist's Duties," 2006). [A:III] The surgeon is responsible for formulating a postoperative care plan and should inform the patient of these arrangements (American Academy of Ophthalmology, "Pretreatment Assessment," 2006; American Academy of Ophthalmology, "An Ophthalmologist's Duties," 2006). [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) (American Academy of Ophthalmology Preferred Practice Patterns Committee, 2005). [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 (Javitt et al., 1992; Tielsch et al., 1996; Norregaard et al., 1996; Singh & Seemongal-Dass, 2001). [A:II]

Recommended Guidelines for Follow-Up

PVD, posterior vitreous detachment

History

A patient history should identify changes in the following:

• Visual symptoms (Boldrey, 1983; Brod et al., 1991; Tasman, 1968; Dayan et al., 1996; Byer, 1994; Boldrey,1997) [A:I]
• Interval history of eye trauma or intraocular surgery (Cooling, 1986; Tielsch et al., 1996; Tasman, 1972) [A:I]

Examination

The eye examination should emphasize the following elements:

• Measurement of visual acuity [A:III]
• Evaluation of the status of the vitreous, with attention to the presence of pigment, hemorrhage, or syneresis (Boldrey, 1983; Brod et al., 1991; Tasman, 1968; Dayan et al., 1996; Byer, 1994; Boldrey, 1997; Coffee et al., 2007) [A:II]
• Examination of the peripheral fundus with scleral depression (Brockhurst, 1956; Schepens, 1952) [A:II]
• B-scan ultrasonography if the media is opaque (DiBernardo, Blodi, & Byrne, 1992) [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 (Byer, 1994). [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

All patients at increased risk of retinal detachment should be instructed to notify their ophthalmologist promptly if they have a substantial change in symptoms, such as a significant increase in floaters, loss of visual field, or decrease in visual acuity (Javitt et al., 1992; Tielsch et al., 1996; Norregaard et al., 1996; Singh & Seemongal-Dass, 2001). [A:III] Patients who undergo refractive surgery to reduce myopia should be informed that they remain at risk of rhegmatogenous retinal detachment (RRD) despite reduction of their refractive error. [A:III]

Definitions:

Ratings of Importance to Care Process

Level A, defined as most important
Level B, defined as moderately important
Level C, defined as 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 (e.g., Preferred Practice Patterns [PPP] panel consensus with external peer review)

None provided

The type of supporting evidence is identified and graded for most recommendations (see "Major Recommendations" field).

• American Academy of Ophthalmology Retina/Vitreous Panel, Preferred Practice Patterns Committee. Posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2008. 20 p. [74 references]

Not applicable: The guideline was not adapted from another source.

1998 Sep (revised 2008 Sep)

American Academy of Ophthalmology - Medical Specialty Society

American Academy of Ophthalmology without commercial support

Retina/Vitreous Panel; Preferred Practice Patterns Committee

Members of the Retina/Vitreous Panel: Emily Y. Chew, MD, Chair, Macula Society and Retina Society Representative; William E. Benson, MD; Barbara A. Blodi, MD; H. Culver Boldt, MD; Timothy G. Murray, MD, Consultant and American Society of Retina Specialists Representative; Timothy W. Olsen, MD; Carl D. Regillo, MD, FACS; Ingrid U. Scott, MD, MPH; Leslie Hyman, PhD, Methodologist

Members of the Preferred Practice Patterns Committee: Sid Mandelbaum, MD, Chair; Emily Y. Chew, MD; Linda M. Christmann, MD; Douglas E. Gaasterland, MD; Samuel Masket, MD; Stephen D. McLeod, MD; Christopher J. Rapuano, MD; Donald S. Fong, MD, MPH, Methodologist

Academy Staff: Flora C. Lum, MD; Nancy Collins, RN, MPH; Doris Mizuiri

These panel and committee members have disclosed the following financial relationships occurring from January 2007 to October 2008:

H. Culver Boldt, MD: Alcon Laboratories, Inc. – Consultant/Advisor

Donald S. Fong, MD, MPH: Merck – Consultant/Advisor

Douglas E. Gaasterland, MD: Inspire Pharmaceuticals – Consultant/Advisor; IRIDEX – Consultant/Advisor, Equity owner, Patents/Royalty

Samuel Masket, MD: Alcon Laboratories, Inc. – Consultant/Advisor, Lecture fees, Grant support; Allergan, Inc. – Lecture fees; Bausch & Lomb, Inc. – Lecture fees; Omeros Pharmaceuticals, Inc. – Consultant/Advisor; Othera Pharmaceuticals, Inc. – Consultant/Advisor; PowerVision – Consultant/Advisor; Visiogen, Inc. – Consultant/Advisor

Stephen D. McLeod, MD: Alcon Laboratories, Inc. – Consultant/Advisor, Grant support; InSite Vision, Inc. – Consultant/Advisor, Visiogen, Inc. – Consultant/Advisor, Equity owner, Grant support

Timothy W. Olsen, MD: iScience – Grant support; Powerscope, Inc. – Grant support

Christopher J. Rapuano, MD: Alcon Laboratories, Inc. – Lecture fees; Allergan, Inc. – Consultant/Advisor, Lecture fees; Inspire Pharmaceuticals – Lecture fees; Ista Pharmaceuticals – Lecture fees; Rapid Pathogen Screening – Equity/owner; Ziemer Ophthalmic Systems AG – Consultant/Advisor

Carl D. Regillo, MD, FACS: Alcon Laboratories, Inc. – Consultant/Advisor; Eyetech, Inc. – Consultant/Advisor, Grant support; Genentech, Inc. – Consultant/Advisor, Grant support; Novartis – Consultant/Advisor, Grant support; QLT Phototherapeutics, Inc. – Consultant/Advisor, Grant support

Ingrid U. Scott, MD, MPH: Eyetech, Inc. – Consultant/Advisor, Lecture fees; Genentech, Inc. – Consultant/Advisor, Lecture fees; Pfizer Ophthalmics – Consultant/Advisor, Lecture fees

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Ophthalmology Retina Panel, Preferred Practice Patterns Committee. Posterior vitreous detachment, retinal breaks, and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current, each is valid for 5 years from the "approved by" date unless superseded by a revision.

None available

This summary was completed by ECRI on February 20, 1999. The information was verified by the guideline developer on April 23, 1999. This summary was updated again on April 30, 2004. The information was verified by the guideline developer May 20, 2004. This NGC summary was updated by ECRI Institute on April 22, 2009. The updated information was verified by the guideline developer on May 15, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Information about the content, ordering, and copyright permissions can be obtained by calling the American Academy of Ophthalmology at (415) 561-8500.