What is the recommended practice management for retinal tears?

Practice Management for Retinal Tears

Acute horseshoe retinal tears and traumatic breaks require immediate treatment with laser photocoagulation or cryotherapy to create chorioretinal adhesion, reducing the risk of retinal detachment from over 50% to less than 5%. 1, 2

Risk Stratification: Which Tears Require Treatment

High-Risk Tears (Immediate Treatment Required)

• Horseshoe (flap) tears with persistent vitreoretinal traction must be treated promptly, as at least 50% will progress to clinical retinal detachment if left untreated 1, 2
• Traumatic retinal breaks require treatment regardless of symptoms 1
• Any tear associated with vitreous hemorrhage, vitreous pigment (Shafer's sign), or visible vitreoretinal traction warrants immediate intervention 2

Low-Risk Tears (Observation Acceptable)

• Asymptomatic atrophic or operculated retinal breaks rarely need treatment, as long-term studies following 74 eyes over 5-11 years showed zero progression to retinal detachment 1, 3
• Atrophic round holes within lattice lesions with minimal non-progressive subretinal fluid can be observed 1
• Eyes lacking evidence of posterior vitreous detachment (PVD) generally do not require prophylactic treatment 1

Treatment Technique: Critical Technical Points

Laser Photocoagulation or Cryotherapy

• Treatment must extend to the ora serrata if the tear cannot be completely surrounded 1
• The most common cause of treatment failure is inadequate treatment along the anterior border where visualization is difficult 1, 4
• Create a complete chorioretinal adhesion barrier around the entire tear with adequate margins 2

When to Consider Vitrectomy

• Horseshoe tears with bridging vessels represent high-risk configurations where vitreous traction may extend the tear beyond treated areas, making pars plana vitrectomy (PPV) advantageous for complete vitreous removal 4
• If a tear has already progressed to clinical retinal detachment, surgical repair (PPV or scleral buckling) is mandatory, as more than 95% of uncomplicated cases can be successfully repaired 3, 4

Follow-Up Protocol: When New Tears Develop

Initial 6-Week Critical Period

• All patients with acute PVD require re-examination within 6 weeks of symptom onset, as this is when new retinal breaks most commonly develop 1, 2
• Patients presenting with acute PVD and no initial retinal breaks still have a 2-5% chance of developing breaks in the following weeks 1, 2
• Approximately 80% of patients who later develop breaks had either pigmented cells, hemorrhage, or visible vitreoretinal traction at initial evaluation 2

Long-Term Surveillance

• Between 5% and 14% of patients with an initial retinal break will develop additional breaks during long-term follow-up 1, 3
• Cataract surgery is a specific risk factor for new retinal breaks requiring heightened vigilance 1

Examination Requirements

Essential Components

• Examination must be performed by an ophthalmologist skilled in binocular indirect ophthalmoscopy with scleral depression 2
• Visual acuity testing, pupillary assessment for relative afferent pupillary defect, and vitreous examination for hemorrhage or pigmented cells are mandatory 2
• If media opacity or poor patient cooperation precludes adequate peripheral retinal examination, B-scan ultrasonography must be performed 2

Patient Education: Warning Signs Requiring Immediate Return

Instruct all patients to return immediately if they experience:

• Increase in number of floaters 2
• New flashes of light (photopsias) 2
• Peripheral visual field loss (shadow or curtain) 2
• Sudden decrease in visual acuity 2

Common Pitfalls to Avoid

• Failing to extend treatment to the ora serrata anteriorly is the most common technical error leading to treatment failure 1, 4
• Assuming asymptomatic horseshoe tears are benign—approximately 5% still progress to detachment and warrant treatment consideration 3
• Discharging patients after initial normal examination without scheduling 6-week follow-up when high-risk features (vitreous pigment, hemorrhage, traction) are present 2
• Underestimating the urgency of early repair before macular involvement, as this is the single most important factor determining visual prognosis 3