What is the treatment for posterior vitreous detachment (PVD)?

Treatment of Posterior Vitreous Detachment

Uncomplicated posterior vitreous detachment requires observation only, with no specific treatment necessary, as symptoms typically resolve spontaneously over several months. 1

Initial Management Approach

The primary management of PVD is observation with patient education and risk stratification based on examination findings. 2, 1

Mandatory Initial Evaluation

• Comprehensive dilated examination with indirect ophthalmoscopy and scleral depression is non-negotiable, as 15% of retinal tears are only visible with indentation and missed on slit-lamp biomicroscopy alone. 1, 3
• Assess the vitreous for hemorrhage, pigmented cells (suggesting retinal break), and detachment status. 1
• B-scan ultrasonography is mandatory when media opacity prevents adequate retinal visualization. 4, 1

Treatment Based on Findings

For uncomplicated PVD (no retinal breaks):

• Observation is the definitive treatment, as most floaters and flashes diminish over time without intervention. 1
• Symptoms may take several months to resolve completely. 1
• No pharmacologic or surgical intervention is indicated initially. 1

For PVD with retinal tears:

• Symptomatic horseshoe tears require immediate treatment with laser photocoagulation or cryotherapy to create chorioretinal adhesion around the tear. 4, 1
• This reduces the risk of retinal detachment from 50% (if untreated) to less than 5%. 4, 5
• Treatment should extend to the ora serrata if the tear cannot be completely surrounded. 4

For PVD with vitreous hemorrhage:

• Weekly follow-up examinations until hemorrhage resolves sufficiently to examine the peripheral retina. 1
• Early vitrectomy within 7 days should be considered for dense vitreous hemorrhage to reduce risk of macula-involving retinal detachment, particularly when a tear is suspected on ultrasonography. 1

Follow-Up Protocol

Standard Follow-Up for Uncomplicated PVD

• Selected high-risk patients should return within 6 weeks following symptom onset, particularly those with vitreous pigment, vitreous/retinal hemorrhage, or visible vitreoretinal traction. 1
• Patients with acute PVD and no retinal breaks have approximately 2% chance of developing retinal breaks in the following weeks. 4, 1
• Recent evidence suggests that asymptomatic patients with negative initial examination may have limited benefit from routine follow-up. 6

Follow-Up After Treatment of Retinal Tears

• First follow-up visit at 1-2 weeks after treatment. 4
• Indirect ophthalmoscopy with scleral depression at 2-6 weeks to determine adequacy of chorioretinal scar. 4
• Between 5% and 14% of patients will develop additional breaks during long-term follow-up. 4

Treatment Options for Persistent Symptomatic Floaters

If floaters remain bothersome after several months and significantly affect quality of life, consider:

• Pars plana vitrectomy as the most definitive option for persistent symptomatic floaters. 1
• Ocriplasmin (microplasmin) for pharmacologic vitreolysis 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 can induce PVD with similar release rates to vitrectomy and greater effectiveness than ocriplasmin by day 28. 1

Critical Patient Education

All patients must be instructed to report immediately if they experience: 4, 1

• Substantial increase in floaters
• New or persistent flashes of light
• Loss of peripheral visual field (described as a curtain or shadow)
• Decrease in visual acuity

This education improves the likelihood of prompt reporting and enhances opportunity for successful treatment before macular involvement, which is the single most important factor determining visual prognosis. 5

Common Pitfalls to Avoid

• Never rely on slit-lamp biomicroscopy alone—15% of retinal tears are only visible with scleral depression. 1, 3
• Absence of Weiss ring does not exclude PVD or retinal tears (Weiss ring was absent in 32% of eyes with retinal tears in one study). 3
• Symptoms alone cannot reliably distinguish PVD with or without retinal breaks, making peripheral examination mandatory. 1
• Patients who undergo refractive surgery to reduce myopia remain at risk of retinal detachment despite reduction of refractive error. 2

Special Populations

• Myopic patients and those with trauma history have earlier PVD onset and higher complication rates. 1
• Younger myopic patients with lattice degeneration and holes need regular follow-up to monitor for subclinical retinal detachments. 4