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Symptoms ⬇

Floaters, blurred vision, and/or flashes of light which are more common in dim illumination or with eye movement. Symptoms usually present acutely and progress over hours to days.

Signs ⬆ ⬇

Critical

One or more discrete near-translucent or light gray vitreous opacities, one often in the shape of a ring (“Weiss ring”) or broken ring, suspended over the optic disc (see Figure 11.1.1).

11-1.1 Posterior vitreous detachment.

Gervasio-ch011-image001

Other

Retinal break/tear (RT), retinal detachment (RD), or vitreous hemorrhage (VH) may occur with or without a posterior vitreous detachment (PVD), with similar symptoms. Peripheral retinal and disc margin hemorrhages, released retinal pigment epithelial cells in the anterior vitreous (“tobacco dust” or Shafer sign).

NOTE:

Approximately 8% to 26% of all patients with acute symptomatic PVD have a retinal break. The presence of pigmented cells in the anterior vitreous or VH in association with an acute PVD indicates a high probability (>70%) of a coexisting retinal break. See 11.2, RETINAL BREAK.

Differential Diagnosis ⬆ ⬇

  • Uveitis: In vitritis, vitreous cells may be found in both the posterior and anterior vitreous, the condition may be bilateral, and the cells are not typically pigmented. Many uveitides, particularly white dot syndromes, will also present with floaters and photopsias. See 12.3, POSTERIOR UVEITIS.
  • Migraine: Multicolored photopsias in a zig-zag pattern that obstructs vision lasts approximately 20 minutes. A headache may or may not follow, and symptoms may be bilateral. Normal fundus examination. See 10.27, MIGRAINE.

Work Up ⬆ ⬇

Workup
  1. History: Duration of symptoms? Distinguish retinal photopsias from the visual distortion of migraine, which may be accompanied by new floaters. Location of photopsias does not correlate with location of retinal break(s), if present. Risk factors for retinal break (trauma, previous intraocular surgery, yttrium aluminum garnet [YAG] laser capsulotomy, high myopia, personal or family history of RT/RD)?
  2. Complete ocular examination, including evaluation of the anterior vitreous for pigmented cells and a dilated fundus examination with indirect ophthalmoscopy and scleral depression to rule out a retinal break and detachment. Optical coherence tomography (OCT) can be helpful in confirming the presence or absence of a PVD. Hyperreflective dots in the vitreous (“falling ash sign”), when present, have a high correlation with peripheral retinal breaks. Pseudophakic patients may have smaller anterior breaks compared to phakic patients. Examine the fellow eye to assess for presence of PVD and peripheral retinal pathology.
  3. Visualize the PVD at the slit lamp with a 60- or 90-diopter lens by identifying a gray-to-black strand suspended in the vitreous. If not visible, have the patient make rapid saccades and then look straight to float the PVD into view.
  4. If VH obscures visualization of the retina, ultrasonography (US) is indicated to identify the PVD and rule out a retinal break, RD, or other causes of vitreous hemorrhage. Inferior layering vitreous hemorrhage may mimic a retinal break on US. See 11.13, VITREOUS HEMORRHAGE.

Treatment ⬆ ⬇

No treatment is indicated for PVD unless an acute retinal break or dense vitreous hemorrhage is found; see 11.2, RETINAL BREAK.

NOTE:

In the setting of acute PVD symptoms, chronic retinal breaks (pigmented) or lattice degeneration usually warrant treatment.

Follow Up ⬆

  • The patient should be given a list of RD symptoms (a significant increase in floaters or flashing lights, worsening vision, or the appearance of a persistent curtain or shadow anywhere in the field of vision) and told to return immediately if these symptoms develop. The timing of symptoms could be anywhere from days to years later.
  • Patients should be informed that they will also likely develop a PVD in their fellow eye, if not already present.
  • If no retinal break or hemorrhage is found, the patient should be scheduled for repeat examination with scleral depression in 4 to 6 weeks. There is a 2% to 5% risk of developing new retinal breaks in patients with PVD and no retinal break at presentation.
  • If no retinal break is found, but mild VH or peripheral punctate retinal hemorrhages are present (indicating increased vitreous traction), repeat examinations are performed in 2 weeks.
  • If no retinal break is found but significant VH or anterior pigmented vitreous cells are present, repeat examination should be performed within 24 hours by a retina specialist because of the high likelihood of a retinal break.