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Symptoms ⬇

Acute retinal break: Flashes of light, floaters (“cobwebs,” “hair,” or “film” that changes position with eye movement) with or without visual acuity changes. Can be identical to PVD symptoms, though may be more profound.

Chronic retinal breaks or atrophic retinal holes: Usually asymptomatic.

Signs ⬆ ⬇

(See Figure 11.2.1.)

Critical

A full-thickness retinal defect, usually seen in the periphery.

Other

Acute retinal break: Pigmented cells in the anterior vitreous, VH, PVD, retinal flap, subretinal fluid (SRF), or an operculum (a free-floating piece of retina suspended above a RT).

Chronic retinal break: Surrounding pigmentation ring or demarcation line between attached and detached retina and signs (but not necessarily symptoms) of an acute retinal break.

11-2.1 Giant retinal tear.

Gervasio-ch011-image002

Predisposing Conditions

Lattice degeneration, high myopia, aphakia, pseudophakia, age-related retinoschisis, vitreoretinal tufts, meridional folds, history of previous retinal break or detachment in the fellow eye, family history of retinal break or detachment, collagen vascular disorders, and trauma.

Differential Diagnosis ⬆ ⬇

  • Lattice degeneration.
  • White without pressure: Abrupt changes in retinal pigmentation that may mimic a break or subretinal fluid. Benign findings, etiology unclear.
  • Choroidal rupture or retinal hemorrhage (all layers): May occur without retinal break or obscure retinal break.
  • Meridional fold: Small radial fold of retina perpendicular to the ora serrata and overlying an oral tooth; may have small retinal hole at the base.
  • Vitreoretinal tuft: Focal area of vitreous traction causing elevation of the retina.

Work Up ⬆ ⬇

Workup

Complete ocular examination with a slit lamp and indirect ophthalmoscopy of both eyes with scleral depression. After trauma, scleral depression may be gently performed once open globe injury has been ruled out. B-scan US may be helpful when the retina is not visible (e.g., vitreous hemorrhage, dense cataract, etc.)

Treatment ⬆ ⬇

In general, laser therapy or cryotherapy is required within 24 hours for acute retinal breaks. Treatment may be less urgent for chronic breaks. However, each case must be individualized based on patient risk factors. We follow these general guidelines:

  1. Treatment recommended:
    • Acute symptomatic break (e.g., a horseshoe or operculated tear).
    • Acute traumatic break (including a dialysis).
    • Acute symptoms and presence of lattice degeneration.
  2. Treatment to be considered:
    • Asymptomatic retinal break that is large (e.g., ≥1.5 mm), above the horizontal meridian, or both, particularly in the absence of PVD.
    • Asymptomatic retinal break in an aphakic or pseudophakic eye, a highly myopic eye, or an eye in which the involved or contralateral eye has had an RD.

Follow Up ⬆

  1. Patients with predisposing conditions or retinal breaks that do not require treatment are followed at 3 months and then every 6 to 12 months if stable.
  2. Patients treated for a retinal break are reexamined in 2 weeks, 6 weeks, 3 months, and then every 6 to 12 months.
  3. RD symptoms (a dramatic increase in floaters or flashing lights, worsening visual acuity, or the appearance of a curtain, shadow, or bubble anywhere in the field of vision) are explained and patients are told to return immediately if these symptoms develop.