The Latest on Retinal Tears Associated with Posterior Vitreous
Detachment (PVD)- Part I
Reference:
Sharma, M. C., et al., “Determination of the Incidence and
Clinical Characteristics of Subsequent Retinal Tears Following
Treatment of the Acute Posterior Vitreous Detachment-related
Initial Retinal Tears.” AJO, August, 2004.
Select Quotes:
“Approximately 15% of all patients presenting with acute symptomatic
PVD harbor a retinal tear and as many as half of these patients
have more than one tear. The incidence of retinal tears
in acute PVD with vitreous hemorrhage was found to be 70%
compared with a 2% to 4% incidence in acute PVD without vitreous
hemorrhage.”
“In patients with vitreous hemorrhage in the setting of acute
PVD where no retinal tears are detected, follow up examination
in 2 to 3 weeks and then at regular intervals until the entire
retina is well visualized, may be considered.”
“It is critical to be aware that subsequent (i.e., after the
initial PVD visit) retinal tears may be asymptomatic or at
least less symptomatic than initial retinal tears.”
M & T Commentary
Most people who develop symptomatic PVDs do so around age 60,
but the common age range is 50 to 70 years. Most of these
patients complain of flashes or floaters, or both. There
is a 10 to15% chance of a patient presenting with a symptomatic
PVD having a retinal tear or break. The retina and vitreous
have a rather intimate anatomic relationship and an abrupt
vitreous detachment (or separation) can occasionally cause
a tear or break in the retina. Left untreated, many of these
tears or breaks can progress to a retinal detachment, which
is why patients with flashes or floaters are always dilated
and thoroughly examined. When breaks do occur, the most
common location is the superior temporal region.
See the end of the next article for a more exhaustive commentary
on this topic.
Another Timely Article Regarding Posterior Vitreous
Detachment – Part II
Reference:
Hikichi, T. and Yoshida, A. “Time Course of Develop of Posterior
Vitreous Detachment in the Fellow Eye After Develop in the
First Eye.” Ophthalmology, September, 2004.
Select Quotes:
“Posterior vitreous detachment (PVD) is a common, mainly senile
degenerative process in which the vitreous cortex separates
from the retina. It occurs in more than 60% of patients
older that 69 years. PVD is the principal predisposing even
to the development of retinal breaks and rhegmatogenous retinal
detachments. At the initial examination, more than 10% of
patients with symptomatic PVD may have retinal breaks or
retinal detachments requiring immediate treatment. The remainder
of these patients will be diagnosed with isolated PVD and
should be re-examined six weeks after the onset of symptoms,
because new retinal breaks may develop in a few patients
during this time.”
In this study, “x PVD developed in the fellow eye in 8% of
eyes within six months, 24% within one year, 65% within two
years, and 90% within three years.”
“PVD is more common in myopic eyes, occurring approximately
six to ten years earlier than in emmetropic and hyperopic eyes.”
“In symptomatic PVD in this study, the most frequent symptom
was floaters alone, about 40%. About 25% had both floaters
and flashes, and a similar number had flashes only.”
M & T Commentary
Missing diagnoses are a common cause of successful litigation
in eye care. Two common culprits are specifically glaucoma
and retinal tears/detachments. Obviously, when any patient
presents with abrupt onset of unilateral floaters and/or
flashes, an exhaustive examination of the peripheral retina
is mandatory. Good dilation followed by binocular indirect
ophthalmoscopy and scleral depression, or the Goldmann 3-mirror
examination is our routine. We generally have patients back
in six to eight weeks to repeat these diagnostic maneuvers.
One sign that is immensely helpful to us is called Shaffer’s
sign. This is commonly described as tobacco dust or paprika-like
debris in the retrolenticular anterior vitreous and is indicative
of a retinal break or tear. This debris represents either
RPE (melanin) pigment particles or red blood cells which
were liberated at the time of the breach in retinal integrity
from the PVD. Especially in the face of a positive Shaffer’s
sign, an exhaustive search must be made for the break or
tear. If none is found, repeat this examination in a month,
and sooner if the patient develops any increase in symptoms.
It should be evident that thorough patient education is foundational
in the setting of an acute PVD. |
