Q. What’s the standard of care for examination when a patient presents with a posterior vitreous detachment (PVD)?The standard of care for a PVD suspect is a dilated fundus exam with BIO and scleral depression, says Kevin L. Alexander, O.D., Ph.D., of Retina Vitreous Associates in Toledo, Ohio. A PVD can be difficult to see and diagnose, he adds. PVD symptoms include photopsia and floaters. But retinal tears may produce the same symptoms, so examine the patient carefully to rule out all possible causes.
To better view the vitreous and peripheral retina, maximally dilate the pupils. Besides BIO and scleral depression, use the biomicroscope to carefully evaluate the vitreous and anterior chamber. This will establish that the vitreous has collapsed and rule out other causes of floaters, such as red blood and pigment cells associated with retinal detachments, or even white blood cells due to inflammation or tumors, Dr. Alexander says.
“Treat patients with these symptoms as emergencies. Schedule an evaluation immediately,” says Nicholas J. Leonardy, M.D., also at Toledo’s Retina Vitreous Associates. “Because symptoms alone cannot distinguish an uncomplicated PVD from a PVD with a retinal tear or detachment, the thoroughness of the retinal examination is the key to successful management.” Carefully record the results in the patient’s chart as well as the techniques you used for the exam and a drawing of your findings, Dr. Leonardy says.
Q. Once I find PVD, should I refer the patient for a retinal consult? What is the comanagement or follow-up schedule?Most patients with PVD don’t require retinal consultation, Dr. Alexander says. Base your decision to refer on the difficulty in examining the patient, the ocular history (eye trauma, ocular surgery, myopia, previous retinal tears or detachment, or family history of retinal detachment), and your own skill level as a practitioner.
Consider how good your BIO and scleral depression skills are (see “A Better Way to Do BIO,” September 1999). Only an exhaustive examination of the retina and periphery can rule out a retinal tear or detachment. If can obtain a good view and you’re certain there’s no retinal pathology, then you may follow the patient. On the other hand, if you cannot rule out associated retinal disease, then a consult would be helpful, Dr. Alexander says.
Certain red flags will dictate a consult, Dr. Leonardy says. If you see blood or pigmented cells in the vitreous, assume there is a tear and refer the patient. Lattice degeneration in the periphery should prompt you to consider a consult too. Also, refer the patient who is difficult to examine due to media opacity, limited pupil dilation, nystagmus or other factors.
“The management and schedule of follow-up visits for a patient with PVD is the same whether the retinal specialist or O.D. is responsible,” Dr. Alexander says. “If the referring O.D. is uncomfortable with BIO and scleral depression, or if there is a complication such as blood on the surface of the retina, then it’s probably best for the retinal specialist to follow the patient. In totally uncomplicated PVD, or where the referring O.D. is very experienced in retinal evaluation, the patient may be returned for follow-up.”
For uncomplicated PVD, see the patient again in one month and then in 3-6 months, Dr. Alexander says. Again, examine the peripheral retina carefully with scleral depression. Late tears are rare, Dr. Leonardy says, but do occur in 1-2% of patients, usually within the first two months following the initial event.
Most patients with uncomplicated PVD report rapid resolution of photopsia and gradually decreasing floaters, Dr. Leonardy says. Instruct patients to call you immediately if they experience new symptoms.
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