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Watch for signs of serious retinal conditions during routine exams
---The typical presentation of a detached retina is a tear in a horseshoe pattern. Patients should be made aware of warning signs of a detachment, such as increasing flashers or floaters and progressive loss of vision.
Early detection of retinal conditions offers patients the greatest chance of avoiding significant vision loss. When a fresh symptomatic retinal tear is detected in a patient, urgent laser treatment is necessary to prevent detachment. Detecting the early signs of diabetic retinopathy and beginning the appropriate management protocol is critical for ensuring that patients maintain as much vision as possible. Optometrists need to keep the risk factors for these severe conditions in mind when conducting otherwise routine slit lamp and funduscopic examinations. Recognizing these indicators and beginning the appropriate management can prevent more serious ophthalmic problems from developing.
Predisposing factors
Elements of the patient’s history could suggest the presence of retinal tears. A family history of tears, moderate to high myopia, trauma to the patient and prior surgical procedures, such as cataract removal, are important risk factors to consider, said Rex Ballinger, OD, FAAO, from the Baltimore Veterans Administration Medical Center, in an interview with Primary Care Optometry News.
Patients who are on miotics also may be predisposed to developing retinal tears or detachments. Those who have been previously diagnosed and treated for retinal tears should be closely monitored in subsequent exams.
“There is a 25% to 40% risk to the fellow eye for developing a retinal detachment,” Dr. Ballinger said. “In the eye that has had the surgery or the repair, there is a risk for redetachment from proliferative vitreoretinopathy.”
| What to Look for in the Fundus Exam |
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- Pigment in the anterior vitreous
- A break in the peripheral retina and a localized hemorrhage
- Operculated retinal material
- Look for localized detachment
- Determine if the tear is a full-thickness break
- Look for subretinal fluid
- Take note of the location of the break
Because of the increased risk of future problems, patients should be seen more frequently following a diagnosis of a retinal tear, said Robert DiMartino, OD, MS, from the University of California – Berkeley School of Optometry.
“When you’ve had a tear in the retina, you are predisposed to a group of problems, depending on how the tear is repaired and to what extent the retina has been torn. These problems include a proliferation of pigment within the eye, and retinal tear is certainly a risk factor for developing a retinal detachment,” Dr. DiMartino said.
After a retinal tear has been successfully repaired, the patient should be seen at least annually for a dilated funduscopic evaluation with scleral depression, he said.
Most retinal tears are part of the aging process. As the vitreous liquefies, added traction is placed on the portions of the vitreous that are adherent to the retina, Dr. DiMartino said. Patients start to experience this liquefaction in their 40s, but tears are more common when patients are in their 60s or 70s, or during more rapid periods of liquefaction, such as following cataract extraction.
Patients with predisposing lesions, such as lattice degeneration, cystic retinal tufts, retinoschisis and atrophic holes also may be at risk for developing further breaks or detachment and should be examined closely, Dr. Ballinger said.
Patient complaints
Patient complaints that could suggest a retinal tear include spots in the vision, flashing lights similar to a sparkler in the periphery of their vision or a black curtain coming across their vision.
“Patients who present with symptoms of flashing lights and floaters routinely undergo scleral indentation and a thorough dilated exam with binocular indirect evaluation,” Dr. DiMartino said. “That is the absolute minimum standard practice. Some people suggest that, in the absence of findings, patients be re-evaluated again 1 to 2 months following the initial complaint.”
| Patient History/Complaints That May Signal Retinal Problems |
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Check vitreous for pigment
The optometrist should look for signs of pigment that has separated from the retinal pigment epithelium and is suspended in the vitreous, said Bert Glaser, MD, co-founder of the Glaser Murphy Retina Treatment Center.
“A really good sign — one that is often neglected — is pigment in the anterior vitreous, which can be seen readily on slit lamp exam. Seeing that, especially if the eye has not had previous trauma or previous detachments, is a good sign that there is a retinal tear or detachment that requires very careful attention,” Dr. Glaser said.
During the funduscopic exam, Dr. DiMartino will look in the far periphery for signs of a peripheral retinal break, which is often associated with a localized peripheral hemorrhage if there were blood vessels in the tissue that was torn. When a tear is detected, he also will look for a localized detachment and will examine the overlying vitreous for operculated retinal material.
Once a break has been detected, the optometrist needs to determine if it is a full-thickness break, Dr. Ballinger said. If it is a full-thickness break, the doctor should look for subretinal fluid and establish if there is traction on the edge of the break.
The optometrist also should take note of the location of the break. If the tear is within the vitreous base, the risk of detachment is reduced because of the strength of adherences in that area, Dr. Ballinger said. Juxtabasalar tears carry added risk of detachment because there is generally traction in that area. Breaks that are extrabasalar are likely to result in an operculated retinal break, where the tractional forces have been relieved. Extrabasalar flap tears may go into retinal detachment if the tractional forces are still present, however.
Perform scleral depression
An important tool in viewing the periphery of the retina in patients suspected of having retinal breaks is scleral depression, but this is often not performed by the examining optometrist, Dr. Ballinger said.
“Often, optometrists will look at a particular lesion and then dismiss it or refer it rather than evaluate it dynamically with scleral depression,” he said. “There are a number of anatomical variances and lesions that occur in the peripheral retina that can often be mistaken for retinal breaks or can be misdiagnosed as something else when they are, in fact, retinal breaks.”
| Alert Patients to the Symptoms of Retinal Detachment |
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Peripheral retinal hemorrhages, retinal pigment hyperplasia and areas that appear as white without pressure can mimic retinal breaks, but may be misdiagnosed if scleral depression is not performed. Any suspicious lesion needs to be evaluated using scleral depression, Dr. Ballinger said.
“When doing the scleral depression, optometrists must make sure they are moving the tissue around inside the eye to see the interrelationship between the vitreous collagen fibrils and the retinal surface, and sometimes the underlying retinal tissue as well,” he said.
When performing scleral depression, the lesion needs to be localized to the clock hour, which will facilitate the depressor placement. Optometrists also should remember that the ora serrata begins at 5 to 7 mm posterior to the limbus. A common mistake is to depress just slightly behind the limbus, which might lead the optometrist to miss the indentation of the scleral depression, Dr. Ballinger said.
Another common mistake during scleral depression is not achieving proper alignment with the lesion, he said. “Optometrists should maintain alignment on the same axis with their binocular indirect lens, the lesion in question and the scleral depressor,” Dr. Ballinger added.
Because the exam is not comfortable to the patient, Dr. Glaser does not recommend performing it on a routine basis. “If someone comes in and is otherwise fine — has no symptoms of retinal tears or detachments and has no predisposing factors or risk factors — then I would not regularly do a scleral depression exam,” he said.
Follow-up care
When the optometrist determines the presence of a retinal break, the next step is to determine the type of break and the risk factors it carries, Dr. Ballinger said. The most common retinal break is the atrophic hole, which may occur either singularly without other predisposing lesions or may often be associated with lattice degeneration. A patient with atrophic holes who does not have substantial risk factors may be followed.
If a patient is asymptomatic and is found to have a flap tear, treatment is often recommended if there is traction on the flap tear because of the higher risk of developing into detachment, Dr. Ballinger said. Flap tears without traction carry a lower risk, but still may need treatment depending on the risk factor.
“All symptomatic fresh flap tears should be treated,” he said. “Asymptomatic flap tears are often treated, although there may be the occasional flap tear that is not treated because of the size or location of the break. Also, those retinal breaks associated with trauma are usually treated.”
Educating patients
Once the break has been diagnosed, patients should be made aware of the seriousness of the condition and told they are at risk for developing a retinal detachment, Dr. Ballinger said. The risks of treatment vs. non-treatment should be explained.
“The most important thing is to educate the patient about the symptoms of retinal detachment, which often include photopsias, flashes, floating debris in the vision and spots in the vision that are increasing in number, size or density. Some patients have described a discoloration in the periphery of the vision, and some have described it as looking like static on a television set. More importantly, if there is a continually progressing loss of vision from the side with the tear, this is an ominous sign of detachment,” he said.
To impress upon the patient the seriousness of the tear, Dr. DiMartino compares the retina to a single layer of tissue paper placed on his desk. A piece of scotch tape attached to the tissue represents one of the locations where the retina is adherent to the vitreous.
“I hold the tissue with one hand and pull the tape with the other hand. This will tear the tissue in a horseshoe pattern. It’s a very good analogy for the patient to understand what is going on, and it is very dramatic,” Dr. DiMartino said.
Expected findings in diabetics
Because diabetic retinopathy is expected in patients with diabetes mellitus, optometrists should be aware of the signs of ocular involvement of the disease during examinations, Dr. Murphy said.
“The early signs include intraretinal hemorrhages and microaneurysms, intraretinal lipid, cotton-wool spots or nerve fiber layer infarctions, venous beading, irregularity of the veins, intraretinal microvascular abnormalities and areas of the retina that lack detail, which are indicative of retinal capillary nonperfusion,” Dr. Murphy said.
Recognizing these signs, and later indicators that the disease is progressing, is important in guiding the patient toward eventual laser treatment, he said.
| Early Signs of Diabetic Retinopathy |
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In each exam, there are subtle indications of progression, such as early stages of neovascularization of the disc, which can be difficult to recognize, so the doctor should approach the exam expecting to find these things.
“The risk is always there for diabetics, so I think you have to approach all the exams for diabetics with a high index of suspicion,” Dr. Murphy said.
Clinically significant macular edema
Another critical observation that will affect the patient’s treatment is the first sign of clinically significant macular edema, Dr. DiMartino said. At that time, the optometrist should obtain an ophthalmic consultation, because treatment is needed to prevent the patient from losing vision. Optometrists should be aware that clinically significant macular edema can occur at any time during the progression of retinopathy, Dr. DiMartino said. Neither the stage of the retinopathy nor visual acuity accurately indicates the level of edema, as patients can have 20/20 vision and still have clinically significant edema.
“If you have a patient with mild nonproliferative diabetic retinopathy, he or she also may have clinically significant macular edema that needs to be treated when the retinopathy does not,” he said.
Follow-up schedule
The national recommendations for the initial treatment schedule indicate that patients with Type II, or non-insulin dependent, diabetes mellitus should have annual examinations following diagnosis. Patients with Type I, or insulin dependent, diabetes mellitus should have their first exam 5 years after the onset of the disease, but Dr. DiMartino disagrees with this approach.
“It is so important that follow-up patterns and habits be well established with a patient, so if you tell a patient that the national recommendation is that you not be examined for 5 years, that patient is usually lost to follow-up, which is quite unfortunate. I tend to say that all diabetics need annual examination,” he said.
For Your Information:
- Rex Ballinger, OD, FAAO, can be reached at the Baltimore Veterans Administration Medical Center, Room 2D-168, 10 N. Green St., Baltimore, MD 21201; (410) 605-7000, ext. 5611; fax: (410) 605-7232; e-mail: rexeye@aol.com. Dr. Ballinger has no direct financial interest in the products mentioned in this article nor is he a paid consultant for any companies mentioned.
- Robert DiMartino, OD, MS, can be reached at the University of California School of Optometry, Berkeley, CA 90274; (510) 643-9517; fax: (510) 642-5109. Dr. DiMartino did not disclose whether he has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.
- Bert Glaser, MD, a member of the Primary Care Optometry News Editorial Board, can be reached at the Glaser Murphy Retina Treatment Center, 5530 Wisconsin Ave., Ste. 835, Chevy Chase, MD 20815; (301) 986-8747; fax: (301) 986-8944. Dr. Glaser has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.