Posterior vitreous detachment

Background

• Separation of posterior vitreous from the retina, as a result of vitreous degeneration and shrinkage
• Age-related event (prevalence):
  • 50-59 yrs = 24%
  • 80-90 yrs = 87
• in the majority of cases PVD is benign
• in acute phase, concern is for causing retinal tear, which can lead to retinal detachment
• Prompt diagnosis and surgical treatment of retinal detachment can prevent impending vision loss or can restore vision

Risk factors

• myopia
• trauma
• intraocular inflammation

Evaluation

• May be asymptomatic
• More frequently:
  • Floaters
  • Flashes

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
• Nonocular causes
  • Migraine aura (classic)
  • Migraine aura (acephalgicmigraine)
  • Occipital lobe disorders
  • Postural hypotension

Management

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

References

Authors

Ross Donaldson, Neil Young, Daniel Ostermayer