Posterior vitreous detachment

Background

Eye anatomy.

• A common age-related condition in which the vitreous gel that fills the eye separates from the retina.
• Separation of posterior vitreous from the retina, as a result of vitreous degeneration and shrinkage
• Usually benign, however in acute phase can occasionally lead to serious complications such as retinal tears or detachment .
  • Prompt diagnosis and surgical treatment of retinal detachment can prevent impending vision loss or can restore vision

Risk factors

• Age (prevalence):
  • 50-59 yrs = 24%
  • 80-90 yrs = 87%
• Myopia
• Trauma
• Intraocular inflammation
• Ocular surgery

Clinical Features

• Sudden onset of floaters (black spots, cobwebs)
• Flashes of light (photopsia), especially in peripheral vision
• A curtain or shadow in the visual field (if associated with retinal tear/detachment)
• Blurred vision or mild visual disturbances
• Often asymptomatic in early stages or in less dramatic detachments

Differential Diagnosis

Acute onset flashers and floaters

• Ocular causes
  • Floaters and/or flashes
    • Posterior vitreous detachment
    • Retinal tear or retinal detachment
    • Posterior uveitis
  • Predominantly floaters
    • Vitreous hemorrhage secondary to proliferative retinopathy
    • Sympathetic ophthalmia
  • Predominantly flashes
    • Oculodigital stimulation
    • Rapid eye movements
    • Neovascular age-related macular degeneration
• Non-ocular causes
  • Intraocular foreign body
  • Migraine aura (classic)
  • Migraine aura (acephalgicmigraine)
  • Occipital lobe disorders
  • Postural hypotension

Evaluation

Fundoscopic exam showing a Weiss ring: a large, ring shaped floater that is sometimes seen if the vitreous body releases from the back of the eye.

Workup

• Detailed history (onset, nature of floaters/flashes, visual changes)
• Visual acuity testing
• Pupillary examination (look for afferent pupillary defect)
• Dilated fundoscopic exam (to assess for retinal tear or detachment)
• Slit-lamp exam with vitreous evaluation
• B-scan ocular ultrasound if fundus not visible due to hemorrhage or opacity

Diagnosis

• Clinical diagnosis based on symptoms and direct visualization of a detached posterior hyaloid membrane or Weiss ring on fundoscopic or slit-lamp exam
• Confirm absence of retinal tear or detachment via dilated eye exam or imaging

Management

• See disposition chart below
• No specific ED; focus of care is in determination of rapidity of ophthalmologic evaluation

Disposition

Referral of patients with presumed posterior vitreous detachment

Clinical Assessment	Disposition
Floaters and/or flashes with “red flag” sign of acute Retinal Detachment Monocular visual field loss (“curtain of darkness”)	Same-day (immediate) referral to retinal surgeon (minutes may matter) High risk of Retinal Detachment
New-onset floaters and/or flashes with high-risk features: Subjective or objective visual reduction examination Vitreous hemorrhage or vitreous pigment on slitlamp examination	Same-day referral to ophthalmologist or retinal surgeon
New-onset floaters and/or flashes without high-risk features	Referral to ophthalmologist within 1 to 2 weeks Counsel patient regarding high-risk features
Recently diagnosed uncomplicated posterior vitreous detachment with New shower of floaters New subjective visual reduction	Rereferral to ophthalmologist to rule out new retinal tear or detachment Contact ophtho to help determine urgency
Stable symptoms of floaters and/or flashes for several weeks to months, not particularly bothersome to the patient and without high-risk features	Elective referral to ophthalmologist Counsel patient regarding high-risk features that should prompt urgent reassessment

See Also

• Acute Onset Flashers and Floaters