NEWS & EVENTS
Retinal Review, Issue 62
Authored by Burton Wisotsky, M.D.
A 52 year old woman noted the sudden onset of flashes and floaters in her right eye one day ago. Past medical history is unremarkable. Past ocular history is significant for moderate myopia. On examination visual acuity was OD: 20/30 and OS: 20/20. IOP’s were normal OU. The SLE was normal OU. DFE of the left eye was normal. In the right eye there was a PVD with moderate central and inferior vitreous hemorrhage. For the retinal findings see photos below:
The view of the left eye was sharp. The retina was intact with minimal peripheral thinning. In the right eye there was a hazy view due to the vitreous hemorrhage. Of note was a large temporal horseshoe tear (surrounded by laser) and an area of inferior lattice degeneration with a small horseshoe tear (surrounded by laser).
Posterior vitreous detachment (PVD) is a common occurrence, especially in myopic patients. It is rare below age 40 unless the patient is a pathologic myope. Symptoms are typically flashes and floaters, sometimes accompanied by haze in the vision. There is a fair amount of misinformation regarding evaluating a patient with new onset of flashes and floaters, so I will review the way we handle these patients. All patients with new onset monocular flashes or floaters should be seen as soon as possible. Binocular symptoms are more commonly due to migraine headache or other neurologic or circulatory issues. It is possible but rare to have simultaneous PVD in both eyes. During the first visit, the retinas should be inspected carefully for tears. This should include a binocular indirect examination, and sclera depression when appropriate. If the PVD in nonhemorrhagic, the chance of a tear is 1-2%. If hemorrhagic (Schaeffer’s sign), the chance of a tear is 70%. If a tear is present, it is important to find it because 70% of symptomatic horseshoe tears due to PVD will progress to retinal detachment if untreated. If the patient is carefully inspected and no tear is present, they should be examined weekly up until the two week point from when symptoms began. If a tear is going to develop, it almost always does so in the first week or two of symptoms, usually the first few days. If a tear “develops” after the first two weeks, it is likely because it was missed. If the patient has no tears by two weeks, no further follow up is necessary. However, at each visit, the patient should be counseled that if there is any worsening of symptoms – increased floaters, flashes, shadows, curtains, or decreased vision, the patient should return for immediate reevaluation. If at any point a tear is present, it should be treated urgently to reduce the risk of retinal detachment.
Our patient had a hemorrhagic PVD with two horseshoe tears. The temporal larger tear had mild surrounding subretinal fluid. Laser was applied immediately to both tears. Several concentric rows were applied via the indirect ophthalmoscope guided laser. The chance of either tear progressing is under 5%. The patient was advised to return one week later for reevaluation and to report any worsening immediately. The following week the vision had improved to OD: 20/20-. Much of the vitreous debris had resolved. The tears were secure and there was no extension of the subretinal fluid. No new tears were present (see photos below). The patient was asked to return to her regular OD for follow up and to report any new symptoms to us. New changes at this point are unlikely. Occasionally patients will develop an epiretinal membrane after hemorrhagic PVD with tear. This can be monitored and referred back if it becomes significant. The patient should also be advised that the other eye will likely experience a PVD at some point, and should be evaluated if symptoms occur.