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
| Type of Lesion |
Treatment* |
| Acute symptomatic horseshoe tears |
Treat promptly (Shea, Davis, & Kamel, 1974; Colyear & Pischel, 1960; Robertson & Norton, 1973; Pollack & Oliver, 1981; Smiddy et al., 1991; Verdaguer & Vaisman, 1979) [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 |
| Eyes with atrophic holes, lattice degeneration, or asymptomatic horseshoe tears where the fellow eye has had a retinal detachment |
No consensus on treatment and insufficient evidence to guide management |
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
| Type of Lesion |
Follow-up Interval |
| Symptomatic PVD with no retinal break |
Depending on symptoms, risk factors, and clinical findings, patients should be followed in 1 to 6 weeks, then 6 months to 1 year |
| 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 |
1 to 2 weeks 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 |
1 to 2 years |
| 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
|
| Eyes with atrophic holes, lattice degeneration, or asymptomatic horseshoe tears in patients in whom the fellow eye has had a retinal detachment |
Every 6 to 12 months |
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)
