Clinical Management of Posterior Vitreous Detachment
All patients presenting with symptoms of PVD require immediate comprehensive dilated fundus examination with indirect ophthalmoscopy and mandatory scleral depression to detect retinal tears, as 15% of tears are missed without indentation and symptoms alone cannot distinguish complicated from uncomplicated PVD. 1
Initial Evaluation and Risk Stratification
Mandatory Examination Components
Perform dilated indirect ophthalmoscopy with scleral depression in every case—this is non-negotiable as slit-lamp biomicroscopy alone misses 15% of retinal tears that are only visible with indentation 1
Assess the vitreous for three critical findings: hemorrhage, pigmented cells (Shafer's sign), and detachment status 1
Document axial length if available, as longer eyes have higher complication rates 1, 2
Note lens status—pseudophakic eyes have 1.85 times higher odds of delayed retinal detachment compared to phakic eyes 2
When Retinal Visualization is Compromised
B-scan ultrasonography is mandatory when media opacity prevents adequate retinal examination, with sensitivity for detecting retinal tears ranging from 44-100% 1
OCT imaging can help evaluate and stage the PVD 1
Risk-Based Management Algorithm
High-Risk Features Requiring Intensive Monitoring
Patients with any of the following warrant closer follow-up:
Vitreous hemorrhage at presentation—42% will have concurrent or delayed retinal breaks, and 10.5% will develop retinal detachment 2
Vitreous pigment (tobacco dust)—indicates higher risk of retinal tear 1
Visible vitreoretinal traction on examination 1
Male sex—men have 30% complication rate versus 21.7% in women 2
Lattice degeneration or peripheral retinal degeneration—44.2% experience complications 2
History of retinal break or detachment in fellow eye—significantly increases risk at all time points 2
Pseudophakia—nearly double the risk of delayed retinal detachment 2
Uncomplicated PVD (No Retinal Breaks Found)
Schedule follow-up examination within 6 weeks for patients with high-risk features listed above 1
Approximately 2% of patients with initially uncomplicated PVD will develop retinal breaks in subsequent weeks 1, 3
Extended follow-up is critical as 19.2% of retinal breaks and 25.8% of retinal detachments are first detected within 6 months after initial PVD 2
When Retinal Tears Are Detected
Treat immediately with laser photocoagulation or cryotherapy—prompt treatment reduces retinal detachment risk from 50% to less than 5% 1, 3
Symptomatic horseshoe or flap tears with persistent vitreoretinal traction have at least 50% risk of progressing to retinal detachment if untreated 3
Note that 9% of patients with retinal tears at initial assessment develop additional tears within 2 months 4
Dense Vitreous Hemorrhage Management
Consider early vitrectomy within 7 days when dense PVD-associated vitreous hemorrhage prevents adequate retinal examination and a tear is suspected on ultrasonography—this reduces risk of macula-involving retinal detachment 1
If hemorrhage is less dense, conduct weekly follow-up examinations until hemorrhage resolves sufficiently to allow peripheral examination 1
Critical Patient Education
Instruct every patient to return immediately if they experience:
- Substantial increase in floaters 1
- New or persistent flashes of light 1
- Loss of peripheral visual field 1
- Decrease in visual acuity 1
This education is crucial because even patients with only one to two floaters and light flashes can have retinal tears (29% in one study) or progress to retinal detachment within 2.5-3 weeks 5
Treatment Options for Symptomatic Floaters
Conservative Management
- Observation is the primary approach—most symptoms diminish over time, though this may require several months 1
Interventional Options (When Quality of Life is Significantly Affected)
Pars plana vitrectomy may be considered if symptomatic floaters remain bothersome after several months and substantially affect quality of life 1
Ocriplasmin (microplasmin) has modest efficacy—31% PVD induction versus 10% placebo, but 20% still require vitrectomy within 6 months and adverse event rates are higher 1
Pneumatic vitreolysis with gas bubble injection shows similar release rates to vitrectomy and greater effectiveness than ocriplasmin by day 28 1
Common Pitfalls to Avoid
Never rely on presence or absence of Weiss ring—32% of eyes with retinal tears have no visible Weiss ring 4
Never skip scleral depression—15% of retinal tears are only visible with indentation 1, 4
Never dismiss patients with minimal symptoms—even one to two floaters with flashes can indicate retinal tears in up to 29% of cases 5
Never assume fellow eye is safe—7% have asymptomatic retinal tears in the fellow eye at presentation 4
Never discharge after single normal examination in high-risk patients—complications continue to emerge throughout 6-month follow-up period, with 25.8% of retinal detachments first detected during follow-up 2