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Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern®

Published:September 25, 2019DOI:https://doi.org/10.1016/j.ophtha.2019.09.027
      AMERICAN ACADEMY OF OPHTHALMOLOGY®
      Protecting Sight. Empowering Lives.®
      © 2019 by the American Academy of Ophthalmology
      Published by Elsevier Inc.
      ISSN 0161–6420/19
      Secretary for Quality of Care
      Timothy W. Olsen, MD
      Academy Staff
      Ali Al-Rajhi, PhD, MPH
      Andre Ambrus, MLIS
      Meghan Daly
      Flora C. Lum, MD
      Medical Editor: Susan Garratt
      Approved by: Board of Trustees
      September 7, 2019
      © 2019 American Academy of Ophthalmology®
      All rights reserved
      AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners.
      Preferred Practice Pattern® guidelines are developed by the Academy's H. Dunbar Hoskins Jr., MD Center for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication.
      Correspondence:
      Ali A. Al-Rajhi, PhD, MPH American Academy of Ophthalmology, P. O. Box 7424, San Francisco, CA 94120–7424. E-mail: [email protected].

      RETINA/VITREOUS PREFERRED PRACTICE PATTERN® DEVELOPMENT PROCESS AND PARTICIPANTS

      The Retina/Vitreous Preferred Practice Pattern® Panel members wrote the Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern® (PPP) guidelines. The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document.
      Retina/Vitreous Preferred Practice Pattern Panel 2018–2019
      Ron A. Adelman, MD, MPH, MBA, FACS
      Jennifer I. Lim, MD
      Steven T. Bailey, MD, Retina Society Representative
      Amani Fawzi, MD, Macula Society Representative
      Gurunadh A. Vemulakonda, MD, American Society of Retina Specialists Representative
      Gui-shang Ying, MD, PhD, Methodologist
      Christina J. Flaxel, MD, Chair
      We thank our partners, the Cochrane Eyes and Vision US Satellite ([email protected]), for identifying reliable systematic reviews that we cite and discuss in support of the PPP recommendations.
      The Preferred Practice Patterns Committee members reviewed and discussed the document during a meeting in June 2019. The document was edited in response to the discussion and comments.
      Preferred Practice Patterns Committee 2019
      Robert S. Feder, MD, Chair
      Roy S. Chuck, MD, PhD
      Steven P. Dunn, MD
      Christina J. Flaxel, MD
      Steven J. Gedde, MD
      Francis S. Mah, MD
      Randall J. Olson, MD
      David K. Wallace, MD, MPH
      David C. Musch, PhD, MPH, Methodologist
      The Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration PPP was then sent for review to additional internal and external groups and individuals in July 2019. All those returning comments were required to provide disclosure of relevant relationships with industry to have their comments considered (indicated with an asterisk below). Members of the Retina/Vitreous Preferred Practice Pattern Panel reviewed and discussed these comments and determined revisions to the document.

      FINANCIAL DISCLOSURES

      In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx), relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at http://one.aao.org/CE/PracticeGuidelines/PPP.aspx). A majority (88%) of the members of the Retina/Vitreous Preferred Practice Pattern Panel 2018–2019 had no financial relationship to disclose.
      Retina/Vitreous Preferred Practice Pattern Panel 2018–2019
      Christina J. Flaxel, MD: No financial relationships to disclose
      Ron A. Adelman, MD, MPH, MBA, FACS: No financial relationships to disclose
      Steven T. Bailey, MD: No financial relationships to disclose
      Amani Fawzi, MD: No financial relationships to disclose
      Jennifer I. Lim, MD: Alcon Laboratories—Consultant/Advisor
      Gurunadh A. Vemulakonda, MD: No financial relationships to disclose
      Gui-shang Ying, MD, PhD: No financial relationships to disclose
      Preferred Practice Patterns Committee 2019
      Robert S. Feder, MD, Chair: No financial relationships to disclose
      Roy S. Chuck, MD, PhD: No financial relationships to disclose
      Steven P. Dunn, MD: No financial relationships to disclose
      Christina J. Flaxel, MD: No financial relationships to disclose
      Steven J. Gedde, MD: No financial relationships to disclose
      Francis S. Mah, MD: Alcon Laboratories—Consultant/Advisor
      Randall J. Olson, MD: No financial relationships to disclose
      David K. Wallace, MD, MPH: No financial relationships to disclose
      David C. Musch, PhD, MPH, Methodologist: IRIDEX, Notal Vision—Consultant/Advisor
      Secretary for Quality of Care
      Timothy W. Olsen, MD: No financial relationships to disclose
      Academy Staff
      Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose
      Andre Ambrus, MLIS: No financial relationships to disclose
      Meghan Daly: No financial relationships to disclose
      Flora C. Lum, MD: No financial relationships to disclose
      The disclosures of relevant relationships to industry of other reviewers of the document from January to October 2019 are available online at www.aao.org/ppp.

      TABLE OF CONTENTS

      • OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P229
      • METHODS AND KEY TO RATINGS P230
      • HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P231
      • INTRODUCTION P232
      • Disease Definition P232
      • Patient Population P232
      • Clinical Objectives P232
      • BACKGROUND P233
      • Posterior Vitreous Detachment P233
      • Evolution of Retinal Breaks and Lattice Degeneration P234
        • Asymptomatic Retinal Breaks P234
        • Symptomatic Retinal Breaks P234
        • Lattice Degeneration P235
      • Incidence of Rhegmatogenous Retinal Detachment P235
      • Risk Factors for Rhegmatogenous Retinal Detachment P235
        • Myopia P236
        • Lattice Degeneration P236
        • Cataract Surgery P236
        • Trauma P236
        • Rhegmatogenous Retinal Detachment in the Fellow Eye P236
        • Other Risk Factors P237
      • CARE PROCESS P237
      • Patient Outcome Criteria P237
      • Diagnosis P237
        • History P237
        • Ophthalmic Examination P238
        • Diagnostic Tests P238
      • Management P239
        • Prevention P239
        • Surgical Management P239
        • Complications of Treatment P242
        • Follow-up Evaluation P242
      • Counseling and Referral P244
      • Socioeconomic Considerations P245
      • APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA P246
      • APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES P248
      • GLOSSARY P249
      • LITERATURE SEARCHES FOR THIS PPP P251
      • RELATED ACADEMY MATERIALS P253
      • REFERENCES P254
      Background:
      Posterior vitreous detachment (PVD) is a separation of the posterior vitreous cortex from the internal limiting membrane of the retina. Retinal breaks are defined as full-thickness defects in the retina. Lattice degeneration is a peripheral vitreoretinal condition characterized by retinal thinning, overlying vitreous liquefaction, and firm vitreoretinal adhesions at the margins of thinning.
      A PVD typically occurs between the ages of 45 and 65 in the general population with earlier onset in men; however, the posterior vitreous may detach earlier in trauma and myopia. PVD may lead to vitreomacular traction (VMT), potentially leading to mechanical distortion of the macula or to retinal tears and potentially retinal detachment. The recommendations of this Preferred Practice Pattern (PPP) are based on Cochrane-identified reliable systematic reviews.
      Rationale for treatment:
      The patient outcome criteria and rational for treatment for PVD and RRD include the prevention of visual loss and functional impairment and maintenance of quality of life. If patients are familiar with the symptoms of retinal tears or detachment, they are recommended to report promptly, thus improving the opportunity for successful treatment.
      Care Process:
      The care process for a patient starts with all the elements of a comprehensive adult eye evaluation with attention to risk factors relevant for a PVD, retinal breaks, and lattice degeneration. Additionally, a PVD should be evaluated for vitreous pigmented cells and includes a thorough peripheral examination looking for retinal tears or holes.
      Management recommendations are detailed in this PPP, which includes surgical management, complications of treatment and follow-up evaluation. At the time of this published PPP, there are no effective methods of preventing the factors that lead to PVD. All patients at increased risk of retinal detachment should be instructed to notify their ophthalmologist as soon as possible if they have a substantial change in symptoms (e.g., increased floaters, loss of visual field, or decrease in visual acuity). Patients who undergo refractive surgery to reduce myopia should be informed that they remain at risk of RRD despite reduction of their refractive error.

      OBJECTIVES OF PREFERRED PRACTICE PATTERN® GUIDELINES

      As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care.
      The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence.
      These documents 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 PPPs 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 Pattern® guidelines 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.
      References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved U.S. Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.
      Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration.
      All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the approved by date unless superseded by a revision. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies. The Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-patterns) to comply with the Code.
      Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems (ICD) codes for the disease entities that this PPP covers. The intended users of the Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration PPP are ophthalmologists.

      METHODS AND KEY TO RATINGS

      Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network
      • Scottish Intercollegiate Guidelines Network (SIGN)
      SIGN 50: a guideline developer's handbook.
      (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation
      • Guyatt GH
      • Oxman AD
      • Vist GE
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American College of Physicians.
      • GRADE Working Group
      Organizations that have endorsed or that are using GRADE.
      • All studies used to form a recommendation for care are graded for strength of evidence individually, and that grade is listed with the study citation.
      • Tabled 1
        I++High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias
        I+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
        I-Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
        II++
        • High-quality systematic reviews of case-control or cohort studies
        • High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
        II+Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
        II-Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
        IIINonanalytic studies (e.g., case reports, case series)
      • Tabled 1
        Good qualityFurther research is very unlikely to change our confidence in the estimate of effect
        Moderate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
        Insufficient quality
        • Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
        • Any estimate of effect is very uncertain
      • Tabled 1
        Strong recommendationUsed when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do not
        Discretionary recommendationUsed when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced
      • The Highlighted Findings and Recommendations for Care section lists points determined by the PPP Panel to be of particular importance to vision and quality of life outcomes.
      • All recommendations for care in this PPP were rated using the system described above. Ratings are embedded throughout the PPP main text in italics.
      • Literature searches to update the PPP were undertaken in April 2018 and June 2019 in PubMed and the Cochrane Library. Complete details of the literature searches are available online at www.aao.org/ppp.

      HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE

      Acute horseshoe retinal tears and traumatic breaks usually require treatment.
      Asymptomatic atrophic or operculated retinal breaks rarely need treatment. More generally, an eye that has atrophic round holes within lattice lesions, has minimal subretinal fluid without progression, or lacks evidence of posterior vitreous detachment (PVD) does not require treatment.
      An early diagnosis of a retinal detachment is important because the rate of successful retinal reattachment is higher and the visual results are better when repaired early, especially before the rhegmatogenous retinal detachment (RRD) involves the macula.
      Lattice degeneration is present in 6% to 8% of the population and increases the risk of retinal detachment.
      Patients presenting with an acute PVD and no retinal breaks have a small chance (∼2%) of developing retinal breaks in the weeks that follow. Selected patients, particularly those with any degree of vitreous pigment, vitreous or retinal hemorrhage, or visible vitreoretinal traction, should be asked to return for a second examination promptly if they have new symptoms or within 6 weeks following the onset of PVD symptoms.
      Between 5% and 14% of patients found to have an initial retinal break will develop additional breaks during long-term follow-up. Cataract surgery is a risk factor for new retinal breaks.
      Treatment of peripheral horseshoe tears should extend to the ora serrata if the tear cannot be surrounded using laser or cryotherapy. The most common cause of failure is inadequate treatment, particularly along the anterior border (where visualization is more difficult).

      INTRODUCTION

       DISEASE DEFINITION

      Posterior vitreous detachment (PVD) is a separation of the posterior vitreous cortex from the internal limiting membrane of the retina.
      • Johnson MW
      Posterior vitreous detachment: evolution and role in macular disease.
      (See Glossary.) This separation may be complete or partial. Vitreous traction at sites of significant vitreoretinal adhesion is responsible for most retinal breaks that lead to retinal detachment. Retinal breaks are defined as full-thickness defects in the retina. Lattice degeneration is a vitreoretinal degenerative process that predisposes to retinal tears and detachment. It is a peripheral vitreoretinal condition characterized by retinal thinning, overlying vitreous liquefaction, and firm vitreoretinal adhesions at the margins of thinning. Most lattice degenerations are ovoid, with the long axes of lattice running parallel to the ora serrata. Perivascular lattice occurs radially and is typically found adjacent to the retinal vessels. Radial lattice is associated with a much higher risk of retinal detachment than circumferential lattice. Round holes occur frequently within areas of lattice degeneration. Vitreomacular traction (VMT) may develop when the vitreous partially separates from the macula, potentially leading to mechanical distortion of the macula that may correspond to visual symptoms.
      • Johnson MW
      Posterior vitreous detachment: evolution and role in macular disease.
      (See Glossary.)

       PATIENT POPULATION

      Individuals may present with symptoms or signs suggestive of PVD, retinal breaks, vitreous hemorrhage, retinal detachment, or VMT. A PVD typically occurs between the ages of 45 and 65 in the general population; however, the posterior vitreous may detach earlier in trauma and myopia.
      • Snead MP
      • Snead DR
      • James S
      • Richards AJ
      Clinicopathological changes at the vitreoretinal junction: posterior vitreous detachment.
      Other individuals may not be symptomatic and, based on clinical examination findings, may have an increased risk of retinal detachment as the vitreous separates.

       CLINICAL OBJECTIVES

      • Identify patients at risk of developing a rhegmatogenous retinal detachment (RRD)
      • Examine symptomatic patients who have an acute PVD to detect and treat associated retinal breaks or tears
      • Recognize the evolution of retinal breaks and lattice degeneration
      • Manage patients at high risk of developing retinal detachment
      • Educate high-risk patients about symptoms of PVD, retinal breaks, and retinal detachments as well as the need for periodic follow-up
      • Discuss treatment options available for VMT (See Idiopathic Epiretinal Membrane and Vitreomacular Traction PPP)
        • American Academy of Ophthalmology Retinal/Vitreous Panel
        Preferred Practice Pattern Guidelines. Idiopathic Epiretinal Membrane and Vitreomacular Traction.
      • Recognize the potential side effects of treatment of VMT (See Idiopathic Epiretinal Membrane and Vitreomacular Traction PPP)
        • American Academy of Ophthalmology Retinal/Vitreous Panel
        Preferred Practice Pattern Guidelines. Idiopathic Epiretinal Membrane and Vitreomacular Traction.

      BACKGROUND

       POSTERIOR VITREOUS DETACHMENT

      Population-based studies that evaluate incidence and prevalence of PVD are difficult to conduct owing to the lack of definite clinical signs and unreliable clinical tests. A PVD typically occurs between the ages of 45 and 65 in the general population with earlier onset in men than women; however, the posterior vitreous may detach earlier in trauma and myopia, or be precipitated by ophthalmic surgical procedures.
      • Snead MP
      • Snead DR
      • James S
      • Richards AJ
      Clinicopathological changes at the vitreoretinal junction: posterior vitreous detachment.
      • Coppe AM
      • Lapucci G
      Posterior vitreous detachment and retinal detachment following cataract extraction.
      • Gavrilov JC
      • Gaujoux T
      • Sellam M
      • Laroche L
      • Borderie V
      Occurrence of posterior vitreous detachment after femtosecond laser in situ keratomileusis: Ultrasound evaluation.
      • Osman MH
      • Khalil NM
      • El-Agha MS
      Incidence of Posterior Vitreous Detachment After Femtosecond LASIK Compared With Microkeratome LASIK.
      Posterior vitreous detachment leads to vitreous traction at the vitreous base and in areas of lattice degeneration, and thereby, secondarily, is thought to cause most symptomatic retinal breaks that may lead to an RRD. The symptoms of a PVD include light flashes (photopsias) and floaters (myodesopias), and patients with such symptoms are at a higher risk for retinal detachment.
      • Boldrey EE
      Risk of retinal tears in patients with vitreous floaters.
      • Brod RD
      • Lightman DA
      • Packer AJ
      • Saras HP
      Correlation between vitreous pigment granules and retinal breaks in eyes with acute posterior vitreous detachment.
      • Tasman WS
      Posterior vitreous detachment and peripheral retinal breaks.
      • Dayan MR
      • Jayamanne DG
      • Andrews RM
      • Griffiths PG
      Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
      • Byer NE
      Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.
      The stages of a PVD are described in Table l.
      • Johnson MW
      Posterior vitreous detachment: evolution and role in macular disease.
      Patients typically report the light flashes characteristic of a PVD as being most noticeable in the dark. Such photopsias are likely the result of vitreous traction on the retina as the vitreous separates from the posterior retina toward the vitreous base. The floaters may be due to blood from a torn or avulsed retinal vessel, condensations of vitreous collagen, or the epipapillary glial tissue (Weiss ring) that is torn from the optic nerve head and area adjacent to the optic nerve head. Between 8% and 22% of patients with acute PVD symptoms have a retinal tear at the time of the initial examination.
      • Tani P
      • Robertson DM
      • Langworthy A
      Rhegmatogenous retinal detachment without macular involvement treated with scleral buckling.
      • Coffee RE
      • Westfall AC
      • Davis GH
      • Mieler WF
      • Holz ER
      Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.
      • Benson WE
      • Grand MG
      • Okun E
      Aphakic retinal detachment. Management of the fellow eye.
      • Scott IU
      • Smiddy WE
      • Merikansky A
      • Feuer W
      Vitreoretinal surgery outcomes. Impact on bilateral visual function.
      There is a direct correlation between the amount of vitreous hemorrhage and the likelihood of a retinal tear.
      • Lincoff H
      • Stopa M
      • Kreissig I
      Ambulatory binocular occlusion.
      Patients with an acute PVD who have no reported retinal breaks on presentation have a 2% to 5% chance of experiencing a detected (missed or new) break in the weeks that follow.
      • Dayan MR
      • Jayamanne DG
      • Andrews RM
      • Griffiths PG
      Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
      • Coffee RE
      • Westfall AC
      • Davis GH
      • Mieler WF
      • Holz ER
      Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.
      • van Overdam KA
      • Bettink-Remeijer MW
      • Mulder PG
      • van Meurs JC
      Symptoms predictive for the later development of retinal breaks.
      TABLE 1Stages
      The proposed staging levels may not imply a linear, staged progression of a posterior vitreous detachment.
      of Posterior Vitreous Detachment
      Stage 1Perifoveal separation with adhesion of vitreous to the fovea
      Stage 2Complete separation of vitreous from the macula
      Stage 3Extensive vitreous separation with adhesion of vitreous to the disc
      Stage 4Complete posterior vitreous detachment
      NOTE: These stages can be studied with optical coherence tomography.
      • Johnson MW
      Posterior vitreous detachment: evolution and role in macular disease.
      • Uchino E
      • Uemura A
      • Ohba N
      Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography.
      * The proposed staging levels may not imply a linear, staged progression of a posterior vitreous detachment.
      Approximately 80% of patients who presented without detected breaks, and then had breaks occur subsequently, had either pigmented cells or hemorrhage in the vitreous or retina at the initial evaluation, or new symptoms that prompted a return visit to the ophthalmologist.
      • Coffee RE
      • Westfall AC
      • Davis GH
      • Mieler WF
      • Holz ER
      Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.
      A spontaneous vitreous hemorrhage can be the presenting sign of PVD or may occur during the evolution of the PVD. Two-thirds of patients who present with associated vitreous hemorrhage were found to have at least one break. In this subgroup, one-third had more than one break and approximately 88% of the breaks occurred in the superior quadrants.
      • Sarrafizadeh R
      • Hassan TS
      • Ruby AJ
      • et al.
      Incidence of retinal detachment and visual outcome in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage.

       EVOLUTION OF RETINAL BREAKS AND LATTICE DEGENERATION

      Precursors to RRDs are PVD, asymptomatic retinal breaks, symptomatic retinal breaks, lattice degeneration, and cystic and zonular traction retinal tufts. (See Glossary.) Because spontaneous retinal reattachment is rare, nearly all patients with a symptomatic clinical RRD will progressively lose vision unless the detachment is repaired. Currently, more than 95% of uncomplicated RRDs can be successfully repaired, although more than one procedure may be required.
      • Adelman RA
      • Parnes AJ
      • Ducournau D
      European Vitreo-Retinal Society (EVRS) Retinal Detachment Study Group
      Strategy for the management of uncomplicated retinal detachments: the European Vitreo-Retinal Society Retinal Detachment Study report 1.
      The prophylactic treatment of high-risk breaks usually prevents RRD. An early diagnosis of an RRD is also important because the rate of successful reattachment is higher and the visual results are better when repaired early and especially before the RRD involves the macula.
      • Tani P
      • Robertson DM
      • Langworthy A
      Rhegmatogenous retinal detachment without macular involvement treated with scleral buckling.
      • Benson WE
      • Grand MG
      • Okun E
      Aphakic retinal detachment. Management of the fellow eye.
      The goal of RRD treatment is to allow patients to maintain their abilities to read, work, drive, care for themselves, and maintain their quality of life.
      • Scott IU
      • Smiddy WE
      • Merikansky A
      • Feuer W
      Vitreoretinal surgery outcomes. Impact on bilateral visual function.

       Asymptomatic Retinal Breaks

      Asymptomatic operculated holes and atrophic round holes rarely lead to retinal detachment. Byer followed 46 asymptomatic eyes with operculated retinal breaks over an average of 11 years.
      • Byer NE
      What happens to untreated asymptomatic retinal breaks, and are they affected by posterior vitreous detachment?.
      Davis followed 28 eyes for up to 5 years in subjects where 80% of the fellow eyes had a retinal detachment.
      • Davis MD
      Natural history of retinal breaks without detachment.
      • Wilkinson CP
      Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment.
      All combined, none of the 74 eyes from these studies progressed to retinal detachment during the follow-up period.
      Eyes with signs and symptoms of acute PVD may have atrophic retinal breaks with clinical features, suggesting that they are unrelated to the acute vitreoretinal traction from the PVD. Such breaks are considered to be pre-existing rather than symptomatic. Treatment may be considered for these breaks in certain situations, although the literature provides little guidance.
      • Wilkinson CP
      Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment.
      Randomized clinical trials are not available; therefore, there is limited evidence to support prophylactic therapy.
      • Wilkinson CP
      Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment.
      Approximately 5% of eyes with asymptomatic horseshoe tears progress to retinal detachment.
      • Byer NE
      What happens to untreated asymptomatic retinal breaks, and are they affected by posterior vitreous detachment?.
      • Byer NE
      Rethinking prophylactic therapy of retinal detachment.
      • Neumann E
      • Hyams S
      Conservative management of retinal breaks. A follow-up study of subsequent retinal detachment.
      Horseshoe tears discovered in asymptomatic fellow eyes are less likely than symptomatic horseshoe tears to lead to clinical retinal detachment (See Glossary). Patients should be encouraged to have follow-up. (See Follow-up Evaluation under Surgical Management.)

       Symptomatic Retinal Breaks

      A symptomatic retinal break is defined as a break caused by vitreoretinal traction in a patient with a new PVD associated with new-onset flashes and/or floaters. At least half of untreated symptomatic retinal breaks with persistent vitreoretinal traction (horseshoe or flap tears) will lead to a clinical retinal detachment unless treatment is applied.
      • Davis MD
      Natural history of retinal breaks without detachment.
      • Shea M
      • Davis MD
      • Kamel I
      Retinal breaks without detachment, treated and untreated.
      • Colyear Jr, BH
      • Pischel D
      Preventive treatment of retinal detachment by means of light coagulation.
      (See Glossary.) Treatment by prompt creation of a chorioretinal adhesion around these symptomatic tears reduces the risk of retinal detachment to less than 5%.
      • Shea M
      • Davis MD
      • Kamel I
      Retinal breaks without detachment, treated and untreated.
      • Colyear Jr, BH
      • Pischel D
      Preventive treatment of retinal detachment by means of light coagulation.
      • Robertson DM
      • Norton EW
      Long-term follow-up of treated retinal breaks.
      • Pollack A
      • Oliver M
      Argon laser photocoagulation of symptomatic flap tears and retinal breaks of fellow eyes.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.
      • Verdaguer J
      • Vaisman M
      Treatment of symptomatic retinal breaks.
      Traumatic dialyses and tears along the vitreous base are managed similarly to symptomatic tears. Symptomatic operculated breaks usually do not progress to a clinical retinal detachment unless the vitreous remains adherent to the retina surrounding the break.
      • Davis MD
      Natural history of retinal breaks without detachment.
      • Colyear Jr, BH
      • Pischel D
      Preventive treatment of retinal detachment by means of light coagulation.

       Lattice Degeneration

      Generally, atrophic round holes within lattice lesions that are accompanied by minimal subretinal fluid and no PVD do not require treatment. However, lattice degeneration is a risk factor for developing an RRD either from round holes without PVD or tractional-related holes associated with PVD. Small asymptomatic peripheral retinal detachments occurring secondary to retinal holes in areas of lattice degeneration are termed subclinical detachments (see Glossary).
      • Byer NE
      Subclinical retinal detachment resulting from asymptomatic retinal breaks: prognosis for progression and regression.
      • Davis MD
      The natural history of retinal breaks without detachment.
      Although these can enlarge and progress to clinical retinal detachments, they have been shown by observation alone to have a low likelihood of progression in most patients.
      • Byer NE
      Subclinical retinal detachment resulting from asymptomatic retinal breaks: prognosis for progression and regression.
      Prophylactic or interventional treatment should be considered when the detachments are documented to become symptomatic, increase in size, or show other signs of progression.
      • Byer NE
      Rethinking prophylactic therapy of retinal detachment.
      • Byer NE
      Long-term natural history of lattice degeneration of the retina.
      One analysis studied 423 eyes with lattice degeneration in 276 patients over a period averaging nearly 11 years.
      • Byer NE
      Long-term natural history of lattice degeneration of the retina.
      Of these, 150 eyes (35%) had atrophic holes in lattice, and 10 of these 150 eyes had subretinal fluid extending more than 1 disc diameter from the break (subclinical retinal detachment). Six other eyes developed new subclinical retinal detachments during follow-up. Clinical retinal detachments developed in 3 of the 423 eyes. Two were due to round retinal holes in lattice lesions of patients in their mid-20s and one was due to a symptomatic tractional tear. These data indicate that patients with lattice degeneration with or without round holes are at a very low risk for progression to clinical retinal detachment without a previous RRD in the fellow eye.
      More commonly, RRD occurs in eyes with lattice degeneration when a PVD induces a horseshoe tear. Such tears should be treated using either laser demarcation or cryotherapy.
      • Byer NE
      Rethinking prophylactic therapy of retinal detachment.
      • Byer NE
      Long-term natural history of lattice degeneration of the retina.

       INCIDENCE OF RHEGMATOGENOUS RETINAL DETACHMENT

      The annual incidence of RRD is approximately 10 to 18 per 100,000 persons.
      • Haimann MH
      • Burton TC
      • Brown CK
      Epidemiology of retinal detachment.
      • Wilkes SR
      • Beard CM
      • Kurland LT
      • Robertson DM
      • O'Fallon WM
      The incidence of retinal detachment in Rochester, Minnesota, 1970-1978.
      • Van de Put MA
      • Hooymans JM
      • Los LI
      The incidence of rhegmatogenous retinal detachment in The Netherlands.
      Of these, 20% to 40% have had cataract surgery and 10% have had ocular trauma.
      • Adelman RA
      • Parnes AJ
      • Ducournau D
      European Vitreo-Retinal Society (EVRS) Retinal Detachment Study Group
      Strategy for the management of uncomplicated retinal detachments: the European Vitreo-Retinal Society Retinal Detachment Study report 1.
      • Javitt JC
      • Tielsch JM
      • Canner JK
      • Kolb MM
      • Sommer A
      • Steinberg EP
      • Cataract Patient Outcomes Research Team
      National outcomes of cataract extraction: increased risk of retinal complications associated with Nd:YAG laser capsulotomy.
      • Tielsch JM
      • Legro MW
      • Cassard SD
      • et al.
      Risk factors for retinal detachment after cataract surgery: a population-based case-control study.
      In a recent study from the Netherlands, the annual RRD incidence was 18 per 100,000 people (95% CI, 11–19), with a peak incidence of 53 per 100,000 people (95% CI, 29–57) between 55 and 59 years of age. The rate of bilateral RRD was 1.7%. Prior cataract surgery was reported in 34% of RRD eyes.
      • Van de Put MA
      • Hooymans JM
      • Los LI
      The incidence of rhegmatogenous retinal detachment in The Netherlands.

       RISK FACTORS FOR RHEGMATOGENOUS RETINAL DETACHMENT

      Aside from retinal breaks, risk factors for RRD include myopia, lattice degeneration, cataract or other intraocular surgery, neodymium yttrium-aluminum-garnet (Nd:YAG) laser surgery, trauma, a history of RRD in the other eye, certain genetic disorders such as Stickler syndrome, or family history of retinal detachments in a first-degree relative. Combinations of these factors may increase the risk.

       Myopia

      More than half of nontraumatic RRD occurs in myopic eyes.
      Eye Disease Case-Control Study Group
      Risk factors for idiopathic rhegmatogenous retinal detachment.
      As axial length increases, the risk of RRD increases proportionately. One study found that individuals with low myopia (1–3 diopters) have a fourfold risk of RRD,
      Eye Disease Case-Control Study Group
      Risk factors for idiopathic rhegmatogenous retinal detachment.
      and higher levels of myopia have higher risks compared with nonmyopic individuals.
      Eye Disease Case-Control Study Group
      Risk factors for idiopathic rhegmatogenous retinal detachment.
      • Bernheim D
      • Rouberol F
      • Palombi K
      • Albrieux M
      • Romanet JP
      • Chiquet C
      Comparative prospective study of rhegmatogenous retinal detachments in phakic or pseudophakic patients with high myopia.

       Lattice Degeneration

      Lattice degeneration is present in 6% to 8% of the population and increases the risk of retinal detachment.
      • Byer NE
      Long-term natural history of lattice degeneration of the retina.
      • Benson WE
      • Morse PH
      The prognosis of retinal detachment due to lattice degeneration.
      Approximately 20% to 30% of patients with RRD have lattice degeneration.
      • Byer NE
      Long-term natural history of lattice degeneration of the retina.
      Perivascular or radial lattice is associated with a higher risk of retinal tear or detachment formation.
      • Byer NE
      Long-term natural history of lattice degeneration of the retina.
      Perivascular lattice it is also frequently seen in Stickler syndrome.
      • Parma ES
      • Korkko J
      • Hagler WS
      • Ala-Kokko L
      Radial perivascular retinal degeneration: a key to the clinical diagnosis of an ocular variant of Stickler syndrome with minimal or no systemic manifestations.

       Cataract Surgery

      The overall risk of RRD after cataract surgery is approximately 1%.
      • Erie JC
      • Raecker MA
      • Baratz KH
      • Schleck CD
      • Burke JP
      • Robertson DM
      Risk of retinal detachment after cataract extraction, 1980-2004: a population-based study.
      • Russell M
      • Gaskin B
      • Russell D
      • Polkinghorne PJ
      Pseudophakic retinal detachment after phacoemulsification cataract surgery: Ten-year retrospective review.
      • Jahn CE
      • Richter J
      • Jahn AH
      • Kremer G
      • Kron M
      Pseudophakic retinal detachment after uneventful phacoemulsification and subsequent neodymium: YAG capsulotomy for capsule opacification.
      • Kassem R
      • Greenwald Y
      • Achiron A
      • et al.
      Peak Occurrence of Retinal Detachment following Cataract Surgery: A Systematic Review and Pooled Analysis with Internal Validation.
      The following conditions have been reported to increase the risk of RRD after cataract surgery: axial myopia, pre-existing vitreoretinal disease, male gender, younger age, vitreous prolapse into the anterior chamber, vitreous loss (ruptured posterior capsule/zonules), and spontaneous extension of the capsulotomy at the time of surgery.
      • Ranta P
      • Tommila P
      • Kivela T
      Retinal breaks and detachment after neodymium: YAG laser posterior capsulotomy: five-year incidence in a prospective cohort.
      • Koch DD
      • Liu JF
      • Gill EP
      • Parke II, DW
      Axial myopia increases the risk of retinal complications after neodymium-YAG laser posterior capsulotomy.
      One study suggests that in the absence of a posterior capsular tear at the time of cataract surgery, subsequent Nd:YAG laser capsulotomy may not increase the risk of retinal detachment.
      • Tuft SJ
      • Minassian D
      • Sullivan P
      Risk factors for retinal detachment after cataract surgery: a case-control study.
      Other studies suggest that Nd:YAG laser capsulotomy is associated with a fourfold increase in the risk of RRD, especially in myopic patients.
      • Javitt JC
      • Tielsch JM
      • Canner JK
      • Kolb MM
      • Sommer A
      • Steinberg EP
      • Cataract Patient Outcomes Research Team
      National outcomes of cataract extraction: increased risk of retinal complications associated with Nd:YAG laser capsulotomy.
      • Tielsch JM
      • Legro MW
      • Cassard SD
      • et al.
      Risk factors for retinal detachment after cataract surgery: a population-based case-control study.
      • Ramos M
      • Kruger EF
      • Lashkari K
      Biostatistical analysis of pseudophakic and aphakic retinal detachments.
      • Ranta P
      • Kivela T
      Retinal detachment in pseudophakic eyes with and without Nd:YAG laser posterior capsulotomy.
      • Glacet-Bernard A
      • Brahim R
      • Mokhtari O
      • Quentel G
      • Coscas G
      Retinal detachment following posterior capsulotomy using Nd:YAG laser. Retrospective study of 144 capsulotomies [in French].
      • Ficker LA
      • Vickers S
      • Capon MR
      • Mellerio J
      • Cooling RJ
      Retinal detachment following Nd:YAG posterior capsulotomy.
      • Arya AV
      • Emerson JW
      • Engelbert M
      • Hagedorn CL
      • Adelman RA
      Surgical management of pseudophakic retinal detachments: a meta-analysis.
      • Lois N
      • Wong D
      Pseudophakic retinal detachment.
      • Ripandelli G
      • Coppe AM
      • Parisi V
      • et al.
      Posterior vitreous detachment and retinal detachment after cataract surgery.
      • Mirshahi A
      • Hoehn F
      • Lorenz K
      • Hattenbach LO
      Incidence of posterior vitreous detachment after cataract surgery.
      Outside of complications at the time of surgery, risk of RRD after cataract surgery usually occurs 1 to 2 years later. A 5-year study using B-scan ultrasonography reported that it was the postoperative onset of a PVD that was the major risk factor for RRD (not the presence or absence of lattice) after cataract surgery and that the majority of eyes after cataract surgery that did not have a pre-existing PVD developed one at a median of 7 months after surgery. Consequently, one can extrapolate that it is the absence of a PVD (in higher risk eyes such as those with myopia and lattice) at the time of cataract surgery that is the major risk of RRD later.
      • Ripandelli G
      • Coppe AM
      • Parisi V
      • et al.
      Posterior vitreous detachment and retinal detachment after cataract surgery.

       Trauma

      Patients with blunt or penetrating ocular injuries that have altered the structure of the vitreous or retina are at increased risk of RRD.
      • Cooling RJ
      Traumatic retinal detachment–mechanisms and management.
      Vitreoretinal interface changes caused by trauma may be detected at the time of injury or even many years later.

       Rhegmatogenous Retinal Detachment in the Fellow Eye

      Patients with a history of nontraumatic detachment in one eye have a 10% increased risk of developing RRD in the fellow eye, since pathologic vitreoretinal changes are frequently bilateral.
      • Byer NE
      Rethinking prophylactic therapy of retinal detachment.
      • Wilkes SR
      • Beard CM
      • Kurland LT
      • Robertson DM
      • O'Fallon WM
      The incidence of retinal detachment in Rochester, Minnesota, 1970-1978.
      • Folk JC
      • Arrindell EL
      • Klugman MR
      The fellow eye of patients with phakic lattice retinal detachment.
      • Rowe JA
      • Erie JC
      • Baratz KH
      • et al.
      Retinal detachment in Olmsted County, Minnesota, 1976 through 1995.
      • Mastropasqua L
      • Carpineto P
      • Ciancaglini M
      • Falconio G
      • Gallenga PE
      Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study.
      The fellow eye in a patient with pseudophakic retinal detachment is also at higher risk of developing a retinal detachment, whether the fellow eye is phakic or pseudophakic. Phakic fellow eyes in patients with pseudophakic retinal detachment have a 7% risk of RRD, suggesting that the risk of developing RRD should not be attributed to cataract surgery alone.
      • Sharma MC
      • Chan P
      • Kim RU
      • Benson WE
      Rhegmatogenous retinal detachment in the fellow phakic eyes of patients with pseudophakic rhegmatogenous retinal detachment.

       Other Risk Factors

      Other risk factors that have been reported include prior retinopathy of prematurity
      • Kaiser RS
      • Trese MT
      • Williams GA
      • Cox Jr., MS
      Adult retinopathy of prematurity: outcomes of rhegmatogenous retinal detachments and retinal tears.
      and Stickler syndrome.
      • Snead MP
      • Payne SJ
      • Barton DE
      • et al.
      Stickler syndrome: correlation between vitreoretinal phenotypes and linkage to COL 2A1.
      • Brown DM
      • Graemiger RA
      • Hergersberg M
      • et al.
      Genetic linkage of Wagner disease and erosive vitreoretinopathy to chromosome 5q13-14.
      There are case reports of retinal detachment in patients who have had keratorefractive surgery; however, large studies have not shown an increased risk in patients when compared with eyes of a similar refractive error.
      • Loewenstein A
      • Goldstein M
      • Lazar M
      Retinal pathology occurring after excimer laser surgery or phakic intraocular lens implantation: evaluation of possible relationship.
      • Ruiz-Moreno JM
      • Alio JL
      Incidence of retinal disease following refractive surgery in 9,239 eyes.
      It remains possible that the risk of vitreoretinal pathology is different among particular keratorefractive techniques.
      • Osman MH
      • Khalil NM
      • El-Agha MS
      Incidence of Posterior Vitreous Detachment After Femtosecond LASIK Compared With Microkeratome LASIK.
      Retinal detachment following refractive lens exchange in patients with high myopia showed a cumulative increase from 2% to 8% over a 7-year incidence.
      • Colin J
      • Robinet A
      • Cochener B
      Retinal detachment after clear lens extraction for high myopia: seven-year follow-up.
      Phakic intraocular lenses have not been associated with increased risk of retinal detachment compared with other intraocular interventions in highly myopic patients.
      • Ruiz-Moreno JM
      • Alio JL
      Incidence of retinal disease following refractive surgery in 9,239 eyes.
      • Chang JS
      • Meau AY
      Visian Collamer phakic intraocular lens in high myopic Asian eyes.
      • Ruiz-Moreno JM
      • Montero JA
      • de la Vega C
      • Alio JL
      • Zapater P
      Retinal detachment in myopic eyes after phakic intraocular lens implantation.

      CARE PROCESS

       PATIENT OUTCOME CRITERIA

      For management and treatment for PVD and RRD, the following outcomes are important:
      • Prevention of visual loss and functional impairment
      • Maintenance of quality of life

       DIAGNOSIS

      The initial evaluation of a patient with risk factors for retinal detachment or symptoms of a PVD involves detection of vitreous pigment cells or debris and includes a thorough peripheral examination looking for retinal tears or holes. It also includes all aspects of the comprehensive adult medical eye evaluation,
      • Feder RS
      • Olsen TW
      • Prum Jr., BE
      • et al.
      Comprehensive adult medical eye evaluation Preferred Practice Pattern® Guidelines.
      with particular attention to those aspects relevant to PVD, retinal breaks, and lattice degeneration. The ophthalmologist should also consider other causes of vitreous cells or debris (e.g., uveitis, infection, inflammation, neoplasia).

       History

      A patient history should include the following elements:
      • Symptoms of PVD
        • Boldrey EE
        Risk of retinal tears in patients with vitreous floaters.
        • Brod RD
        • Lightman DA
        • Packer AJ
        • Saras HP
        Correlation between vitreous pigment granules and retinal breaks in eyes with acute posterior vitreous detachment.
        • Tasman WS
        Posterior vitreous detachment and peripheral retinal breaks.
        • Dayan MR
        • Jayamanne DG
        • Andrews RM
        • Griffiths PG
        Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
        • Byer NE
        Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.
      • Family history of retinal detachment, genetic disorders (e.g., Stickler syndrome)
        • Snead MP
        • Payne SJ
        • Barton DE
        • et al.
        Stickler syndrome: correlation between vitreoretinal phenotypes and linkage to COL 2A1.
        • Brown DM
        • Graemiger RA
        • Hergersberg M
        • et al.
        Genetic linkage of Wagner disease and erosive vitreoretinopathy to chromosome 5q13-14.
      • Prior eye trauma
        • Cooling RJ
        Traumatic retinal detachment–mechanisms and management.
      • Myopia
        Eye Disease Case-Control Study Group
        Risk factors for idiopathic rhegmatogenous retinal detachment.
        • Austin KL
        • Palmer JR
        • Seddon JM
        • et al.
        Case-control study of idiopathic retinal detachment.
      • History of ocular surgery, including refractive lens exchange and cataract surgery
        • Javitt JC
        • Tielsch JM
        • Canner JK
        • Kolb MM
        • Sommer A
        • Steinberg EP
        • Cataract Patient Outcomes Research Team
        National outcomes of cataract extraction: increased risk of retinal complications associated with Nd:YAG laser capsulotomy.
        • Tielsch JM
        • Legro MW
        • Cassard SD
        • et al.
        Risk factors for retinal detachment after cataract surgery: a population-based case-control study.
        • Rowe JA
        • Erie JC
        • Baratz KH
        • et al.
        Retinal detachment in Olmsted County, Minnesota, 1976 through 1995.
        • Norregaard JC
        • Thoning H
        • Andersen TF
        • Bernth-Petersen P
        • Javitt JC
        • Anderson GF
        Risk of retinal detachment following cataract extraction: results from the International Cataract Surgery Outcomes Study.
        • Javitt JC
        • Vitale S
        • Canner JK
        • Krakauer H
        • McBean AM
        • Sommer A
        National outcomes of cataract extraction. I. Retinal detachment after inpatient surgery.
        • Kraff MC
        • Sanders DR
        Incidence of retinal detachment following posterior chamber intraocular lens surgery.
      • History of YAG laser capsulotomy
      • History of an intravitreal injection
        • Geek U
        • Pustolla N
        • Baraki H
        • Atili A
        • Feltgen N
        • Hoerauf H
        Posterior vitreous detachment following intravitreal drug injection.

       Ophthalmic Examination

      The eye examination should include the following elements:
      • Confrontation visual field examination
      • Visual acuity testing
      • Pupillary assessment for the presence of a relative afferent pupillary defect
      • Examination of the vitreous for hemorrhage, detachment, and pigmented cells
        • Boldrey EE
        Risk of retinal tears in patients with vitreous floaters.
        • Brod RD
        • Lightman DA
        • Packer AJ
        • Saras HP
        Correlation between vitreous pigment granules and retinal breaks in eyes with acute posterior vitreous detachment.
        • Tasman WS
        Posterior vitreous detachment and peripheral retinal breaks.
        • Dayan MR
        • Jayamanne DG
        • Andrews RM
        • Griffiths PG
        Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
        • Byer NE
        Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.
        • Coffee RE
        • Westfall AC
        • Davis GH
        • Mieler WF
        • Holz ER
        Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.
        • Boldrey EE
        Vitreous cells as an indicator of retinal tears in asymptomatic or not recently symptomatic eyes.
      • Careful examination of the peripheral fundus using scleral depression
        • Brockhurst RJ
        Modern indirect ophthalmoscopy.
        (see Table 3)
        TABLE 3Recommended Guidelines for Follow-up
        Type of LesionFollow-up Interval
        Symptomatic PVD with no retinal breakDepending on symptoms, risk factors, and clinical findings, patients may be followed within 2 months, then 6–12 months
        Symptomatic PVD with no retinal break but with some vitreous or retinal hemorrhage
        • Depending on the severity of the retinal hemorrhage, 1–2 weeks
        • For vitreous hemorrhage, weekly until resolved. Ultrasonography to check for retinal tears
        Acute symptomatic horseshoe tears1–2 weeks after treatment, then 4–6 weeks, then 3–6 months, then annually
        Acute symptomatic operculated holes2–4 weeks, then 1–3 months, then 6–12 months, then annually
        Acute symptomatic dialyses1–2 weeks after treatment, then 4–6 weeks, then 3–6 months, then annually
        Traumatic retinal breaks1–2 weeks after treatment, then 4–6 weeks, then 3–6 months, then annually
        Asymptomatic horseshoe tears1–4 weeks, then 2–4 months, then 6–12 months, then annually
        Asymptomatic operculated holes1–4 months, then 6–12 months, then annually
        Asymptomatic atrophic round holes1–2 years
        Asymptomatic lattice degeneration without holesAnnually
        Asymptomatic lattice degeneration with holesAnnually
        Asymptomatic dialyses
        • If untreated, 1–4 weeks, then 3 months, then 6 months, then every 6 months
        • If treated, 1–2 weeks after treatment, then 4–6 weeks, then 3–6 months, then annually
        Eyes with atrophic holes, lattice degeneration, or asymptomatic horseshoe tears in patients who have had a retinal detachment in the fellow eyeEvery 6–12 months
        PVD = posterior vitreous detachment
      There are no symptoms that can reliably distinguish between a PVD with or without an associated retinal break; therefore, a peripheral retinal examination is required.
      • Brockhurst RJ
      Modern indirect ophthalmoscopy.
      The preferred method of evaluating patients for peripheral vitreoretinal pathology is to use an indirect ophthalmoscope combined with scleral depression.
      • Natkunarajah M
      • Goldsmith C
      • Goble R
      Diagnostic effectiveness of noncontact slitlamp examination in the identification of retinal tears.
      Many patients with retinal tears have blood and pigmented cells in the anterior vitreous. In fully dilated eyes, slit-lamp biomicroscopy with a mirrored contact lens or a condensing lens is an alternative method in fully dilated eyes instead of a scleral depressed indirect examination of the peripheral retina.

       Diagnostic Tests

      Optical coherence tomography may be helpful to evaluate and stage the PVD.
      • Johnson MW
      Posterior vitreous detachment: evolution and role in macular disease.
      • Uchino E
      • Uemura A
      • Ohba N
      Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography.
      • Benz MS
      • Packo KH
      • Gonzalez V
      • et al.
      A placebo-controlled trial of microplasmin intravitreous injection to facilitate posterior vitreous detachment before vitrectomy.
      If media opacity or patient cooperation precludes an adequate examination of the peripheral retina, B-scan ultrasonography should be performed to search for retinal tears, RRD, mass lesions, or other causes of vitreous hemorrhage.
      • DiBernardo C
      • Blodi B
      • Byrne SF
      Echographic evaluation of retinal tears in patients with spontaneous vitreous hemorrhage.
      Bilateral patching and/or elevation of the head while sleeping may be used when attempting to clear the vitreous hemorrhage.
      • Wilkinson CP
      What ever happened to bilateral patching?.
      If no abnormalities are found, frequent follow-up examinations are recommended (i.e., every 1–2 weeks initially). Wide-field color photography can detect some peripheral retinal breaks but does not replace careful ophthalmoscopy and may be useful in patients not able to tolerate the exam.
      Even if the vitreous hemorrhage is sufficiently dense to obscure the posterior pole, the peripheral retina frequently can be examined using indirect ophthalmoscopy and scleral depression. Patients who present with vitreous hemorrhage sufficient to obscure all retinal details and have a negative B-scan ultrasonographic evaluation should be followed closely. Often, patients are seen weekly until the vitreous hemorrhage resolves or until a thorough indirect ophthalmoscopic depressed peripheral exam can be done to rule out an underlying retinal tear. When a retinal tear is suspected, repeat ultrasonographic examination should be performed within 1 to 2 weeks of the initial evaluation. There is considerable variation in the reported sensitivity (44%–100%) of B-scan ultrasonography for detecting retinal tears in cases of PVD-associated fundus-obscuring vitreous hemorrhage.
      • DiBernardo C
      • Blodi B
      • Byrne SF
      Echographic evaluation of retinal tears in patients with spontaneous vitreous hemorrhage.
      • Rabinowitz R
      • Yagev R
      • Shoham A
      • Lifshitz T
      Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage.
      • Sandinha MT
      • Kotagiri AK
      • Owen RI
      • Geenen C
      • Steel DH
      Accuracy of B-scan ultrasonography in acute fundus obscuring vitreous hemorrhage using a standardized scanning protocol and a dedicated ophthalmic ultrasonographer.
      • Tan HS
      • Mura M
      • Bijl HM
      Early vitrectomy for vitreous hemorrhage associated with retinal tears.
      Early vitrectomy (usually defined as within 7 days of presentation) for dense PVD-associated vitreous hemorrhage has been reported to have a low rate of complications and may be considered to reduce the risk of vision loss occurring secondary to macula-involving retinal detachment.
      • Tan HS
      • Mura M
      • Bijl HM
      Early vitrectomy for vitreous hemorrhage associated with retinal tears.
      • Dhingra N
      • Pearce I
      • Wong D
      Early vitrectomy for fundus-obscuring dense vitreous haemorrhage from presumptive retinal tears.
      • Melamud A
      • Pham H
      • Stoumbos Z
      Early Vitrectomy for Spontaneous, Fundus-Obscuring Vitreous Hemorrhage.
      Prompt intervention is indicated if there is a tear seen on ultrasonography and the vitreous cavity precludes a view.

       MANAGEMENT

       Prevention

      There are no effective methods of preventing the vitreous syneresis and liquefaction that lead to a PVD and possibly an RRD. If factors associated with an increased risk of retinal detachment are discovered during a routine eye examination in an asymptomatic patient, a careful peripheral fundus examination is recommended. Patients at high risk should also be educated about the symptoms of PVD and retinal detachment as well as about the value of periodic follow-up examinations.
      • Byer NE
      Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.
      Patients with retinal or vitreous hemorrhage have an increased risk of multiple retinal tears.
      • Karahan E
      • Karti O
      • Er D
      • et al.
      Risk factors for multiple retinal tears in patients with acute posterior vitreous detachment.
      Moreover, a systematic review performed in 2012 found that there is also no strong evidence in the literature to support or refute the use of 360-degree laser intervention in the fellow eyes of patients with a unilateral giant retinal tear.
      • Ang GS
      • Townend J
      • Lois N
      Interventions for prevention of giant retinal tear in the fellow eye.
      Pharmacotherapy for the management of VMT has been developed. In a placebo-controlled trial of microplasmin (a precursor of ocriplasmin) to induce a PVD, intravitreal injection of 125 micrograms of microplasmin led to a moderate increase in the likelihood of induction and progression of PVD (10% vs. 31%).
      • Benz MS
      • Packo KH
      • Gonzalez V
      • et al.
      A placebo-controlled trial of microplasmin intravitreous injection to facilitate posterior vitreous detachment before vitrectomy.
      Please refer to the Idiopathic ERM and VMT PPP for a detailed discussion.
      • American Academy of Ophthalmology Retinal/Vitreous Panel
      Preferred Practice Pattern Guidelines. Idiopathic Epiretinal Membrane and Vitreomacular Traction.
      The analysis showed that ocriplasmin was better than sham or placebo for inducing PVD, although adverse events were more common in the treated group. In addition, 20% still needed pars plana vitrectomy within 6 months.
      • Chan CK
      • Mein CE
      • Crosson JN
      Pneumatic vitreolysis for management of symptomatic focal vitreomacular traction.
      Pneumatic vitreolysis is also used to induce a PVD. In a meta-analysis, pneumatic vitreolysis approached similar release rates of pars plana vitrectomy and was more effective than ocriplasmin by day 28.
      • Yu G
      • Duguay J
      • Marra KV
      • et al.
      Efficacy and safety of treatment options for vitreomacular traction: a case series and meta-analysis.
      Complications of this procedure are typically related to PVD formation and include retinal tear, retinal detachment, epiretinal membrane, and lamellar or macular hole formation.
      • Chan CK
      • Mein CE
      • Crosson JN
      Pneumatic vitreolysis for management of symptomatic focal vitreomacular traction.
      • Yu G
      • Duguay J
      • Marra KV
      • et al.
      Efficacy and safety of treatment options for vitreomacular traction: a case series and meta-analysis.

       Surgical Management

      It is essential that clinical personnel be familiar with the symptoms of PVD and retinal detachment and that they recognize the need for urgent ophthalmologic evaluation of symptomatic patients.
      • Byer NE
      Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.
      Patients with symptoms of possible or suspected PVD or retinal detachment and related disorders should be examined as soon as is feasible by an ophthalmologist skilled in binocular indirect ophthalmoscopy and supplementary techniques. Patients with retinal breaks or detachments should be treated by an ophthalmologist with experience in the management of these conditions. A Cochrane systematic review found low to very low certainty evidence indicating little or no difference between pars plana vitrectomy and scleral buckling in anatomical and visual acuity outcomes.
      • Znaor L
      • Medic A
      • Binder S
      • Vucinovic A
      • Marin Lovric J
      • Puljak L
      Pars plana vitrectomy versus scleral buckling for repairing simple rhegmatogenous retinal detachments.
      Posterior vitreous detachment symptoms (e.g., flashes and floaters) usually diminish over time, sometimes requiring several months. Appropriate reassurance and precautions regarding the symptoms of retinal detachment should be given. However, some patients may be debilitated in the absence of tears or detachments in the retina. The impact of floaters or floater-related visual symptoms may have an adverse effect on a person's vision-related quality of life. Pars plana vitrectomy is an option if symptomatic floaters are still bothersome after several months. In fact, it has been documented using contrast sensitivity function, that patients with a PVD have a significant reduction in contrast sensitivity function.
      • Garcia GA
      • Khoshnevis M
      • Yee KMP
      • Nguyen-Cuu J
      • Nguyen JH
      • Sebag J
      Degradation of contrast sensitivity function following posterior vitreous detachment.
      Laser treatments and pharmacotherapies have been proposed to decrease these symptoms; however, such therapies currently lack sufficient evidence to support their use.
      • Kokavec J
      • Wu Z
      • Sherwin JC
      • Ang AJ
      • Ang GS
      Nd:YAG laser vitreolysis versus pars plana vitrectomy for vitreous floaters.
      Pars plana vitrectomy has been used for removal of floaters, and improvement in contrast sensitivity function has been documented.
      • Sebag J
      • Yee KM
      • Wa CA
      • Huang LC
      • Sadun AA
      Vitrectomy for floaters: prospective efficacy analyses and retrospective safety profile.
      In a recent review of series that compared pars plana vitrectomy and Nd:YAG laser for floaters,
      • Ivanova T
      • Jalil A
      • Antoniou Y
      • Bishop PN
      • Vallejo-Garcia JL
      • Patton N
      Vitrectomy for primary symptomatic vitreous opacities: an evidence-based review.
      pars plana vitrectomy showed evidence of greater patient satisfaction compared with only moderate resolution of symptoms following the Nd:YAG laser procedure. Another study found YAG vitreolysis to yield greater improvement in symptoms than sham laser.
      • Shah CP
      • Heier JS
      YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial.
      The goal of treatment for retinal breaks is to create a firm chorioretinal adhesion in the attached retina immediately adjacent to and surrounding the retinal tear using cryotherapy or laser photocoagulation surgery to halt the progression of subretinal fluid from detaching the neurosensory retina.
      Treatment of peripheral horseshoe tears should be extended to the ora serrata if the tear cannot be surrounded using laser or cryotherapy.
      • Robertson DM
      • Norton EW
      Long-term follow-up of treated retinal breaks.
      • Benson WE
      • Morse PH
      • Nantawan P
      Late complications following cryotherapy of lattice degeneration.
      • Delaney Jr., WV
      Retinal tear extension through the cryosurgical scar.
      The most common cause of failure in treating horseshoe tears is failure to adequately treat the tear, particularly at the anterior border. Continued vitreous traction may extend the tear beyond the treated area and allow fluid to dissect through the subretinal space to cause a clinical retinal detachment.
      • Robertson DM
      • Norton EW
      Long-term follow-up of treated retinal breaks.
      • Benson WE
      • Morse PH
      • Nantawan P
      Late complications following cryotherapy of lattice degeneration.
      • Delaney Jr., WV
      Retinal tear extension through the cryosurgical scar.
      Treatment of dialyses must extend over the entire length of the dialysis, reaching the ora serrata beyond each horn or end of the dialysis.
      Sufficient evidence exists to warrant treating acute, symptomatic horseshoe tears.
      • Davis MD
      Natural history of retinal breaks without detachment.
      There is insufficient evidence for management of other vitreoretinal abnormalities. A Cochrane systematic review found that in making the decision to treat other vitreoretinal abnormalities, including lattice degeneration and asymptomatic retinal breaks, that the risks that treatment would be unnecessary, ineffective, or harmful must be weighed against the possible benefit of reducing the rate of subsequent retinal detachment.
      • Wilkinson CP
      Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment.
      (I+, Good quality, Strong recommendation) Table 2 summarizes recommendations for management. A Cochrane systematic review in 2014 shows that no randomized controlled clinical trials have been performed to support treatment of asymptomatic retinal breaks of lattice degeneration.
      • Wilkinson CP
      Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment.
      There is no level 1 evidence to support the use of prophylactic laser to areas of lattice degeneration prior to anterior segment surgery.
      • Folk JC
      • Arrindell EL
      • Klugman MR
      The fellow eye of patients with phakic lattice retinal detachment.
      • Mastropasqua L
      • Carpineto P
      • Ciancaglini M
      • Falconio G
      • Gallenga PE
      Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study.
      A primary limitation of prophylactic therapy is that causative breaks leading to retinal detachment often occur during a PVD in areas that appear normal prior to the PVD.
      • Mastropasqua L
      • Carpineto P
      • Ciancaglini M
      • Falconio G
      • Gallenga PE
      Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study.
      TABLE 2Management Recommendations
      Type of LesionTreatment
      There is insufficient evidence to recommend prophylaxis of asymptomatic retinal breaks for patients undergoing cataract surgery.
      Acute symptomatic horseshoe tearsTreat promptly
      • Shea M
      • Davis MD
      • Kamel I
      Retinal breaks without detachment, treated and untreated.
      • Colyear Jr, BH
      • Pischel D
      Preventive treatment of retinal detachment by means of light coagulation.
      • Robertson DM
      • Norton EW
      Long-term follow-up of treated retinal breaks.
      • Pollack A
      • Oliver M
      Argon laser photocoagulation of symptomatic flap tears and retinal breaks of fellow eyes.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.
      • Verdaguer J
      • Vaisman M
      Treatment of symptomatic retinal breaks.
      Acute symptomatic operculated holesTreatment may not be necessary
      Acute symptomatic dialysesTreat promptly
      Traumatic retinal breaksUsually treated
      Asymptomatic horseshoe tears (without subclinical RD)Consider treatment unless there are signs of chronicity
      • Byer NE
      Rethinking prophylactic therapy of retinal detachment.
      Asymptomatic operculated tearsTreatment is rarely recommended
      Asymptomatic atrophic round holesTreatment is rarely recommended
      Asymptomatic lattice degeneration without holesNot treated unless PVD causes a horseshoe tear
      Asymptomatic lattice degeneration with holesUsually does not require treatment
      Asymptomatic dialysesNo consensus on treatment and insufficient evidence to guide management
      Eyes with atrophic holes or lattice degeneration where the fellow eye has had an RDNo consensus on treatment and insufficient evidence to guide management
      PVD = posterior vitreous detachment; RD = retinal detachment
      * There is insufficient evidence to recommend prophylaxis of asymptomatic retinal breaks for patients undergoing cataract surgery.
      The surgeon should inform the patient of the risks, benefits, and alternatives to surgery.
      • American Academy of Ophthalmology
      Preoperative assessment: responsibilities of the ophthalmologist.
      • American Academy of Ophthalmology
      An ophthalmologist's duties concerning postoperative care - 2012.
      The treating surgeon is responsible for formulating a postoperative care plan and should inform the patient of these arrangements.
      • American Academy of Ophthalmology
      Preoperative assessment: responsibilities of the ophthalmologist.
      • American Academy of Ophthalmology
      An ophthalmologist's duties concerning postoperative care - 2012.
      Retinal detachments may occur in spite of appropriate therapy. Traction is an important component and may pull the tear from the treated area, especially when there are larger breaks or bridging retinal blood vessels. The laser- or cryotherapy-induced treatment adhesion (chorioretinal scar) may not be firm or complete for up to 1 month following treatment.
      • Robertson DM
      • Norton EW
      Long-term follow-up of treated retinal breaks.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.
      • Benson WE
      • Morse PH
      • Nantawan P
      Late complications following cryotherapy of lattice degeneration.
      Furthermore, 10% to 16% of patients will develop additional breaks during long-term follow-up.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.
      • Goldberg RE
      • Boyer DS
      Sequential retinal breaks following a spontaneous initial retinal break.
      • Sharma MC
      • Regillo CD
      • Shuler MF
      • Borrillo JL
      • Benson WE
      Determination of the incidence and clinical characteristics of subsequent retinal tears following treatment of the acute posterior vitreous detachment-related initial retinal tears.
      Pseudophakic patients are more likely to require retreatment or to develop new breaks.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.

       Complications of Treatment

      Proliferation of the epiretinal membrane (ERM), or macular pucker, has been occasionally observed following treatment for a retinal break; however, a direct cause and effect relationship of treatment of a retinal break to ERM remains unclear, since an ERM may also occur spontaneously following the PVD. (See Glossary.) In one long-term follow-up study, the percentage of eyes that developed macular pucker after treatment of retinal breaks was no greater than the percentage of eyes observed to have macular pucker before treatment.
      • Robertson DM
      • Norton EW
      Long-term follow-up of treated retinal breaks.
      Therefore, the method of creating a chorioretinal adhesion may be unrelated to the incidence of postoperative macular pucker.
      • Saran BR
      • Brucker AJ
      Macular epiretinal membrane formation and treated retinal breaks.

       Follow-up Evaluation

      The guidelines in Table 3 are recommendations for the timing of re-evaluation in the absence of additional symptoms. Patients with new symptoms or a change in symptoms may require more frequent evaluation. Patients with no positive findings at the initial examination should be seen at the intervals recommended in the Comprehensive Adult Medical Eye Evaluation PPP.
      • Feder RS
      • Olsen TW
      • Prum Jr., BE
      • et al.
      Comprehensive adult medical eye evaluation Preferred Practice Pattern® Guidelines.
      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.
      • Javitt JC
      • Tielsch JM
      • Canner JK
      • Kolb MM
      • Sommer A
      • Steinberg EP
      • Cataract Patient Outcomes Research Team
      National outcomes of cataract extraction: increased risk of retinal complications associated with Nd:YAG laser capsulotomy.
      • Tielsch JM
      • Legro MW
      • Cassard SD
      • et al.
      Risk factors for retinal detachment after cataract surgery: a population-based case-control study.
      • Norregaard JC
      • Thoning H
      • Andersen TF
      • Bernth-Petersen P
      • Javitt JC
      • Anderson GF
      Risk of retinal detachment following cataract extraction: results from the International Cataract Surgery Outcomes Study.
      • Singh AJ
      • Seemongal-Dass RR
      The influence of counselling on patient return following uncomplicated posterior vitreous detachment.
      Younger myopic patients who have lattice degeneration with holes need regular follow-up visits to monitor for subclinical retinal detachments that may slowly enlarge to become clinical retinal detachments. Treatment should be considered if the detachments progress in size.
      • Byer NE
      Rethinking prophylactic therapy of retinal detachment.
      • Byer NE
      Long-term natural history of lattice degeneration of the retina.
      Patients presenting with an acute PVD and no retinal breaks have a small chance (approximately 2%) of developing retinal breaks in the weeks that follow.
      • Dayan MR
      • Jayamanne DG
      • Andrews RM
      • Griffiths PG
      Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
      Thus, selected patients, particularly those with any degree of vitreous pigment, vitreous or retinal hemorrhage, or visible vitreoretinal traction, should be asked to return for a second examination within 6 weeks following the onset of symptoms.
      • Dayan MR
      • Jayamanne DG
      • Andrews RM
      • Griffiths PG
      Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
      • Sharma MC
      • Regillo CD
      • Shuler MF
      • Borrillo JL
      • Benson WE
      Determination of the incidence and clinical characteristics of subsequent retinal tears following treatment of the acute posterior vitreous detachment-related initial retinal tears.

       History at Follow-up Encounter

      A patient history should identify changes in the following:

       Ophthalmic Examination

      The eye examination should emphasize the following elements:
      • Measurement of visual acuity
      • Evaluation of the vitreous status, with attention to the presence of pigment, hemorrhage, or syneresis
        • Boldrey EE
        Risk of retinal tears in patients with vitreous floaters.
        • Brod RD
        • Lightman DA
        • Packer AJ
        • Saras HP
        Correlation between vitreous pigment granules and retinal breaks in eyes with acute posterior vitreous detachment.
        • Tasman WS
        Posterior vitreous detachment and peripheral retinal breaks.
        • Dayan MR
        • Jayamanne DG
        • Andrews RM
        • Griffiths PG
        Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
        • Byer NE
        Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.
        • Coffee RE
        • Westfall AC
        • Davis GH
        • Mieler WF
        • Holz ER
        Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.
        • Boldrey EE
        Vitreous cells as an indicator of retinal tears in asymptomatic or not recently symptomatic eyes.
      • Examination of the peripheral fundus using scleral depression
        • Brockhurst RJ
        Modern indirect ophthalmoscopy.
        or a fundus contact or non-contact lens using the slit-lamp biomicroscope
      • Wide-field photography may be helpful but does not replace careful ophthalmoscopy
      • Optical coherence tomography if VMT is present
        • Johnson MW
        Posterior vitreous detachment: evolution and role in macular disease.
        • Uchino E
        • Uemura A
        • Ohba N
        Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography.
        • Benz MS
        • Packo KH
        • Gonzalez V
        • et al.
        A placebo-controlled trial of microplasmin intravitreous injection to facilitate posterior vitreous detachment before vitrectomy.
      • B-scan ultrasonography when the media is opaque
        • DiBernardo C
        • Blodi B
        • Byrne SF
        Echographic evaluation of retinal tears in patients with spontaneous vitreous hemorrhage.
      If the treatment for treated patients appears satisfactory at the first follow-up visit at 1 to 2 weeks, indirect ophthalmoscopy and scleral depression at 2 to 6 weeks will determine the adequacy of the chorioretinal scar, especially around the anterior boundary of the tear. If the tear and the accompanying subretinal fluid are not completely surrounded by the chorioretinal scar, additional treatment should be administered. At any postoperative visit, additional treatment should be considered if subretinal fluid has accumulated beyond the edge of treatment.
      • Robertson DM
      • Norton EW
      Long-term follow-up of treated retinal breaks.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.
      Even when a patient has had adequate treatment, additional examinations are important. Between 5% and 14% of patients found to have an initial retinal break will develop additional breaks during long-term follow-up. These statistics appear to be similar regardless of how the initial breaks were treated.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.
      • Goldberg RE
      • Boyer DS
      Sequential retinal breaks following a spontaneous initial retinal break.
      New breaks may be particularly likely in eyes that have had cataract surgery.
      • Smiddy WE
      • Flynn Jr., HW
      • Nicholson DH
      • et al.
      Results and complications in treated retinal breaks.

       COUNSELING AND REFERRAL

      All patients at increased risk of retinal detachment should be instructed to notify their ophthalmologist as soon as possible if they have a substantial change in symptoms, such as an increase in floaters, loss of visual field, or decrease in visual acuity.
      • Javitt JC
      • Tielsch JM
      • Canner JK
      • Kolb MM
      • Sommer A
      • Steinberg EP
      • Cataract Patient Outcomes Research Team
      National outcomes of cataract extraction: increased risk of retinal complications associated with Nd:YAG laser capsulotomy.
      • Tielsch JM
      • Legro MW
      • Cassard SD
      • et al.
      Risk factors for retinal detachment after cataract surgery: a population-based case-control study.
      • Norregaard JC
      • Thoning H
      • Andersen TF
      • Bernth-Petersen P
      • Javitt JC
      • Anderson GF
      Risk of retinal detachment following cataract extraction: results from the International Cataract Surgery Outcomes Study.
      • Singh AJ
      • Seemongal-Dass RR
      The influence of counselling on patient return following uncomplicated posterior vitreous detachment.
      If patients are familiar with the symptoms of retinal tears or detachment, they may be more likely to report promptly, thus improving the opportunity for successful treatment and subsequent visual results.
      • Benson WE
      • Grand MG
      • Okun E
      Aphakic retinal detachment. Management of the fellow eye.
      Patients who undergo refractive surgery to reduce myopia should be informed that they remain at risk of RRD despite reduction of their refractive error.

       SOCIOECONOMIC CONSIDERATIONS

      Limited data exist on the socioeconomic impacts of PVD, retinal breaks, or lattice degeneration. However, research on the impact of the symptoms of these conditions (e.g., vitreous floaters) has suggested that vitreous symptoms may have an unfavorable effect on a patient's vision-related quality of life.
      • Wagle AM
      • Lim WY
      • Yap TP
      • Neelam K
      • Au Eong KG
      Utility values associated with vitreous floaters.
      • Sebag J
      Floaters and the quality of life.
      The modeled cost of evaluating a patient with PVD and treating associated pathology in the facility/hospital (nonfacility/Ambulatory Surgery Centers)-based setting was $65 to $190 ($25-$71) depending on whether a single or two-examination protocol was used. The cost per quality-adjusted life year (QALY) saved was $255 to $638/QALY ($100-$293/QALY). Treatment of a symptomatic horseshoe tear resulted in a net cost savings of $1,749 ($1,314) and improved utility, whereas treatment of an asymptomatic horseshoe tear resulted in $2,981/QALY ($1,436/QALY). Treatment of asymptomatic lattice degeneration in an eye in which the fellow eye had a history of RD resulted in $4,414/QALY ($2,187/QALY).
      • Yannuzzi NA
      • Chang JS
      • Brown GC
      • Smiddy WE
      Cost-Utility of Evaluation for Posterior Vitreous Detachment and Prophylaxis of Retinal Detachment.

      APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA

      Providing quality care is the physician's foremost ethical obligation, and is the basis of public trust in physicians.
      AMA Board of Trustees, 1986
      Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of the patient. The discussion that follows characterizes the core elements of such care.
      The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate patient fear and suffering. The ophthalmologist strives to develop and maintain clinical skills at the highest feasible level, consistent with the needs of patients, through training and continuing education. The ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and responds accordingly. The ophthalmologist also ensures that needy patients receive necessary care directly or through referral to appropriate persons and facilities that will provide such care, and he or she supports activities that promote health and prevent disease and disability.
      The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state. The ophthalmologist respects the dignity and integrity of his or her patients and does not exploit their vulnerability.
      Quality ophthalmic care has the following optimal attributes, among others.
      • The essence of quality care is a meaningful partnership relationship between patient and physician. The ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their needs and concerns. In turn, the ophthalmologist educates his or her patients about the nature and prognosis of their condition and about proper and appropriate therapeutic modalities. This is to ensure their meaningful participation (appropriate to their unique physical, intellectual, and emotional state) in decisions affecting their management and care, to improve their motivation and compliance with the agreed plan of treatment, and to help alleviate their fears and concerns.
      • The ophthalmologist uses his or her best judgment in choosing and timing appropriate diagnostic and therapeutic modalities as well as the frequency of evaluation and follow-up, with due regard to the urgency and nature of the patient's condition and unique needs and desires.
      • The ophthalmologist carries out only those procedures for which he or she is adequately trained, experienced, and competent, or, when necessary, is assisted by someone who is, depending on the urgency of the problem and availability and accessibility of alternative providers.
      • Patients are assured access to, and continuity of, needed and appropriate ophthalmic care, which can be described as follows.
        • The ophthalmologist treats patients with due regard to timeliness, appropriateness, and his or her own ability to provide such care.
        • The operating ophthalmologist makes adequate provision for appropriate pre- and postoperative patient care.
        • When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and procedures for obtaining it.
        • The ophthalmologist refers patients to other ophthalmologists and eye care providers based on the timeliness and appropriateness of such referral, the patient's needs, the competence and qualifications of the person to whom the referral is made, and access and availability.
        • The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other medical or surgical problem. Consultants are suggested for their skill, competence, and accessibility. They receive as complete and accurate an accounting of the problem as necessary to provide efficient and effective advice or intervention, and in turn they respond in an adequate and timely manner. The ophthalmologist maintains complete and accurate medical records.
        • On appropriate request, the ophthalmologist provides a full and accurate rendering of the patient's records in his or her possession.
        • The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective manner and takes appropriate actions.
        • The ophthalmologist and those who assist in providing care identify themselves and their profession.
        • For patients whose conditions fail to respond to treatment and for whom further treatment is unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and social services, and referral as appropriate and accessible.
      • Prior to therapeutic or invasive diagnostic procedures, the ophthalmologist becomes appropriately conversant with the patient's condition by collecting pertinent historical information and performing relevant preoperative examinations. Additionally, he or she enables the patient to reach a fully informed decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks, benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks and benefits of no treatment.
      • The ophthalmologist adopts new technology (e.g., drugs, devices, surgical techniques) in judicious fashion, appropriate to the cost and potential benefit relative to existing alternatives and to its demonstrated safety and efficacy.
      • The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and assessing his or her personal performance in relation to established standards, and by revising or altering his or her practices and techniques appropriately.
      • The ophthalmologist improves ophthalmic care by communicating to colleagues, through appropriate professional channels, knowledge gained through clinical research and practice. This includes alerting colleagues of instances of unusual or unexpected rates of complications and problems related to new drugs, devices, or procedures.
      • The ophthalmologist provides care in suitably staffed and equipped facilities adequate to deal with potential ocular and systemic complications requiring immediate attention.
      • The ophthalmologist also provides ophthalmic care in a manner that is cost effective without unacceptably compromising accepted standards of quality.
      Reviewed by: Council
      Approved by: Board of Trustees
      October 12, 1988
      2nd Printing: January 1991
      3rd Printing: August 2001
      4th Printing: July 2005

      APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES

      Precursors to rhegmatogenous retinal detachment and related entities with the following ICD-9 and ICD-10 classifications (see Glossary):
      Tabled 1
      ICD-9 CMICD-10 CM
      Rhegmatogenous retinal detachment:
       Break, unspecified361.00H33.00-
       Break, giant361.03H33.03-
       Break, multiple361.02H33.02-
       Break, single361.01H33.01-
      Vitreous detachment/degeneration379.21H43.81-
      Retinal break without detachment:
       Retinal break, unspecified361.30H33.30-
       Horseshoe tear361.32H33.31-
       Multiple361.33H33.33-
       Round hole361.31H33.32-
      Multiple defects of retina without detachment361.33H33.33-
      Horseshoe tear of retina without detachment361.32H33.31-
      Operculated break without detachment361.32H33.31-
      Round hole without detachment361.31H33.32-
      Retinal dialysis361.04H33.04-
      Lattice degeneration of the retina362.63H35.41-
      ICD = International Classification of Diseases; CM = Clinical Modification used in the United States; (−) = 1, right eye; 2, left eye; 3, bilateral
      Additional Information for ICD-10 Codes:
      • Certain ICD-10 CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
      • For bilateral sites, the final character of the codes in the ICD-10 CM indicates laterality. If no bilateral code is provided and the condition is bilateral, separate codes for both the left and right side should be assigned. Unspecified codes should be used only when there is no other code option available.
      • When the diagnosis code specifies laterality, regardless of which digit it is found in (i.e., 4th digit, 5th digit, or 6th digit):
        • Right is always 1
        • Left is always 2
        • Bilateral is always 3

      GLOSSARY

      Atrophic retinal breaks or holes: Full-thickness retinal defects, unrelated to vitreoretinal traction. These can occur within lattice lesions or in areas of the retina that appear otherwise normal.
      Clinical retinal detachment: A retinal detachment that either impairs a portion of the visual field or extends more than 2 disc diameters posterior to the equator.
      Cystic retinal tufts: Small congenital lesions of the peripheral retina. They are slightly elevated and usually whitish in color with variable surrounding pigmentation. They are firmly attached to the overlying vitreous cortex and are sometimes a cause of retinal tears following PVD.
      Epiretinal membrane (ERM): See Macular pucker.
      ERM: See Macular pucker.
      Flap tear: A horseshoe tear.
      Horseshoe tear: A retinal tear caused by vitreoretinal traction on the retina. The tear is horseshoe shaped owing to a flap of torn tissue that remains attached to the detached vitreous gel.
      ICD-9: International Statistical Classification of Diseases and Related Health Problems, Ninth Edition.
      ICD-10: International Statistical Classification of Diseases and Related Health Problems, Tenth Edition.
      Lattice degeneration: A peripheral vitreoretinal lesion characterized by retinal thinning, overlying vitreous liquefaction, and firm vitreoretinal adhesions at its margins. Most lesions are ovoid with long axes parallel to the ora serrata. Round holes frequently occur within the lattice lesion unassociated with PVD. If horseshoe tears are present, they are seen at the development of PVD and usually are observed at the margins of lattice lesions.
      Macular pucker: Distortion of the retina in the macular region due to proliferation and contraction of a fibrocellular membrane on the inner surface of the retina.
      Operculated retinal tear or break: A defect in the retina caused by vitreoretinal traction at the site of the lesion. The traction pulls a circular or oval piece of retinal tissue (the operculum) free from the retinal surface. If this occurs during PVD, all traction in the vicinity of the retinal break is usually eliminated.
      Posterior vitreous detachment (PVD): A separation of the posterior vitreous cortex from the internal surface of the retina. This usually occurs as an acute event after substantial age-related liquefaction in the vitreous gel; the separation usually extends rapidly to the posterior margin of the vitreous base in all quadrants. Adhesions between the vitreous cortex and retina or retinal blood vessels may cause retinal breaks and/or vessel rupture. Vitreous hemorrhage and/or localized intraretinal hemorrhage may accompany this event. Posterior vitreous detachment is diagnosed by slit-lamp biomicroscopy, which will usually show a prominent plane defining the posterior vitreous face. The presence of a glial annulus in the vitreous cavity (Weiss ring) is strong evidence of PVD.
      PVD: See Posterior vitreous detachment.
      Retinal breaks: Full-thickness defects in the retina. Those caused by vitreoretinal traction are usually called tears. Those that are round and unassociated with vitreoretinal traction are usually called holes.
      Retinal dialysis: A specific type of crescentic peripheral retinal break at the ora serrata, usually associated with trauma.
      Rhegmatogenous retinal detachment (RRD): A separation of the retina from the retinal pigment epithelium caused by fluid passing from the vitreous cavity into the subretinal space through a break in the retina (from Greek rhegma, “rent”).
      Round retinal hole: A round, full-thickness defect or break in the retina, unassociated with vitreoretinal traction.
      RRD: See Rhegmatogenous retinal detachment.
      Stickler syndrome: The most common inherited vitreoretinal and systemic disorder associated with RRD. Ocular features include (1) high myopia; (2) retrolental, transvitreal, and epiretinal membranes and strands; (3) chorioretinal pigment alterations; (4) lattice degeneration, often with a perivascular component that extends posteriorly; and (5) various other abnormalities including glaucoma and cataract. Systemic features include a generalized skeletal dysplasia, often with a marfanoid habitus, flattened facies, high arched or cleft palate, hearing loss, and other extracranial skeletal anomalies, many of which can be very subtle. The inheritance pattern is autosomal dominant, and a gene defect has been related to COL2A1.
      Subclinical retinal detachment: A retinal detachment that extends more than 1 disc diameter from the posterior edge of the retinal break, less than 2 disc diameters from the equator, and does not impair the field of vision.
      Vitreoretinal adhesion (VMA): A firm attachment between the cortical vitreous and the inner surface of the retina. Condensed vitreous strands adhering to the retina may sometimes be visualized using biomicroscopy or indirect ophthalmoscopy and scleral depression. Traction of the vitreous on the retina during PVD may cause retinal breaks to occur at these sites.
      Vitreomacular traction (VMT): Partial vitreous separation from the retina resulting in mechanical distortion of the macula.
      VMA: See Vitreomacular adhesion
      VMT: See Vitreomacular traction
      Zonular traction retinal tufts: Small congenital lesions of the peripheral retina caused by thickened zonules that have been displaced posteriorly to the anterior retina.

      LITERATURE SEARCHES FOR THIS PPP

      Literature searches of the PubMed and Cochrane databases were conducted in April 2018; the search strategies are provided at www.aao.org/ppp. Specific limited update searches were conducted after June 2019.
      (Retinal Detachment/epidemiology[mh]) AND (rhegmatogenous retinal detachment[tiab])
      (Retinal Detachment/etiology[MAJR:noexp] OR Retinal Perforations/etiology[MAJR:noexp] OR Vitreous Detachment/etiology[MAJR:noexp] OR Retinal Degeneration/etiology[MAJR:noexp]) AND (rhegmatogenous retinal detachment[tiab] OR posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (Retinal Detachment/diagnosis[MAJR:noexp] OR Retinal Perforations/diagnosis[MAJR:noexp] OR Vitreous Detachment/diagnosis[MAJR:noexp] OR Retinal Degeneration/diagnosis[MAJR:noexp]) AND (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (Retinal Detachment[MAJR:noexp] OR Retinal Perforations[MAJR:noexp] OR Vitreous Detachment[MAJR:noexp] OR Retinal Degeneration[MAJR:noexp]) AND (Risk Factors[mh]) AND (rhegmatogenous retinal detachment[tiab] OR posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab] OR cataract*[tiab] OR trauma*[tiab] OR injur*[tiab] OR fellow[tiab] OR retinopathy of prematurity[tiab] OR Stickler[tiab] OR keratorefractive[tiab] OR refractive lens exchange*[tiab] OR phakic intraocular lens*[tiab])
      (Retinal Detachment/surgery[MAJR:noexp] OR Retinal Detachment/therapy[MAJR:noexp] OR Retinal Detachment/drug therapy[MAJR:noexp] OR Retinal Perforations/surgery[MAJR:noexp] OR Retinal Perforations/therapy[MAJR:noexp] OR Retinal Perforations/drug therapy[MAJR:noexp] OR Vitreous Detachment/surgery[MAJR:noexp] OR Vitreous Detachment/therapy [MAJR:noexp] OR Vitreous Detachment/drug therapy[MAJR:noexp] OR Retinal Degeneration/surgery[MAJR:noexp] OR Retinal Degeneration/therapy[MAJR:noexp] OR Retinal Degeneration/drug therapy[MAJR:noexp]) AND (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (Retinal Detachment/surgery[MAJR:noexp] OR Retinal Detachment/therapy[MAJR:noexp] OR Retinal Detachment/drug therapy[MAJR:noexp] OR Retinal Perforations/surgery[MAJR:noexp] OR Retinal Perforations/therapy[MAJR:noexp] OR Retinal Perforations/drug therapy[MAJR:noexp] OR Vitreous Detachment/surgery[MAJR:noexp] OR Vitreous Detachment/therapy [MAJR:noexp] OR Vitreous Detachment/drug therapy[MAJR:noexp] OR Retinal Degeneration/surgery[MAJR:noexp] OR Retinal Degeneration/therapy[MAJR:noexp] OR Retinal Degeneration/drug therapy[MAJR:noexp]) AND (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (Retinal Detachment [MAJR:noexp] OR Retinal Perforations [MAJR:noexp] OR Vitreous Detachment [MAJR:noexp] OR Retinal Degeneration[MAJR:noexp]) AND (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab]) AND ((review*[tiab] AND (literature[tiab] OR systematic[tiab] OR search*[tiab])) OR meta-analysis [tiab])
      (Retinal Detachment [mh] OR Retinal Perforations [mh] OR Vitreous Detachment [mh] OR Retinal Degeneration[mh]) AND (Quality of Life[mh]) AND (rhegmatogenous retinal detachment[tiab] OR posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (Retinal Detachment [mh] OR Retinal Perforations [mh] OR Vitreous Detachment [mh] OR Retinal Degeneration[mh]) AND (Cost-Benefit Analysis[mh] OR Cost of Illness[mh]) AND (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (Retinal Detachment/economics [mh] OR Retinal Perforations/economics [mh] OR Vitreous Detachment/economics [mh] OR Retinal Degeneration/economics[mh]) AND (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])
      (Retinal Detachment[mh:noexp] OR Retinal Perforations[mh:noexp] OR Vitreous Detachment[mh:noexp] OR Retinal Degeneration[mh:noexp]) AND (Postoperative Complications[mh]) AND (posterior vitreous detachment[tiab] OR retinal break*[tiab] OR lattice degeneration[tiab])

      RELATED ACADEMY MATERIALS

      Basic and Clinical Science Course
      Retina and Vitreous (Section 12, 2019–2020)
      Focal Points
      Floaters and Flashes (2016)
      Ophthalmic Technology Assessment
      The Repair of Rhegmatogenous Retinal Detachments (1996; reviewed for currency 2006)
      Patient Education Brochure
      Detached and Torn Retina (2005)
      Preferred Practice Pattern® Guidelines – Free download available at www.aao.org/ppp.
      Comprehensive Adult Medical Eye Evaluation (2015)
      To order any of these products, except for the free materials, please contact the Academy's Customer Service at 866.561.8558 (U.S. only) or 415.561.8540 or www.aao.org/store.

      REFERENCES

        • Scottish Intercollegiate Guidelines Network (SIGN)
        SIGN 50: a guideline developer's handbook.
        SIGN, Edinburgh2015 (SIGN publication no. 50). [November 2015].
        • Guyatt GH
        • Oxman AD
        • Vist GE
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • GRADE Working Group
        Organizations that have endorsed or that are using GRADE.
        http://www.gradeworkinggroup.org/
        Date accessed: September , 2019
        • Johnson MW
        Posterior vitreous detachment: evolution and role in macular disease.
        Retina. 2012; 32: S174-178
        • Snead MP
        • Snead DR
        • James S
        • Richards AJ
        Clinicopathological changes at the vitreoretinal junction: posterior vitreous detachment.
        Eye (Lond). 2008; 22: 1257-1262
        • American Academy of Ophthalmology Retinal/Vitreous Panel
        Preferred Practice Pattern Guidelines. Idiopathic Epiretinal Membrane and Vitreomacular Traction.
        American Academy of Ophthalmology, San Francisco, CA2019
        • Coppe AM
        • Lapucci G
        Posterior vitreous detachment and retinal detachment following cataract extraction.
        Curr Opin Ophthalmol. 2008; 19: 239-242
        • Gavrilov JC
        • Gaujoux T
        • Sellam M
        • Laroche L
        • Borderie V
        Occurrence of posterior vitreous detachment after femtosecond laser in situ keratomileusis: Ultrasound evaluation.
        J Cataract Refract Surg. 2011; 37: 1300-1304
        • Osman MH
        • Khalil NM
        • El-Agha MS
        Incidence of Posterior Vitreous Detachment After Femtosecond LASIK Compared With Microkeratome LASIK.
        Cornea. 2017; 36: 1036-1039
        • Boldrey EE
        Risk of retinal tears in patients with vitreous floaters.
        Am J Ophthalmol. 1983; 96: 783-787
        • Brod RD
        • Lightman DA
        • Packer AJ
        • Saras HP
        Correlation between vitreous pigment granules and retinal breaks in eyes with acute posterior vitreous detachment.
        Ophthalmology. 1991; 98: 1366-1369
        • Tasman WS
        Posterior vitreous detachment and peripheral retinal breaks.
        Trans Am Acad Ophthalmol Otolaryngol. 1968; 72: 217-224
        • Dayan MR
        • Jayamanne DG
        • Andrews RM
        • Griffiths PG
        Flashes and floaters as predictors of vitreoretinal pathology: is follow-up necessary for posterior vitreous detachment?.
        Eye. 1996; 10: 456-458
        • Byer NE
        Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment.
        Ophthalmology. 1994; 101: 1503-1514
        • Tani P
        • Robertson DM
        • Langworthy A
        Rhegmatogenous retinal detachment without macular involvement treated with scleral buckling.
        Am J Ophthalmol. 1980; 90: 503-508
        • Coffee RE
        • Westfall AC
        • Davis GH
        • Mieler WF
        • Holz ER
        Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis.
        Am J Ophthalmol. 2007; 144: 409-413
        • Benson WE
        • Grand MG
        • Okun E
        Aphakic retinal detachment. Management of the fellow eye.
        Arch Ophthalmol. 1975; 93: 245-249
        • Scott IU
        • Smiddy WE
        • Merikansky A
        • Feuer W
        Vitreoretinal surgery outcomes. Impact on bilateral visual function.
        Ophthalmology. 1997; 104: 1041-1048
        • Lincoff H
        • Stopa M
        • Kreissig I
        Ambulatory binocular occlusion.
        Retina. 2004; 24: 246-253
        • van Overdam KA
        • Bettink-Remeijer MW
        • Mulder PG
        • van Meurs JC
        Symptoms predictive for the later development of retinal breaks.
        Arch Ophthalmol. 2001; 119: 1483-1486
        • Uchino E
        • Uemura A
        • Ohba N
        Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography.
        Arch Ophthalmol. 2001; 119: 1475-1479
        • Sarrafizadeh R
        • Hassan TS
        • Ruby AJ
        • et al.
        Incidence of retinal detachment and visual outcome in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage.
        Ophthalmology. 2001; 108: 2273-2278
        • Adelman RA
        • Parnes AJ
        • Ducournau D
        • European Vitreo-Retinal Society (EVRS) Retinal Detachment Study Group
        Strategy for the management of uncomplicated retinal detachments: the European Vitreo-Retinal Society Retinal Detachment Study report 1.
        Ophthalmology. 2013; 120: 1804-1808
        • Byer NE
        What happens to untreated asymptomatic retinal breaks, and are they affected by posterior vitreous detachment?.
        Ophthalmology. 1998; 105: 1045-1050
        • Davis MD
        Natural history of retinal breaks without detachment.
        Arch Ophthalmol. 1974; 92: 183-194
        • Wilkinson CP
        Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment.
        Cochrane Database Syst Rev. 2014; CD003170
        • Byer NE
        Rethinking prophylactic therapy of retinal detachment.
        in: Stirpe M Advances in Vitreoretinal Surgery. Ophthalmic Communications Society, New York, NY1992: 399-411
        • Neumann E
        • Hyams S
        Conservative management of retinal breaks. A follow-up study of subsequent retinal detachment.
        Br J Ophthalmol. 1972; 56: 482-486
        • Shea M
        • Davis MD
        • Kamel I
        Retinal breaks without detachment, treated and untreated.
        Mod Probl Ophthalmol. 1974; 12: 97-102
        • Colyear Jr, BH
        • Pischel D
        Preventive treatment of retinal detachment by means of light coagulation.
        Trans Pac Coast Oto-Ophthalmol Soc. 1960; 41: 193-217
        • Robertson DM
        • Norton EW
        Long-term follow-up of treated retinal breaks.
        Am J Ophthalmol. 1973; 75: 395-404
        • Pollack A
        • Oliver M
        Argon laser photocoagulation of symptomatic flap tears and retinal breaks of fellow eyes.
        Br J Ophthalmol. 1981; 65: 469-472
        • Smiddy WE
        • Flynn Jr., HW
        • Nicholson DH
        • et al.
        Results and complications in treated retinal breaks.
        Am J Ophthalmol. 1991; 112: 623-631
        • Verdaguer J
        • Vaisman M
        Treatment of symptomatic retinal breaks.
        Am J Ophthalmol. 1979; 87: 783-788
        • Byer NE
        Subclinical retinal detachment resulting from asymptomatic retinal breaks: prognosis for progression and regression.
        Ophthalmology. 2001; 108 (discussion 1503-1494.): 1499-1503
        • Davis MD
        The natural history of retinal breaks without detachment.
        Trans Am Ophthalmol Soc. 1973; 71: 343-372
        • Byer NE
        Long-term natural history of lattice degeneration of the retina.
        Ophthalmology. 1989; 96 (discussion 1401-1392.): 1396-1401
        • Haimann MH
        • Burton TC
        • Brown CK
        Epidemiology of retinal detachment.
        Arch Ophthalmol. 1982; 100: 289-292
        • Wilkes SR
        • Beard CM
        • Kurland LT
        • Robertson DM
        • O'Fallon WM
        The incidence of retinal detachment in Rochester, Minnesota, 1970-1978.
        Am J Ophthalmol. 1982; 94: 670-673
        • Van de Put MA
        • Hooymans JM
        • Los LI
        The incidence of rhegmatogenous retinal detachment in The Netherlands.
        Ophthalmology. 2013; 120: 616-622
        • Javitt JC
        • Tielsch JM
        • Canner JK
        • Kolb MM
        • Sommer A
        • Steinberg EP
        • Cataract Patient Outcomes Research Team
        National outcomes of cataract extraction: increased risk of retinal complications associated with Nd:YAG laser capsulotomy.
        Ophthalmology. 1992; 99: 1487-1498
        • Tielsch JM
        • Legro MW
        • Cassard SD
        • et al.
        Risk factors for retinal detachment after cataract surgery: a population-based case-control study.
        Ophthalmology. 1996; 103: 1537-1545
        • Eye Disease Case-Control Study Group
        Risk factors for idiopathic rhegmatogenous retinal detachment.
        Am J Epidemiol. 1993; 137: 749-757
        • Bernheim D
        • Rouberol F
        • Palombi K
        • Albrieux M
        • Romanet JP
        • Chiquet C
        Comparative prospective study of rhegmatogenous retinal detachments in phakic or pseudophakic patients with high myopia.
        Retina. 2013; 33: 2039-2048
        • Benson WE
        • Morse PH
        The prognosis of retinal detachment due to lattice degeneration.
        Ann Ophthalmol. 1978; 10: 1197-1200
        • Parma ES
        • Korkko J
        • Hagler WS
        • Ala-Kokko L
        Radial perivascular retinal degeneration: a key to the clinical diagnosis of an ocular variant of Stickler syndrome with minimal or no systemic manifestations.
        Am J Ophthalmol. 2002; 134: 728-734
        • Erie JC
        • Raecker MA
        • Baratz KH
        • Schleck CD
        • Burke JP
        • Robertson DM
        Risk of retinal detachment after cataract extraction, 1980-2004: a population-based study.
        Ophthalmology. 2006; 113: 2026-2032
        • Russell M
        • Gaskin B
        • Russell D
        • Polkinghorne PJ
        Pseudophakic retinal detachment after phacoemulsification cataract surgery: Ten-year retrospective review.
        J Cataract Refract Surg. 2006; 32: 442-445
        • Jahn CE
        • Richter J
        • Jahn AH
        • Kremer G
        • Kron M
        Pseudophakic retinal detachment after uneventful phacoemulsification and subsequent neodymium: YAG capsulotomy for capsule opacification.
        J Cataract Refract Surg. 2003; 29: 925-929
        • Kassem R
        • Greenwald Y
        • Achiron A
        • et al.
        Peak Occurrence of Retinal Detachment following Cataract Surgery: A Systematic Review and Pooled Analysis with Internal Validation.
        J Ophthalmol. 2018; 20189206418
        • Ranta P
        • Tommila P
        • Kivela T
        Retinal breaks and detachment after neodymium: YAG laser posterior capsulotomy: five-year incidence in a prospective cohort.
        J Cataract Refract Surg. 2004; 30: 58-66
        • Koch DD
        • Liu JF
        • Gill EP
        • Parke II, DW
        Axial myopia increases the risk of retinal complications after neodymium-YAG laser posterior capsulotomy.
        Arch Ophthalmol. 1989; 107: 986-990
        • Tuft SJ
        • Minassian D
        • Sullivan P
        Risk factors for retinal detachment after cataract surgery: a case-control study.
        Ophthalmology. 2006; 113: 650-656
        • Ramos M
        • Kruger EF
        • Lashkari K
        Biostatistical analysis of pseudophakic and aphakic retinal detachments.
        Semin Ophthalmol. 2002; 17: 206-213
        • Ranta P
        • Kivela T
        Retinal detachment in pseudophakic eyes with and without Nd:YAG laser posterior capsulotomy.
        Ophthalmology. 1998; 105: 2127-2133
        • Glacet-Bernard A
        • Brahim R
        • Mokhtari O
        • Quentel G
        • Coscas G
        Retinal detachment following posterior capsulotomy using Nd:YAG laser. Retrospective study of 144 capsulotomies [in French].
        J Fr Ophtalmol. 1993; 16: 87-94
        • Ficker LA
        • Vickers S
        • Capon MR
        • Mellerio J
        • Cooling RJ
        Retinal detachment following Nd:YAG posterior capsulotomy.
        Eye. 1987; 1: 86-89
        • Arya AV
        • Emerson JW
        • Engelbert M
        • Hagedorn CL
        • Adelman RA
        Surgical management of pseudophakic retinal detachments: a meta-analysis.
        Ophthalmology. 2006; 113: 1724-1733
        • Lois N
        • Wong D
        Pseudophakic retinal detachment.
        Surv Ophthalmol. 2003; 48: 467-487
        • Ripandelli G
        • Coppe AM
        • Parisi V
        • et al.
        Posterior vitreous detachment and retinal detachment after cataract surgery.
        Ophthalmology. 2007; 114: 692-697
        • Mirshahi A
        • Hoehn F
        • Lorenz K
        • Hattenbach LO
        Incidence of posterior vitreous detachment after cataract surgery.
        J Cataract Refract Surg. 2009; 35: 987-991
        • Cooling RJ
        Traumatic retinal detachment–mechanisms and management.
        Trans Ophthalmol Soc UK. 1986; 105: 575-579
        • Folk JC
        • Arrindell EL
        • Klugman MR
        The fellow eye of patients with phakic lattice retinal detachment.
        Ophthalmology. 1989; 96: 72-79
        • Rowe JA
        • Erie JC
        • Baratz KH
        • et al.
        Retinal detachment in Olmsted County, Minnesota, 1976 through 1995.
        Ophthalmology. 1999; 106: 154-159
        • Mastropasqua L
        • Carpineto P
        • Ciancaglini M
        • Falconio G
        • Gallenga PE
        Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study.
        Br J Ophthalmol. 1999; 83: 1046-1049
        • Sharma MC
        • Chan P
        • Kim RU
        • Benson WE
        Rhegmatogenous retinal detachment in the fellow phakic eyes of patients with pseudophakic rhegmatogenous retinal detachment.
        Retina. 2003; 23: 37-40
        • Kaiser RS
        • Trese MT
        • Williams GA
        • Cox Jr., MS
        Adult retinopathy of prematurity: outcomes of rhegmatogenous retinal detachments and retinal tears.
        Ophthalmology. 2001; 108: 1647-1653
        • Snead MP
        • Payne SJ
        • Barton DE
        • et al.
        Stickler syndrome: correlation between vitreoretinal phenotypes and linkage to COL 2A1.
        Eye. 1994; 8: 609-614
        • Brown DM
        • Graemiger RA
        • Hergersberg M
        • et al.
        Genetic linkage of Wagner disease and erosive vitreoretinopathy to chromosome 5q13-14.
        Arch Ophthalmol. 1995; 113: 671-675
        • Loewenstein A
        • Goldstein M
        • Lazar M
        Retinal pathology occurring after excimer laser surgery or phakic intraocular lens implantation: evaluation of possible relationship.
        Surv Ophthalmol. 2002; 47: 125-135
        • Ruiz-Moreno JM
        • Alio JL
        Incidence of retinal disease following refractive surgery in 9,239 eyes.
        J Refract Surg. 2003; 19: 534-547
        • Colin J
        • Robinet A
        • Cochener B
        Retinal detachment after clear lens extraction for high myopia: seven-year follow-up.
        Ophthalmology. 1999; 106 (discussion 2285.): 2281-2284
        • Chang JS
        • Meau AY
        Visian Collamer phakic intraocular lens in high myopic Asian eyes.
        J Refract Surg. 2007; 23: 17-25
        • Ruiz-Moreno JM
        • Montero JA
        • de la Vega C
        • Alio JL
        • Zapater P
        Retinal detachment in myopic eyes after phakic intraocular lens implantation.
        J Refract Surg. 2006; 22: 247-252
        • Feder RS
        • Olsen TW
        • Prum Jr., BE
        • et al.
        Comprehensive adult medical eye evaluation Preferred Practice Pattern® Guidelines.
        Ophthalmology. 2016; 123: P209-236
        • Austin KL
        • Palmer JR
        • Seddon JM
        • et al.
        Case-control study of idiopathic retinal detachment.
        Int J Epidemiol. 1990; 19: 1045-1050
        • Norregaard JC
        • Thoning H
        • Andersen TF
        • Bernth-Petersen P
        • Javitt JC
        • Anderson GF
        Risk of retinal detachment following cataract extraction: results from the International Cataract Surgery Outcomes Study.
        Br J Ophthalmol. 1996; 80: 689-693
        • Javitt JC
        • Vitale S
        • Canner JK
        • Krakauer H
        • McBean AM
        • Sommer A
        National outcomes of cataract extraction. I. Retinal detachment after inpatient surgery.
        Ophthalmology. 1991; 98: 895-902
        • Kraff MC
        • Sanders DR
        Incidence of retinal detachment following posterior chamber intraocular lens surgery.
        J Cataract Refract Surg. 1990; 16: 477-480
        • Geek U
        • Pustolla N
        • Baraki H
        • Atili A
        • Feltgen N
        • Hoerauf H
        Posterior vitreous detachment following intravitreal drug injection.
        Graefes Arch Clin Exp Ophthalmol. 2013; 251: 1691-1695
        • Boldrey EE
        Vitreous cells as an indicator of retinal tears in asymptomatic or not recently symptomatic eyes.
        Am J Ophthalmol. 1997; 123: 263-264
        • Brockhurst RJ
        Modern indirect ophthalmoscopy.
        Am J Ophthalmol. 1956; 41: 265-272
        • Natkunarajah M
        • Goldsmith C
        • Goble R
        Diagnostic effectiveness of noncontact slitlamp examination in the identification of retinal tears.
        Eye. 2003; 17: 607-609
        • Benz MS
        • Packo KH
        • Gonzalez V
        • et al.
        A placebo-controlled trial of microplasmin intravitreous injection to facilitate posterior vitreous detachment before vitrectomy.
        Ophthalmology. 2010; 117: 791-797
        • DiBernardo C
        • Blodi B
        • Byrne SF
        Echographic evaluation of retinal tears in patients with spontaneous vitreous hemorrhage.
        Arch Ophthalmol. 1992; 110: 511-514
        • Wilkinson CP
        What ever happened to bilateral patching?.
        Retina. 2005; 25: 393-394
        • Rabinowitz R
        • Yagev R
        • Shoham A
        • Lifshitz T
        Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage.
        Eye (Lond). 2004; 18: 253-256
        • Sandinha MT
        • Kotagiri AK
        • Owen RI
        • Geenen C
        • Steel DH
        Accuracy of B-scan ultrasonography in acute fundus obscuring vitreous hemorrhage using a standardized scanning protocol and a dedicated ophthalmic ultrasonographer.
        Clin Ophthalmol. 2017; 11: 1365-1370
        • Tan HS
        • Mura M
        • Bijl HM
        Early vitrectomy for vitreous hemorrhage associated with retinal tears.
        Am J Ophthalmol. 2010; 150: 529-533
        • Dhingra N
        • Pearce I
        • Wong D
        Early vitrectomy for fundus-obscuring dense vitreous haemorrhage from presumptive retinal tears.
        Graefes Arch Clin Exp Ophthalmol. 2007; 245: 301-304
        • Melamud A
        • Pham H
        • Stoumbos Z
        Early Vitrectomy for Spontaneous, Fundus-Obscuring Vitreous Hemorrhage.
        Am J Ophthalmol. 2015; 160 (e1071.): 1073-1077
        • Karahan E
        • Karti O
        • Er D
        • et al.
        Risk factors for multiple retinal tears in patients with acute posterior vitreous detachment.
        Int Ophthalmol. 2018; 38: 257-263
        • Ang GS
        • Townend J
        • Lois N
        Interventions for prevention of giant retinal tear in the fellow eye.
        Cochrane Database Syst Rev. 2012; CD006909
        • Chan CK
        • Mein CE
        • Crosson JN
        Pneumatic vitreolysis for management of symptomatic focal vitreomacular traction.
        J Ophthalmic Vis Res. 2017; 12: 419-423
        • Yu G
        • Duguay J
        • Marra KV
        • et al.
        Efficacy and safety of treatment options for vitreomacular traction: a case series and meta-analysis.
        Retina. 2016; 36: 1260-1270
        • Znaor L
        • Medic A
        • Binder S
        • Vucinovic A
        • Marin Lovric J
        • Puljak L
        Pars plana vitrectomy versus scleral buckling for repairing simple rhegmatogenous retinal detachments.
        Cochrane Database Syst Rev. 2019; 3CD009562
        • Garcia GA
        • Khoshnevis M
        • Yee KMP
        • Nguyen-Cuu J
        • Nguyen JH
        • Sebag J
        Degradation of contrast sensitivity function following posterior vitreous detachment.
        Am J Ophthalmol. 2016; 172: 7-12
        • Kokavec J
        • Wu Z
        • Sherwin JC
        • Ang AJ
        • Ang GS
        Nd:YAG laser vitreolysis versus pars plana vitrectomy for vitreous floaters.
        Cochrane Database Syst Rev. 2017; 6CD011676
        • Sebag J
        • Yee KM
        • Wa CA
        • Huang LC
        • Sadun AA
        Vitrectomy for floaters: prospective efficacy analyses and retrospective safety profile.
        Retina. 2014; 34: 1062-1068
        • Ivanova T
        • Jalil A
        • Antoniou Y
        • Bishop PN
        • Vallejo-Garcia JL
        • Patton N
        Vitrectomy for primary symptomatic vitreous opacities: an evidence-based review.
        Eye (Lond). 2016; 30: 645-655
        • Shah CP
        • Heier JS
        YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial.
        JAMA Ophthalmol. 2017; 135: 918-923
        • Benson WE
        • Morse PH
        • Nantawan P
        Late complications following cryotherapy of lattice degeneration.
        Am J Ophthalmol. 1977; 84: 514-516
        • Delaney Jr., WV
        Retinal tear extension through the cryosurgical scar.
        Br J Ophthalmol. 1971; 55: 205-209
        • American Academy of Ophthalmology
        Preoperative assessment: responsibilities of the ophthalmologist.
        https://www.aao.org/about/policies
        Date: 2012
        Date accessed: September , 2019
        • American Academy of Ophthalmology
        An ophthalmologist's duties concerning postoperative care - 2012.
        • Goldberg RE
        • Boyer DS
        Sequential retinal breaks following a spontaneous initial retinal break.
        Ophthalmology. 1981; 88: 10-12
        • Sharma MC
        • Regillo CD
        • Shuler MF
        • Borrillo JL
        • Benson WE
        Determination of the incidence and clinical characteristics of subsequent retinal tears following treatment of the acute posterior vitreous detachment-related initial retinal tears.
        Am J Ophthalmol. 2004; 138: 280-284
        • Saran BR
        • Brucker AJ
        Macular epiretinal membrane formation and treated retinal breaks.
        Am J Ophthalmol. 1995; 120: 480-485
        • Singh AJ
        • Seemongal-Dass RR
        The influence of counselling on patient return following uncomplicated posterior vitreous detachment.
        Eye. 2001; 15: 152-154
        • Wagle AM
        • Lim WY
        • Yap TP
        • Neelam K
        • Au Eong KG
        Utility values associated with vitreous floaters.
        Am J Ophthalmol. 2011; 152: 60-65
        • Sebag J
        Floaters and the quality of life.
        Am J Ophthalmol. 2011; 152: 3-4
        • Yannuzzi NA
        • Chang JS
        • Brown GC
        • Smiddy WE
        Cost-Utility of Evaluation for Posterior Vitreous Detachment and Prophylaxis of Retinal Detachment.
        Ophthalmology. 2018; 125: 43-50

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      • Corrigendum
        OphthalmologyVol. 127Issue 9
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          The authors of “Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern®” (Ophthalmology. 2020;127(1):P146-P181) would like to note the following correction to their author listing as it appears in PubMed:
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