A double horseshoe tear in an area of lattice from a PVD. The tear was not present at the first visit but instead found at the one-month follow-up. Photo: Anna Bedwell, OD. Click image to enlarge.
After a patient’s initial diagnosis of posterior vitreous detachment (PVD), reevaluation in the short-term is critical to identify and address any visual consequences, but guidelines regarding the timing of the second exam are unclear. In a recent analysis of data from the IRIS registry, researchers aimed to determine the timing to delayed retinal pathology in eyes presenting with acute PVD. They found that follow-up examination after initial PVD within six weeks or less is necessary to diagnose retinal complications.
Patients coded to have a PVD from 2013 to 2018 along with CPT coding of extended ophthalmoscopy were included. Ocular baseline characteristics included visual acuity, lens status, presence or absence of vitreous hemorrhage, myopia, lattice degeneration and subspecialty training of the treating physician.
A total of 434,046 eyes met inclusion/exclusion criteria, and 10,518 eyes (2.42%) presented with a delayed retinal break or detachment after initial PVD. The median time to retinal break and detachment after initial PVD was 42 days and 51 days, respectively.
In PVD eyes with at least one ocular risk factor among vitreous hemorrhage, lattice degeneration, fellow eye retinal break or detachment, and myopia, the median time to retinal break or detachment was shortened to 34 and 39 days, respectively. In eyes documented only with vitreous hemorrhage, the median time to retinal break was just 14 days.
“We did note a statistically significant difference in timing to delayed retinal detachment in non-retina specialists (median = 57 days) vs. retina specialists (median = 46 days),” the authors pointed out in their paper for Ophthalmology Retina. “No significant difference, however, was found in timing of delayed retinal break in this subset (median = 38 days). Differences in timing to delayed pathology may be a result of variations in counseling regarding symptoms and return precautions between specialists vs. generalists, as well as established practice follow-up patterns.”
If PVD is not managed appropriately, potentially devastating consequences can occur. Thus, the timing of a follow-up exam after the initial visit is crucial to detect delayed retinal pathology. The authors recommend at least one repeat exam within the first six weeks in all patients, and sooner and more frequent exams within one month for eyes with higher risk features.
Anna Bedwell, OD, of Indiana University School of Optometry—an active member of the Optometric Retina Society and editor of its newsletter—noted that she is in agreement with the findings of this study and highlighted two important components for monitoring acute PVD that the study emphasizes: follow-up timing and risk assessment.
“In the past few years, I’ve adjusted my follow-up timeline based on risk factors,” she explained. “I follow-up on all acute PVDs with a four- to six-week follow-up. For those with risk factors, particularly lattice degeneration, high myopia, history of retinal break in the fellow eye or vitreous hemorrhage at presentation, I recommend a second follow-up another four to six weeks later. This study reinforces that idea. Even though the incidence of a delayed retinal break is low, a missed retinal break can have significant visual consequences.”
Vangipuram G, Li C, Liu L, et al. Timing of delayed retinal pathology in patients presenting with acute posterior vitreous detachment in the IRIS Registry. Ophthalmol Retina. April 10, 2023. [Epub ahead of print].