CLINICAL

  the back

The RD Exam

Early detection is key to managing patients who have retinal breaks and detachment

SHERROL A. REYNOLDS O.D., F.A.A.O., FT. LAUDERDALE, FLA.

Early diagnosis and patient education, especially high-risk patients, about symptoms of retinal breaks and retinal detachment (RD), as well as the need for periodic follow-up, are crucial to proper treatment.

Risk factors

Risk factors for retinal breaks and RD include:

1. Systemic disease. Diseases such as diabetes, hypertension and atherosclerosis can potentially lead to a vitreous hemorrhage or other types of RD.

2. Advancing age.

3. History of prior RD or retinal tears or any prior ocular procedures.

4. Trauma.

5. Moderate to high myopia.

6. Lattice degeneration

7. Ocular disease. (Chronic uveitis, ocular tumors, retinopathy of prematurity and Stickler syndrome.)

8. Family history of RD.

9. Development of posterior vitreous detachment (PVD). According to Ophthalmology, approximately 8% to 26% of patients with acute PVD symptoms have a retinal tear. The presence of pigment cells (“tobacco dust” or Shafer’s sign) and/or red blood cells in the anterior vitreous is strongly indicative of a retinal tear or RD. They also suggest the presence of multiple breaks, and that the most likely location of the break is in the superior retina.

Diagnostic considerations

► Conduct a slit lamp exam. A good slit lamp evaluation is vital in assessing patients who have retinal breaks or RD. Some patients with an RD may have a low-grade uveitis; therefore, it’s important to check the anterior chamber for cells and flare.

► Employ condensing lenses. Wide-field lenses provide a large field of view or more magnification. Some lenses boast an upgraded light source along with scleral indentation, while others are comprised of a three-mirror lens that provides a detailed view of peripheral changes.

► Acquire fundus photography. Wide-field retinal imaging offers panoramic fundus assessment that can help to detect the presence of a retinal tear or RD.

► Perform SD-OCT. It can help you to detect the presence of a vitreomacular adhesion/traction as the underlying cause of the patient’s complaint and aid you in ascertaining the status of the macula.

• Employ ultrasound. A B-scan ultrasound can help you to identify media opacity (e.g., from vitreous hemorrhage or severe cataract).

Management

Knowing when to refer patients at risk of developing a retinal break or RD for surgical consultation is essential. Even asymptomatic patients with retinal breaks are at risk for the development of an RD. The American Academy of Ophthalmology’s 2014 published standard of care offers the most up-to-date management guidelines (see Table 1, page 23.).

Follow-up

Follow-up care varies depending on the type and degree of retinal break or RD (See Table 1 for recommendations.) However, long-term follow-up care is important, even when a patient has had adequate treatment. Between 5% and 14% of patients who have an initial retinal break will develop additional breaks during long-term follow-up, according to Ophthalmology. New breaks may occur in eyes that have had cataract surgery.

Case presentation

G.B., a 52-year-old female, presented for a routine eye exam with no visual complaints. Best-corrected visual acuity was 20/20 OD/OS. Dilated exam revealed an inferior retinal horseshoe tear with a cuff of sub retinal fluid and a pre-retinal hemorrhage OD (see Figure 1). Although asymptomatic, the clinical findings necessitated a retinal consultation and eventual treatment for this patient.

Figure 1: Horseshoe tear with a cuff of subretinal fluid and a pre-retinal hemorrhage.

On average, today’s practitioners find retinal breaks, or full-thickness defects in the retina (retinal tears and retinal holes), in about 5% to 10 % of the general population. Yet, the risk of a retinal break developing into a sight-threatening rhegmatogenous retinal detachment, the most common type of RD, is about one in 10,000 to 20,000 each year.

Although G.B. did not present with visual complaints, many patients who have retinal breaks and RD do, so it’s important to be aware of the red flags.

Floaters and flashes of light (photopsia) are the most common complaints. Floaters described as “cobweb” are typically consistent with collagen alterations from vitreous liquefaction (synchysis) and contraction (syneresis). Floaters described as a “big fly” or “ring-shaped” signal the possible presence of a Weiss ring in patients who have undergone an uncomplicated PVD. Small spots that resemble specks of pepper or cheesecloth are associated with vitreous hemorrhages. Bright flashes or streaks of light similar to a lightening streak are more indicative of retinal tears and detachments.

Vision loss is not uncommon, especially if the RD is large or affecting the macula. Further, peripheral visual field defects are described as a black curtain or shadow; the location of the field defect helps to further localize the RD. An afferent pupillary defect can be observed in patients who have chronic RD.

For G.B., she had laser photocoagulation treatment for the tear. She returned for a follow-up six weeks after treatment with resolution of traction, sub retinal fluid and preretinal hemorrhage of the tear. OM

Dr. Reynolds is an associate professor at the Nova Southeastern University College of Optometry. She is the clinical preceptor/attending in the college’s diabetes and macular clinic and a fellow in the Optometric Retinal Society. She serves as the chairperson for the Florida Optometric Association Healthy Eyes Healthy People Committee. Comment to optometricmanagement@gmail.com.