Symptomatic vitreous detachment is a very common, mostly harmless and transient phenomenon in people past middle age.
Shadows or specks appear in the visual field that move as the eyes move and that the patient can see through.
Clear symptoms of vitreous detachment warrant examination by an ophthalmologist within a week to make sure that the detachment has not caused any complications, such as vitreous haemorrhage or a macular hole.
Examination by an ophthalmologist is indicated within 24 hours if vision in the affected eye is clearly impaired, if there is an opaque shadow in the visual field or if the patient describes the symptom as a shower of black specks.
Causes
The back of the vitreous becomes detached from the surface of the retina. This is a normal change associated with ageing, as the vitreous shrinks with age.
Vitreous detachment usually appears after the age of 60 but it may appear earlier in people who are near-sighted or as a result of eye injury or a surgical procedure, for example.
Symptoms
Vitreous detachment may be asymptomatic, particularly if it occurs slowly.
In acute vitreous detachment, the patient will report moving shadows, floating specks or opacities in their visual field. These move with the eyes, and the patient can see through them.
There is no pain involved.
The pull exerted on the retina as the vitreous detaches can cause the patient to see flashes of light which usually become stronger in the dark. This pulling may also lead to a macular hole and further to retinal detachment.
If the retina is detached, a shadow will appear in the visual field that the patient cannot see through.
A macular hole is found in about 10-15% of cases of symptomatic vitreous detachment.
Rupture of a blood vessel may cause vitreous haemorrhage, often described by the patient as floaters. Profuse bleeding will impair visual acuity.
Diagnosis
Careful history taking
Eye examination; vision of both eyes separately, wearing glasses for distance vision
More severe vitreous haemorrhage can be detected by the red reflex test and retinal detachment by finger perimetry.
An ophthalmological examination should be performed within 24 hours if vision in the affected eye is clearly impaired, the patient sees a shower of black specks or there is an opaque shadow in the visual field.
Symptomatic vitreous detachment requires an ophthalmological examination within one week, except if there is just a single floating speck that has been there for less than one month and if there are no other symptoms, in which case the examination should be performed within one month.
Vitreous detachment as such does not require treatment once an ophthalmologist has confirmed that it has not caused any complications.
The symptoms will gradually subside within several months when the vitreous becomes completely detached. Small floating shadows or specks may remain permanently in the visual field but they rarely affect vision.
If the retina is attached and there are no tears in it, no routine follow-up is required. Patients should contact their ophthalmologist if the symptoms get worse.
Follow-up by an ophthalmologist after one month is necessary if:
the patient has a history of retinal tear or retinal detachment
the affected eye is the patient's only sighted eye
pigment cells or blood have been found in the vitreous or haematomas on the retina.
If the flashes of light increase or if a veil or curtain appears from some direction in the visual field, an ophthalmologist should be contacted within 24 hours.
References
Gishti O, van den Nieuwenhof R, Verhoekx J, et al. Symptoms related to posterior vitreous detachment and the risk of developing retinal tears: a systematic review. Acta Ophthalmol 2019;97(4):347-352. [PubMed]
de Smet MD, Gad Elkareem AM, Zwinderman AH. The vitreous, the retinal interface in ocular health and disease. Ophthalmologica 2013;230(4):165-78. [PubMed]