In this episode of Ready, Set Retina, Daniel Epshtein, OD, FAAO, and Jessica Haynes, OD, FAAO, offer professional insights on identifying retinal tears and determining the best course of treatment. The information they share can make it easier to assess retinal tear severity and lower the risk of complications.
Dr. Haynes is an expert optometrist who practices at the Charles Retina Institute in Germantown, Tennessee. She regularly speaks on and treats retinal disease and is a Diplomat of the American Board of Optometry.
Retinal tears fast facts
- New flashes and floaters are often signs of a retinal tear and require evaluation as soon as possible.
- Acute symptomatic horseshoe tears increase the risk of potentially serious complications, such as vision loss, and should be treated promptly.
- Pigmentation around an asymptomatic retinal tear may indicate chronicity and can affect the urgency of an ophthalmologist referral.
- Vitreous hemorrhage can increase the likelihood of a retinal tear, but it can also make retinal damage harder to detect.
- Treatment for retinal tears varies from patient to patient. Optometrists should consider several factors, including the individual’s overall risk profile and the health of their fellow eye.
Deeper dive: Assessing and managing retinal tears as an optometrist
Dr. Epshtein and Dr. Haynes explained that although retinal tears are somewhat common, their severity and risk profile vary greatly depending on a patient’s symptoms, family history, and the chronicity of the tear itself.
Because of these nuances, optometrists must educate themselves on the different types of retinal tears and understand which ones require prompt attention and which may warrant less urgent evaluation.
Retinal tears aren’t all the same
“What we think of when we think of a retinal tear usually in our mind is the acute symptomatic horseshoe tear.”
When a patient reports new floaters and flashes out of the blue, the acute symptomatic horseshoe tear is an important consideration. In this situation, it’s important to act quickly to reduce the risk of more serious complications, such as retinal detachment. However, retinal tears can vary in risk level and presentation.
For instance, asymptomatic tears may be discovered during a routine eye exam. Some may show signs of chronicity and have a lower immediate risk of retinal detachment, while others may require closer investigation.
Considering this range, optometrists should focus on three things to determine the urgency of a retinal evaluation:
- The type of retinal tear
- The patient’s symptoms
- The health of the fellow eye
Recognize retinal tears that require an urgent referral
Dr. Epshtein and Dr. Haynes noted that acute symptomatic horseshoe tears need to be treated right away because they can progress to retinal detachment. These tears often occur alongside acute posterior vitreous detachment (PVD), which can pull on the retina and contribute to a retinal tear.
Hemorrhagic PVD can be another warning sign of a retinal tear. However, because the blood makes it more challenging to see the patient’s retina, a tear may not always be visible.1 Despite that, Dr. Epshtein and Dr. Haynes encouraged optometrists to refer these patients out, saying that just because you can’t see a retinal tear doesn’t mean it isn’t there.
“So, even if you didn't find that retinal tear … that may be someone you decide to send out because the view in that eye is really challenging. And there's a good chance that there's something present.”
Figures 1 and 2: Closeup and full-scale fundus photograph of acute symptomatic horseshoe tear with a hemorrhagic PVD.
Figure 1: Courtesy of Jessica Haynes, OD, FAAO.
Figure 2: Courtesy of Jessica Haynes, OD, FAAO.
Figures 3 and 4: Optical coherence tomography (OCT) and fundus imaging, respectively of an acute symptomatic horseshoe tear before and after laser treatment.
Figure 3: Courtesy of Jessica Haynes, OD, FAAO.
Figure 4: Courtesy of Jessica Haynes, OD, FAAO.
Why asymptomatic retinal tears don’t always require the same level of urgency
On the opposite end of the spectrum are asymptomatic retinal tears. Since these tears don’t present signs such as flashes and floaters, they may go undetected for years and only be discovered during a routine eye exam.
Dr. Epshtein and Dr. Haynes noted that these tears can be more challenging to determine the appropriate course of action for, especially if they have pigmentation which can be a sign of chronicity.2 As a result, an optometrist may conclude the tear has been there for a long time, so its risk of progressing to retinal detachment in the near term is lower.
That doesn’t mean you should ignore the tear or wait for it to become more pigmented. However, you also don’t need to act as quickly as you would with an acute symptomatic horseshoe tear.
Figures 5 and 6: Fundus imaging of an asymptomatic horseshoe tear before and after laser treatment; note the presence of significant pigment around the lesion, which is a sign of chronicity.
Figure 5: Courtesy of Jessica Haynes, OD, FAAO.
Figure 6: Courtesy of Jessica Haynes, OD, FAAO.
Assess risk on a patient-by-patient basis
Another thing to consider when assessing and managing retinal tears is the patient’s individual risk level. Dr. Haynes shared the story of a gentleman who had multiple asymptomatic breaks, including horseshoe tears and operculated holes.
In many cases, these conditions wouldn’t have warranted an urgent referral, but because the patient’s fellow eye had a macula-off retinal detachment, she felt it was more important to preserve the vision in that eye.
When assessing retinal tears, Drs. Epshtein and Haynes recommended focusing on several factors. These include the patient’s:
- Family history
- Personal preferences
- Fellow eye
- Access to nearby retinal specialists
- Trauma risk
- Physical activity level
It’s equally important to consider your own level of comfort in monitoring the lesion. An optometrist who specializes in retinal tears and related issues may feel confident in managing the situation, whereas one with little experience in this area may feel more comfortable referring the patient out.
“[The] big take-home here? Always treat your patient as an entire situation.”
Figure 7: Fundus photograph of macula-off retinal detachment and horseshoe tear OS.
Figure 7: Courtesy of Jessica Haynes, OD, FAAO.
Figures 8 to 10: Fundus imaging of six asymptomatic retinal tears OD in the same patient.
Figure 8: Courtesy of Jessica Haynes, OD, FAAO.
Figure 9: Courtesy of Jessica Haynes, OD, FAAO.
Figure 10: Courtesy of Jessica Haynes, OD, FAAO.
Is laser treatment the best way to manage retinal tears?
Advances in laser technology have made certain types of retinal tears easier to treat, and since retinal breaks can increase the risk of retinal detachment, clinicians are increasingly weighing the pros and cons of prophylactic laser intervention.
Dr. Epshtein and Dr. Haynes shared that they’ve witnessed this practice. However, they explained that laser treatment isn’t completely benign. In fact, there’s some early evidence that lasers may even contribute to epiretinal membrane formation,3 though that link hasn’t been confirmed.
At the same time, lasers may affect the vitreoretinal interface and ciliary nerves, and some patients find it uncomfortable. Clinicians should consider these potential risks and downsides before developing a treatment plan that includes laser intervention.
Retinal tear management depends on risk and urgency
Dr. Epshtein and Dr. Haynes confirmed that assessing and managing retinal tears can be challenging. Even so, by understanding the factors that affect risk and urgency, clinicians can better support their patients and act confidently.
If a patient presents with new symptoms, such as flashes and floaters, and you confirm a retinal tear, don’t wait to take action. On the other hand, if a retinal tear is uncovered during a routine eye exam, it may not require the same level of urgency, but still deserves thoughtful evaluation.
Several factors can best guide your decision making, including the patient’s general health, the health of their fellow eye, and their history of retinal problems.
Final thoughts
Perhaps most importantly, Dr. Epshtein and Dr. Haynes encouraged all optometrists to maintain a good working relationship with a retinal specialist in their area. This alone can provide peace of mind should a patient require more thorough evaluation.
Dr. Epshtein concluded: "I think the importance for us ODs and those comprehensive ophthalmologists out there is that you have to have that working relationship with your retina specialist. Sometimes you just text them, sometimes you give them a call and ask, 'Hey, what do you want to do? You let me know how soon you want to see this patient.' And that … is the best answer we [can] get … the one straight from the retina specialist's mouth.”
This article was written by Chad Birt based on the recorded video with Drs. Epshtein and Haynes.
