In this episode of Ready, Set, Retina, Dan Epshtein, OD, FAAO, Associate Clinical Professor at SUNY College of Optometry, and Jessica Haynes, OD, FAAO, a consultative optometrist at the world-renowned Charles Retina Institute in Germantown, Tennessee, discuss the evaluation and management of retinal holes.
Management guidelines
Dr. Haynes notes that the decision to monitor or treat a patient often depends on the lesion's presentation. According to the American Academy of Ophthalmology Preferred Practice Pattern for posterior vitreous detachment, retinal breaks, and lattice degeneration, management varies by presentation:1
- Asymptomatic atrophic round holes: Treatment is rarely recommended.
- Asymptomatic lattice degeneration: Usually not treated unless a complication, such as a horseshoe tear from a posterior vitreous detachment (PVD), occurs. Monitoring is typically sufficient even when atrophic holes are present.
- Fellow eye concerns: If a patient has a history of retinal detachment in the other eye, it may influence the decision to monitor or treat. However, there is no definitive medical consensus.
- Operculated holes caused by vitreous traction:
- Acute symptomatic operculated holes: Occur during an acute PVD event (accompanied by flashes and floaters). Even in these cases, treatment may not always be necessary, though they warrant greater concern.
- Asymptomatic operculated holes: Discovered during routine exams without acute PVD symptoms; these are generally safe to monitor.
Retinal holes complications and risks
While most retinal holes remain stable, certain presentations carry meaningful risk for progression to retinal detachment and warrant closer clinical scrutiny.
These include:
- Lattice degeneration
- Atrophic holes
- Vitreous and pre-retinal hemorrhages
Lattice degeneration is characterized by thinning of the retina. It can lead to full-thickness atrophic holes or cause complications from vitreous traction such as horseshoe-shaped breaks and subsequent retinal detachments during PVD.1
Atrophic holes can slowly allow fluid to seep between the neurosensory retina and the retinal pigment epithelium. Providers should use clinical evaluation, wide-field imaging, or peripheral optical coherence tomography (OCT) to ensure that fluid is not accumulating around the hole, as this may require referral and treatment.1
“It's interesting, we always think about vitreous hemorrhages and pre-retinal hemorrhages with our PVD-type patients, but you really can, like you said, get intraretinal hemorrhages from these breaks.”
Vitreous and pre-retinal hemorrhages during an acute PVD indicate a very high risk for a tear. Additionally, intraretinal hemorrhages can occur due to localized vitreous traction pulling on a blood vessel, representing a sign of an acute problem.1
When to refer patients
Optometrists and primary eyecare providers should refer patients to a retina specialist if the patient needs treatment beyond the provider's scope of practice, if the provider is unsure about the best course of action, is uncomfortable explaining the risk/benefits/advantages of monitoring vs. treatment, or if the provider is unsure how to confidently diagnose the lesion.
Dr. Haynes laid out instances in which referral is completely acceptable: “Patients who are outside your realm of comfort. If you don't feel confident to make the decision with the patient, don't feel comfortable talking about the pros and cons, or if you're not sure what you're looking at, that is still reasonable to refer.”
Case-by-case variables: Navigating the "gray zone"
“You must consider the amount and the size of some of these holes, [operculums], things like that. So again, not always so easy. It's not black-and-white.”
Dr. Haynes states that a patient's specific profile can shift the management plan away from standard monitoring guidelines.
Factors that may prompt treatment over monitoring include:
- Active symptoms like flashes and floaters
- A family history of retinal detachment or a detachment in the patient's fellow eye
- Involvement in high-impact contact sports
- A high quantity or unusually large size of the holes
