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Symptoms Predictive for the Later Development of Retinal Breaks
Koen A. van Overdam, MD;
Marijke Wefers Bettink-Remeijer, MD;
Paul G. Mulder, PhD;
Jan C. van Meurs, MD
Arch Ophthalmol. 2001;119:1483-1486.
ABSTRACT
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Objective To identify symptoms in patients with isolated posterior vitreous detachment
predictive for the later development of retinal breaks.
Methods Two hundred eighty consecutive patients seen with symptoms of posterior
vitreous detachment were prospectively asked to complete a questionnaire detailing
their symptoms. At the time of presentation and follow-up, all patients had
a full ophthalmologic examination including slitlamp biomicroscopy with Goldmann
3-mirror contact lens after maximal pupil dilatation. Two hundred fifty patients
with an isolated posterior vitreous detachment were included and reexamined
6 weeks after the onset of symptoms. If small retinal or vitreous hemorrhages
were detected, patients were reexamined after 2 weeks.
Results In 13 patients (5.2%) a retinal break was detected at reexamination.
Logistic regression analysis with backward elimination revealed that symptoms
of flashes in combination with clouds or multiple (>10) small dots at the
time of the initial examination or an increase of floaters after the initial
examination were statistically significantly (P<.001)
related to the development of new breaks. These symptoms had a predictive
value for the presence or absence of a new retinal break of 75.0% and 99.6%,
respectively.
Conclusions Specific symptoms can identify patients at risk for the development
of new retinal breaks after an initial examination in which no abnormalities
were found and may obviate the need for follow-up appointments of patients
not at risk.
INTRODUCTION
APOSTERIOR vitreous detachment (PVD) is a common, degenerative process
in which the vitreous cortex separates from the retina. At least 20% of patients
with PVDs may be asymptomatic, but patients often describe a variety of acute
symptoms including floaters and flashing lights.1-2
These patients make up a significant portion of cases presenting to ophthalmic
casualty departments. At the initial examination between 10% and 30% of these
patients may have retinal breaks or retinal detachments requiring immediate
treatment.3-8
The remainder of these patients will be diagnosed as having an isolated PVD
and are generally reexamined 6 weeks after the onset of symptoms, because
in a few patients new retinal breaks may develop during this time frame.5, 7 Consequently, the management of an
isolated PVD consumes considerable resources in time for both the ophthalmologist
and the patient.
This prospective study of patients with symptoms of PVD was designed
to identify specific symptoms that may predict the later development of new
retinal breaks. If predicting symptoms could be identified, this information
can be used to schedule follow-up visits only for patients at risk.
PATIENTS AND METHODS
A prospective study of consecutive patients initially evaluated in the
casualty department of the Rotterdam Eye Hospital, Rotterdam, the Netherlands,
a community-based tertiary referral center, with acute symptoms suggestive
of a PVD such as flashes or floaters was performed during a 10-month period
between January 1, 1999, and October 31, 1999. Patients with preexisting ocular
diseases and/or a history of ocular surgery or blunt trauma were excluded
from this study.
All patients gave informed consent and completed a questionnaire detailing
their symptoms at the initial examination and at their second visit. Patients
were asked to draw and describe the flashes and floaters they experienced
(ie, shape, color, number, location, and movement). The number of floaters
was used to divide the study group into the following 4 classifications: A,
patients with 1 to 3 floaters; B, patients with between 3 and 10 floaters;
C, patients with more than 10 floaters; and D, patients describing a curtain
or cloud. An increase in the number of floaters after the initial examination
was defined as a change of group A or B floaters to group C or D floaters.
Subjective vision reduction (SVR) was defined as the report of blurred vision
not corresponding to a decrease in Snellen visual acuity. All patients had
a full ophthalmologic examination at the first and second visit including
indirect ophthalmoscopy and slitlamp biomicroscopy with a Goldmann 3-mirror
contact lens after maximal pupil dilatation. Scleral indentation was not performed,
nor was examination of the anterior vitreous for pigment granules part of
the examination. Posterior vitreous detachment was only diagnosed when the
site of the hyaloid detachment to the optic disc (Weiss ring) could be identified
within the vitreous cavity. Findings from the 2 examinations were recorded
on a customized form.
Patients found to have retinal breaks or retinal detachments at the
first examination were referred for treatment and were excluded from the study
group. If no preretinal or vitreous hemorrhages were found at the initial
examination, patients were scheduled for a reexamination 6 weeks after the
onset of symptoms. If retinal or vitreous hemorrhages in the absence of retinal
tears were found, patients were scheduled for a reexamination 2 and 4 weeks
after the initial examination. All patients were instructed to return earlier
if symptoms worsened. Patients were discharged from follow-up if no significant
pathologic abnormality was found at the 6-week examination.
All data were entered into a database. To correlate specific symptoms
and signs at the initial examination and during follow-up visits with the
later development of retinal breaks, logistic regression analysis with backward
elimination was performed, with the likelihood ratio to test for statistical
significance.
RESULTS
During the 10-month study period, 280 patients with symptoms of PVDs
were examined in our ophthalmic casualty department and completed a questionnaire.
Thirty patients were found to have retinal breaks or detachments at the initial
examination and were excluded from the study. Of the 250 patients diagnosed
as having an isolated PVD, 13 patients developed a retinal break after the
initial examination (12 horseshoe tears and 1 operculated break).
Two hundred ten patients were given follow-up appointments 6 weeks after
the initial examination of which 8 developed a retinal break. Seven of these
retinal breaks were detected at the 6-week examination. Of the 40 patients
scheduled for reexamination after 2 weeks because of retinal or vitreous hemorrhages,
new retinal tears were found in 5. Seven patients returned to the ophthalmic
casualty department prior to their scheduled follow-up appointment because
of worsening symptoms. A retinal break was found in 1 of these patients.
At the initial examination 21 of the 250 patients with isolated PVDs
had symptoms of flashes alone (Table 1).
One of these patients had developed a new retinal break at the 6-week reexamination.
This patient developed floaters (group D) after the initial examination. Thirty-four
patients mentioned floaters only, of which none was found to have a retinal
break at follow-up. No patients mentioned SVR only.
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Table 1. Symptoms at the Initial Evaluation of 250 Patients With Isolated
Posterior Vitreous Detachment and the Number of New Retinal Breaks at Follow-up
Visits
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The combination of flashes and floaters without SVR was mentioned by
116 patients. Seven of these patients developed a new retinal break after
the initial examination. Sixty-eight patients mentioned SVR in combination
with both floaters and flashes, of which 5 were found to have new retinal
breaks. Eleven patients described SVR in combination with floaters or flashes.
None of them developed a retinal break after the initial examination.
Apart from the 7 patients returning earlier because of a worsening of
symptoms, a worsening of symptoms was mentioned by a further 24 patients at
the scheduled 6-week appointment. At the initial examination 137 patients
classified their floaters in group A (1-3 floaters). Only 1 patient with this
number of floaters was found to have a retinal break at follow-up (Table 2 and Table 3). This patient mentioned an increase in the number of floaters
to group C (>10 floaters) at reexamination. Sixty-eight patients classified
their floaters as group B (3-10 floaters), of which 2 patients developed a
new retinal break. At the second visit the number of floaters had increased
to group C in both patients. Twelve patients described more than 10 floaters
or dots (group C) at the initial examination. Six of these patients developed
a new retinal break after the initial examination. Eleven patients mentioned
a curtain or cloud (group D) at the first visit. Three of them appeared to
have a retinal break at follow-up. No retinal breaks were detected in the
4 patients who noticed more flashes at follow-up.
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Table 2. Findings From 250 Patients With Isolated Posterior Vitreous
Detachment Who Have Floaters and the Number of New Retinal Breaks Found at
Follow-up Visits
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Table 3. Change of Symptoms After the Initial Examination of 250 Patients
With Isolated Posterior Vitreous Detachment and the Number of New Retinal
Breaks at Follow-up Visits
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Two of 9 patients with a positive family history of retinal detachment,
3 of 24 patients who had a history of retinal breaks, 4 of 64 patients with
myopia of more than 2 diopters, 2 of 11 patients with lattice, and none of
the 21 pseudophakic patients (Table 4)
developed a retinal break at follow-up. At the initial examination, 18 patients
were found to have a vitreous hemorrhage; 3 developed a retinal break. Of
22 patients with retinal hemorrhages at the initial examination, only 2 had
a retinal break at follow-up.
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Table 4. Relevant History and Clinical Findings at the Initial Examination
and Number of Retinal Breaks at Follow-up Visits
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Logistic regression analysis with backward elimination of all relevant
factors revealed that only the combination of flashes and more than 10 floaters
(group C floaters) or a cloud or curtain (group D floaters) at the initial
examination and an increase in the number of floaters after the initial examination
were significantly (P<.001) related to the development
of new retinal breaks. Using this analysis a predictive value to predict and
exclude the development of a new retinal break could be estimated of 75.0%
and 99.6%, respectively.
COMMENT
Many patients visit the ophthalmic casualty department because of symptomatic
PVDs. Up to one third of these patients may have retinal breaks or retinal
detachments at the initial examination. The remainder will be reexamined usually
6 to 8 weeks after the onset of symptoms, but only a few patients may develop
a new retinal break in this time frame. These reexaminations claim considerable
time and manpower of the ophthalmic casualty department, as each visit requires
a detailed dilatated fundus examination. In this study we tried to isolate
specific symptoms or clinical signs at the initial examination that may predict
the later development of retinal breaks to better enable us to schedule follow-up
visits only for patients at risk.
In our study 13 patients (5.3%) developed new retinal breaks after the
initial examination. Analysis of specific symptoms revealed that patients
had difficulty with describing flashes in detail, but that they were better
able to detail their report of floaters. Logistic regression analysis with
backward elimination showed that the following factors significantly (P<.001) contribute to the prediction of new retinal
breaks: symptoms of light flashes, more than 10 floaters or a cloud or curtain
at the initial examination, and an increase in the number of floaters after
the initial examination. Using these symptoms we are able to identify all
patients with new retinal breaks in this study.
In a retrospective study of Dayan et al7
(n = 158), 3 of all reviewed patients with an isolated PVD were found to have
a retinal break at follow-up. In contrast with our findings, this study revealed
that the presence of SVR instead of the report of flashes and/or floaters
was highly predictive for the development of a new retinal break. In our study,
SVR was not an independent predictor for the development of retinal breaks,
whereas detailed analysis of the symptoms proved the number of floaters to
be an independent predictor.
The focus of our study was to determine factors that can identify patients
with isolated PVDs who are at risk for the development of new breaks, whereas
previous studies elucidated findings to identify patients with breaks at the
initial examination.5-10
In contrast with previous study findings, we found symptoms of flashes and
floaters to be predictive for the development of new retinal breaks. This
may be explained by the fact that our study was prospective and incorporated
a standardized and detailed history taking form.
Compared with the findings from previous studies,5, 7
we found more retinal breaks at follow-up, whereas the number of retinal breaks
or retinal detachments found at the initial examination (12%) in our study
is lower. The latter difference may be caused by the fact that our institution
not only has a general emergency unit that serves the local community, but
also is a referral center where patients with retinal breaks or detachments
are directly sent in for treatment, bypassing the emergency unit. Furthermore,
because this study concerned patients with an initial isolated PVD, several
patients with breaks or detachments detected at the emergency unit were directly
forwarded for treatment while their data were erroneously not processed for
the study.
Our study findings showed that only patients who mention symptoms of
light flashes in combination with multiple floaters or a cloud or curtain
at the initial examination must be reexamined within 6 weeks. A follow-up
visit for all other patients with an isolated PVD is only necessary if these
symptoms occur or worsen after the initial visit. With these data it is possible
to decrease the number of scheduled follow-up visits by 76%.
However, before we implement our conclusions, we will start another
study to validate the predictive power of the presence or absence of light
flashes in combination with group C or D floaters or an increase in the number
of floaters for the development of a retinal break at the second visit.
AUTHOR INFORMATION
Accepted for publication May 24, 2001.
Corresponding author: Jan C. van Meurs, MD, Rotterdam Eye Hospital,
Schiedamse Vest 180, 3011 BH Rotterdam, the Netherlands (e-mail: janvanmeurs{at}cs.com).
From the Vitreo-Retinal Department, Rotterdam Eye Hospital (Drs van
Overdam, Bettink-Remeijer, and van Meurs), and the Department of Epidemiology
and Biostatistics, Erasmus University Medical Centre–Rotterdam (Dr Mulder),
Rotterdam, the Netherlands.
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