Guideline:
Posterior vitreous detachment, retinal breaks and lattice degeneration
Bibliographic Source(s)
- American Academy of Ophthalmology Retina Panel Preferred Practice Patterns Committee. Posterior vitreous detachment retinal breaks and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p. [55 references]
Guideline Status
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Health Plans
Physicians
Guideline Objective(s)
To prevent visual loss and functional impairment related to retinal detachment and to maintain quality of life by addressing the following goals:
- Identify patients at risk for rhegmatogenous retinal detachment (RRD)
- Examine patients with symptoms of acute posterior vitreous detachment (PVD) to detect and treat significant retinal breaks
- Manage patients at high risk for developing retinal detachment
- Educate high-risk patients about symptoms of posterior vitreous detachment retinal breaks and retinal detachments and about the need for periodic follow-up
Target Population
- Individuals with symptoms or signs suggestive of posterior vitreous detachment (PVD) retinal breaks vitreous hemorrhage or retinal detachment
- Asymptomatic individuals with an increased risk for retinal detachment
Interventions and Practices Considered
Diagnosis/Evaluation
- Comprehensive adult eye examination and history
- Examination of the vitreous for detachment pigmented cells hemorrhage and condensation
- Peripheral fundus examination with scleral depression
- B-scan ultrasonography
Treatment
- Cryotherapy
- Laser photocoagulation
Management
- Follow-up evaluations
- Patient education
Major Outcomes Considered
- Identification of patients at risk
- Prevention of visual loss and functional impairment
- Maintenance of quality of life
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
A detailed MEDLINE literature search for articles in the English language was conducted on the subject of posterior vitreous detachment retinal breaks and lattice degeneration for the years 1997 to 2002.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Ratings of Strength of Evidence
- Level I includes evidence obtained from at least one properly conducted well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
- Level II includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies preferably from more than one center
- Multiple-time series with or without the intervention
- Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization
- Expert opinion (e.g. Preferred Practice Pattern panel consensus)
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The results of a literature search on the subject of posterior vitreous detachment retinal breaks and lattice degeneration were reviewed by the Retina Panel and used to prepare the recommendations which they rated in two ways. The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient’s care in a meaningful way. The panel also rated each recommendation on the strength of the evidence in the available literature to support the recommendation made.
Rating Scheme for the Strength of the Recommendations
Ratings of Importance to Care Process
Level A most important
Level B moderately important
Level C relevant but not critical
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
These guidelines were reviewed by Council and approved by the Board of Trustees of the American Academy of Ophthalmology (September 2003). All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly.
Major Recommendations
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The ratings of importance to the care process (A B C) and the ratings for strength of evidence (I II III) are defined at the end of the "Major Recommendations" field.
Diagnosis
The initial evaluation of a patient with risk factors or symptoms includes all features of the comprehensive adult medical eye evaluation with particular attention to those aspects relevant to posterior vitreous detachment (PVD) retinal breaks and lattice degeneration.
History
- Symptoms of PVD [A:I]
- Family history [A:II]
- Prior eye trauma including surgery [A:II]
- Myopia [A:II]
- History of cataract surgery [A:II]
Examination
- Examination of the vitreous [A:III] for detachment pigmented cells hemorrhage and condensation
- Peripheral fundus examination with scleral depression [A:III]
There are no symptoms that can reliably distinguish PVD with an associated retinal break from PVD without an associated retinal break; therefore a peripheral retinal examination is required. [A:III] The preferred method of evaluating peripheral vitreoretinal pathology is with indirect ophthalmoscopy combined with scleral depression.
Diagnostic Tests
If it is impossible to evaluate the peripheral retina B-scan ultrasonography should be performed to search for retinal tears or detachment and for other causes of vitreous hemorrhage. [A:II]
Treatment
The table below summarizes recommendations for management.
| Type of Lesion | Treatment |
|---|---|
| Acute symptomatic horseshoe tears | Treat promptly [A:II] |
| Acute symptomatic operculated tears | Treatment may not be necessary [A:III] |
| Traumatic retinal breaks | Usually treated [A:III] |
| Asymptomatic horseshoe tears | Usually can be followed without treatment [A:III] |
| Asymptomatic operculated tears | Treatment is rarely recommended [A:III] |
| Asymptomatic atrophic round holes | Treatment is rarely recommended [A:III] |
| Asymptomatic lattice degeneration without holes | Not treated unless PVD causes a horseshoe tear [A:III] |
| Asymptomatic lattice degeneration with holes | Usually does not require treatment [A:III] |
| Asymptomatic dialyses | No consensus on treatment and insufficient evidence to guide management |
| Fellow eyes with atrophic holes lattice degeneration or asymptomatic horseshoe tears | No consensus on treatment and insufficient evidence to guide management |
Treatment of peripheral horseshoe tears should be extended well into the vitreous base even to the ora serrata. [A:II] The surgeon should inform the patient of the relative risks benefits and alternatives to surgery. [A:III] The surgeon has the responsibility for formulating a postoperative care plan and should inform the patient of these arrangements. [A:III]
Follow-up
The guidelines in the table below are for routine follow-up in the absence of additional symptoms. Patients with no positive findings at the initial examination should be seen at the intervals recommended in the Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern (PPP). [A:III] All patients with risk factors should be advised to contact their ophthalmologist promptly if new symptoms such as flashes floaters peripheral visual field loss or decreased visual acuity develop. [A:II]
| Type of Lesion | Follow-up Interval |
|---|---|
| Symptomatic PVD with no retinal break | Depending on symptoms risk factors and amount of vitreous traction patients should be followed in 1 to 6 weeks |
| Acute symptomatic horseshoe tears | 1 to 2 weeks after treatment then 4 to 6 weeks then 3 to 6 months then annually |
| Acute symptomatic operculated tears | 2 to 4 weeks then 1 to 3 months then 6 to 12 months then annually |
| Traumatic retinal breaks | 7 to 14 days after treatment then 4 to 6 weeks then 3 to 6 months then annually |
| Asymptomatic horseshoe tears | 1 to 4 weeks then 2 to 4 months then 6 to 12 months then annually |
| Asymptomatic operculated tears | 2 to 4 weeks then 1 to 3 months then 6 to 12 months then annually |
| Asymptomatic atrophic round holes | Annually |
| Asymptomatic lattice degeneration without holes | Annually |
| Asymptomatic lattice degeneration with holes | Annually |
| Asymptomatic dialyses | If untreated 1 month then 3 months then 6 months then every 6 months
If treated 1 to 2 weeks after treatment then 4 to 6 weeks then 3 to 6 months then annually |
| Fellow eyes with atrophic holes lattice degeneration or asymptomatic horseshoe tears | Every 6 to 12 months |
History
- Visual symptoms [A:I]
- Interval history of eye trauma including intraocular surgery [A:I]
Examination
- Measurement of visual acuity [A:III]
- Evaluation of the status of the vitreous with attention to the presence of pigment or syneresis [A:II]
- Examination of the peripheral fundus with scleral depression [A:II]
- B-scan ultrasonography if the media is opaque [A:II]
Provider
It is essential that ancillary clinical personnel be familiar with the symptoms of PVD and retinal detachment so that symptomatic patients can gain prompt access to the health care system. [A:II]
Patients with symptoms of possible or suspected PVD or retinal detachment and related disorders should be examined promptly by an ophthalmologist skilled in binocular indirect ophthalmoscopy and supplementary techniques. [A:III] Patients with retinal breaks or detachments should be treated by an ophthalmologist with experience in the management of these conditions. [A:III]
Counseling/Referral
Patients at high risk of developing retinal detachment should also be educated about the symptoms of PVD and retinal detachment as well as about the value of periodic follow-up examinations.[A:II]
All patients at increased risk of retinal detachment should be instructed to notify their ophthalmologist promptly if they have a significant change in symptoms such as a significant increase in floaters loss of visual field or decrease in visual acuity. [A:III]
Definitions:
Ratings of Importance to Care Process
Level A most important
Level B moderately important
Level C relevant but not critical
Ratings of Strength of Evidence
- Level I includes evidence obtained from at least one properly conducted well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
- Level II includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies preferably from more than one center
- Multiple-time series with or without the intervention
- Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization
- Expert opinion (e.g. Preferred Practice Pattern panel consensus)
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations.")
Potential Benefits
When untreated patients with symptomatic rhegmatogenous retinal detachment will progressively lose vision in the involved eye. There is a substantial economic benefit to society of preventing retinal detachments or limiting their extent and therefore maintaining the ability of its citizens to read work drive and care for themselves.
Potential Harms
- The treatment of peripheral retinal abnormalities can be performed using a variety of anesthesia techniques that include general anesthesia and local (regional) anesthesia (e.g. retrobulbar peribulbar periocular sub-Tenon's injection or topical). Sedation may be used with local anesthesia to minimize pain anxiety and discomfort. Complications of periocular injection of anesthesia include hemorrhage and globe perforation. Retrobulbar anesthesia while not required has complications that include strabismus globe perforation retrobulbar hemorrhage and macular infarction.
- Epiretinal membrane proliferation (macular pucker) has been observed after treatment but the association of treatment with epiretinal membrane formation is uncertain. In one long-term follow-up study the percentage of eyes developing macular pucker after treatment of retinal breaks was no greater than the percentage of eyes observed to have macular pucker before treatment. In any case the method of creating a chorioretinal adhesion appears to be unrelated to the incidence of postoperative macular pucker. Extensive cryotherapy can be harmful.
Qualifying Statements
- Preferred Practice Patterns provide guidance for the pattern of practice not for the care of a particular individual. While they should generally meet the needs of most patients they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients’ needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.
- Preferred Practice Patterns are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind from negligence or otherwise for any and all claims that may arise out of the use of any recommendations or other information contained herein.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Patient Resources
Personal Digital Assistant (PDA) Downloads
Quick Reference Guides/Physician Guides
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Academy of Ophthalmology Retina Panel Preferred Practice Patterns Committee. Posterior vitreous detachment retinal breaks and lattice degeneration. San Francisco (CA): American Academy of Ophthalmology (AAO); 2003. 17 p. [55 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Academy of Ophthalmology
Guideline Committee
Preferred Practice Patterns Committee; Retina Panel
Composition of Group that Authored the Guideline
Retina Panel Members: Emily Y. Chew MD (Chair); William E. Benson MD; H. Culver Boldt MD; Tom S. Chang MD; Louis A. Lobes Jr. MD; Joan W. Miller MD; Timothy G. Murray MD; Marco A. Zarbin MD PhD; Leslie Hyman PhD (Methodologist)
Preferred Practice Patterns Committee Members: Joseph Caprioli MD (Chair); J. Bronwyn Bateman MD; Emily Y. Chew MD; Douglas E. Gaasterland MD; Sid Mandelbaum MD; Samuel Masket MD; Alice Y. Matoba MD; Donald S. Fong MD MPH
Financial Disclosures/Conflicts of Interest
No proprietary interests were disclosed by members of the Preferred Practice Patterns Retina Panel for the past 3 years up to and including June 2003 for product investment or consulting services regarding the equipment process or products presented or competing equipment process or products presented.
Guideline Status
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.
Guideline Availability
Electronic copies of the updated guideline: Available from the American Academy of Ophthalmology (AAO) Web site.
Print copies: Available from American Academy of Ophthalmology P.O. Box 7424 San Francisco CA 94120-7424; telephone (415) 561-8540.
Availability of Companion Documents
The following is available:
- Summary benchmarks for preferred practice patterns. San Francisco (CA): American Academy of Ophthalmology; 2006 Nov. 21 p.
Available in Portable Document Format (PDF) from the American Academy of Ophthalmology (AAO) Web site.
Print copies: Available from American Academy of Ophthalmology P.O. Box 7424 San Francisco CA 94120-7424; telephone (415) 561-8540.
Patient Resources
The following patient education brochure is available:
- Detached and torn retina (1998)
Print copies: Available from the American Academy of Ophthalmology (AAO) P.O. Box 7424 San Francisco CA 94120-7424; Phone: (415) 561-8540.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC STATUS
This summary was completed by ECRI on February 20 1999. The information was verified by the guideline developer on April 23 1999. This summary was updated again on April 30 2004. The information was verified by the guideline developer May 20 2004.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. Information about the content ordering and copyright permissions can be obtained by calling the American Academy of Ophthalmology at (415) 561-8500.
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Tools
No Quick Reference tools have been developed.
Details
FDA Warning
- Category:
- Conditions:
- Precursors to rhegmatogenous retinal detachment and the following related entities:Posterior vitreous detachmentRetinal break without detachmentMultiple retinal breaks without detachmentHorseshoe tear without detachmentOperculated break without detachmentRound hole without detachmentRetinal dialysisLattice degeneration of the retina
- Published:
- 1998 Sep (revised 2003)
- Endorsed by:
- American Academy of Ophthalmology