Choosing not to comanage PVD

July 1, 2014

Since the baby boomers have boomed, the syneresis process seems to be moving as fast as the polar ice cap is melting. I understand the sudden appearance of a large dark object is worrisome and needs to be managed in our offices. Yet, can we overdo it? What is really the most appropriate time frame to get these patients in for a look and when should they be seen again?

Another day in the office and another phone call from a patient who has a large spot hovering over the central vision, like the aliens that settled over major cities in Independence Day. Much like those dark alien spheres that drew people in like flies to the light, a sense of dread and worry manifests. Since the baby boomers have boomed, the syneresis process seems to be moving as fast as the polar ice cap is melting. I understand the sudden appearance of a large dark object is worrisome and needs to be managed in our offices. Yet, can we overdo it? What is really the most appropriate time frame to get these patients in for a look and when should they be seen again? The answer is easy if they bear gifts, like a venti soy, extra-wet cappuccino-barring that, what is appropriate?          

I was recently speaking with fellow Optometry Times Editorial Advisory Board member Steve Ferrucci OD, FAAO, about the sad state of affairs his Boston Red Sox have found themselves in and the topic of posterior vitreous detachment (PVD) came up. (Long story, don’t ask.) The conversation turned to PVD follow-up and what is appropriate protocol in his expert opinion. Steve stated, “If the patient is symptomatic and has no retinal pathology, I will bring him back in six weeks.” Yet, much like statistical chances of the Sox making it back to the World Series, I play the odds and hold the patient to some accountability. My protocol has been to see the patient for the acute attack, educate her about the signs and symptoms of a retinal detachment, and instruct her to return upon the occurrence of those or the regularly scheduled appointment.

No urgency? No referral   

A PVD may be the impetus for retinal breaks that may then lead to retinal detachments. Which does lead to the relative urgency of a thorough dilated fundus examination. The light flashes are typically best seen in the dark and are caused by vitreous traction on the peripheral retina. The floaters may be due to blood, condensations of vitreous collagen, or epipapillary glial tissue torn from the optic nerve head or the area adjacent to the optic nerve head.

Now, approximately 20 percent of patients with acute symptoms of PVD have a retinal tear at the time of the initial examination. A good clue for the OD is the direct correlation between the amount of vitreous hemorrhage and the likelihood of a retinal tear. Thus, without seeing a significant amount of vitreous cells or blood, comanaging with a retinal specialist is not warranted. I have always held the feeling that referring a patient to an ophthalmologist is necessary when I felt the patient needed surgery. Without that sense of urgency, comanaging with another OD or keeping the patient in the practice is my modus operandi.        

A good offense

Patients with acute PVD who have no retinal breaks on presentation have a two to five percent chance of developing them in the weeks that follow. Thus, you have a really low risk of developing a new break or tear. Furthermore, approximately 80 percent of patients who have no breaks on presentation, but then develop breaks later, had some pigmented cells or hemorrhage in the vitreous or retina at the initial evaluation, or simply they had new symptoms or signs that initiated a new follow-up. The best defense is a good offense and providing your patients with the tools to manage this tectonic shifting of the vitreous, which for some is a scary as the separation of Pangea. As doctors, we walk that fine line between a calming effect and alarmists. Thus, in the case of this highly probable event, we can be both and provide our patients the necessary doctoring to feel secure. In the case of the PVD, I think that the wise and prophetic Peter Griffin can both illustrate and verbalize what the PVD most means to our patients.          

There is obviously not a single answer on how to manage the PVD, and thus is referred to each doctor’s comfort level. However, comanaging in this instance is not always a necessity without more significant signs of a tear or detachment. Print up some good papers, invest in some visual aids, invite Peter Griffin into your practice, or just guide your patient to another OD who sees that transparent layer of brain tissue better than you. And remember, without Jacoby Elllsbury, the chances of the Sox winning the World Series are about as good as that asymptomatic retinal detachment. Sorry, Steve.ODT

References

1. Byer NE. Natural history of posterior vitreous detachment with early management as the premier line of defense- against retinal detachment. Ophthalmology. 1994; 101: 1503-1514.

2. Richardson PSR, Benson MT, Kirby GR. The posterior vitreous detachment clinic: do retinal breaks develop in the six weeks following an isolated symptomatic posterior vitreous detachment? Eye. 1999; 13: 237-40.

3. Waigle AM, Lim WY, Yap TP, Neelam K, Eong KGA. Utility values associated with vitreous floaters. Am J Ophthalmol 2011; 152:60-5.

4. Van Overdam KA, et al. Symptoms and findings predictive for the development of new retinal Breaks. Arch Ophthalmol. 2005;123: 479-84.