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A vitreous detachment by itself does not cause any visual problems. However, it is associated with a significant number of patients who have retinal tears or the formation of a macular hole. These are serious threats to the eyesight and so require immediate treatment. Thus, anyone who has the symptoms of vitreous detachment may also have a retinal break or detachment.
These symptoms include a sudden increase in floaters or in flashes of light in the peripheral field of vision. Such patients should consult an eye specialist for a detailed eye examination. In patients with an incomplete vitreous detachment, complete detachment of the vitreous is associated with the spontaneous resolution of photopsia.
At least 10-15% of these patients will have a retinal tear. This risk shoots up to almost 70% if there is vitreous bleeding associated with the posterior vitreous detachment. This is due to a tear or avulsion of a retinal blood vessel and often presents with a marked diminution of sight in the affected eye due to the presence of blood throughout the vitreous. Such patients have an increased risk of retinal tears and detachment.
Some measures that patients with vitreous hemorrhage may be asked to observe include avoiding the lifting of heavy weights, bending over and other taxing activity. This is to ensure that the bleeding into the vitreous settles to the bottom of the eye where it will not interfere with normal vision. For the same reason, the patient’s bed may be elevated at the head end. These steps will spare central vision. Such patients are not required to change or stop any anticoagulants or antiplatelet drugs they are on currently. These have never been shown to change the incidence or outcome of vitreous bleeds.
In patients with posterior vitreous detachment but without any tears or retinal detachment, it is advisable to examine both eyes using 360-degree scleral depression to inspect the area of the entire retina through a dilated pupil. Tears, detachment of the retina, vitreous traction on the macular, or the presence of blood or ‘tobacco dust,’ specks within the vitreous, are all looked for.
Retinal tears are not necessarily dangerous, but may lead to detachment of the neurosensory retinal membrane. This is because fluid from the eye chambers seeps under the retina at the edges of the tear, leading to subretinal accumulation. This pushes up and peels off the retina from the underlying nutritive retinal pigment epithelium. For this reason, retinal tears which are detected before the onset of retinal detachment are treated by the application of laser or cryotherapy.
If the vitreous detachment is associated with retinal breaks or detachment, treatment is directed towards the latter condition. This may include drainage of the subretinal fluid with scleral buckling, along with laser retinopexy or cryoretinopexy. Pneumatic retinopexy holds the retina pressed against the eye to hasten the process of reattachment, while vitrectomy may be necessary if there is vitreomacular traction or vitreous hemorrhage.
Laser retinopexy (also called ‘laser barricade’ or ‘laser demarcation’) is an outpatient procedure to treat retinal breaks before macular detachment occurs. Laser energy is used to produce small controlled burns around the edges of the tear, which will heal by fibrosis, binding down the retina firmly.
Once it has been confirmed that the vitreous detachment is isolated, follow-up examinations are recommended at regular intervals thereafter. The period between examinations depends, of course, on the presence of blood in the vitreous or other signs which could increase the likelihood of retinal detachment. Thus the first re-visit may be after a week or a month, according to the nature of the detachment.