Delayed Retinal Breaks and Detachments after Acute Posterior Vitreous Detachment
Uhr JH, Obeid A, Wibbelsman et al. Delayed Retinal Breaks and Detachments after Acute Posterior Vitreous Detachment. Ophthalmology Volume 127, Number 4, April 2020.
Posterior vitreous detachment (PVD) is one of the most common vitreoretinal diagnoses that the retina specialist encounters in his or her day-to-day practice. Although the typical follow up period for an acute PVD is approximately 6 weeks due to the risk of a tear and 10% rule, there is not much literature beyond this time point. This was a retrospective cohort of 7999 eyes who presented with an acute PVD and an extended ophthalmoscopy initial visit at a single tertiary referral center (Wills Eye, Mid Atlantic Retina) between 2015 to 2018. Eyes were followed to determine the incidence of delayed retinal breaks after initial presentation.
Of the 7999 study eyes, 16% (1280 eyes) had a retinal break and 6.2% (499 eyes) a retinal detachment (RD) on initial presentation, respectively. Delayed retinal breaks were noted in 2.6% of PVDs (209 eyes). The average time to a delayed retinal break diagnosis was 101 days or 14.4 weeks (median 35 days, SD 150 days). Fifty-five percent of delayed retinal breaks were noted before 6 weeks of follow up. Interestingly, of those with delayed retinal breaks, an additional 13.9% of eyes (29/209) had subsequent delayed breaks. Symptom-wise, 30.2% and 52.7% exhibited new or worsening symptoms before and after 6 weeks, respectively. Vitreous hemorrhage (VH) and male gender were associated with delayed breaks with VH specifically being associated with earlier (<6 weeks) breaks.
One percent of eyes (n=8) presented with a delayed RD, of which 30% had prior treated retinal breaks and initial or prior follow up visits and were noted within 6 weeks (32%) of initial presentation. The mean of onset was 166 days and median 75 days. Younger age and pseudophakia were risk factors for delayed RD onset.
The major conclusion of this study is that a large percentage of delayed onset breaks (44.5%) and RDs (67.5%) occur after the traditional 6 week time frame. While the true etiology is unknown, increased vitreous mobility with saccadic movements may play a role in delayed breaks. The authors list a variety of limitations, including inability to record refractive error, assess for a Shafer’s sign, assumptions about loss to follow-up, ambiguity of CPT codes, and variability in practice patterns.
Overall, this is a strong article that provides new insight into how we approach follow up for acute PVD patients. The “6 week and done” criteria may no longer apply and these patients may need one or two more additional visits.