Incomplete Vitreous Detachment of the Left Eye
Short Summary

63-year-old female with clinical ocular history of mild myopia and presbyopia, started seeing floaters in her right eye, which worsened on the next day and were accompanied by photophobia. Examination revealed the existence of posterior vitreous detachment, with no evidence for retinal tear. Three days later she was examined again due to worsening of the symptoms and laser photocoagulation was performed at an area of suspected retinal traction. She still experiences the existence of floaters as well as light flashes.

 

Patient's Questions
1)         What do you consider to be the cause of the vitreous detachment?
2)         Will the vitreous detachment stabilize or will it fully detach? Is the patient at risk for retinal detachment? What precautions and/or care must be taken to promote improvement of the situation? Can sports activities be pursued (skiing, tennis, swimming)?
3)         What possible treatments do you suggest?
Medical Background

Female , 63 years old
Diagnosis:
Incomplete vitreous detachment of the left eye
General medical history:
No significant pathological conditions
Eye history:
Slight myopia at a young age.
Presbyopia around age 50.
Currently corrected myopia.
Reading glasses.
Good far vision: 9/10.
History:
On 12/2008, the patient reported seeing "floaters" in her right eye. The next day symptoms worsened with photophobia and persistent “floaters.”
On 12/2008, the patient then went to the Emergency Room, where, after being visited by an ophthalmology specialist, the following diagnosis was given: “posterior vitreous detachment, 360° retinal adhesion, no signs of rhegmatogenous tears."
The patient was discharged with the following treatment: Rest; hydration by mouth (1-1.5 liters of water per day for 10 days); Vitreoclar crono at the dose of 1 tablet per day on a full stomach (1 pack). No reading for 1 week. Eye exam in 1 month, sooner if symptoms worsen.
On 01/2009, the clinical picture worsened due to the persistence of symptoms and the appearance of "flashes of light" when going from light to darkness. The patient was again sent to the Emergency Room where the following was determined: incomplete vitreous detachment with visible strands at VI, VII-X and XII o’clock. In these sectors, several appreciable small hemorrhages can be seen, but no rhegmatogenous alterations, whereas in the middle periphery vitreoretinal traction with perivascular adhesion is seen at IX o'clock. In this same site, Barrage laser photocoagulation was performed on the degeneration at IX o’clock. The patient was advised to follow-up on 1/2009.
Despite this, the patient continues to see "cobwebs" in front of her eye, as well as some light flashes in the dark. At the follow-up eye exam performed on 1/2009, the clinical situation was stable and showing signs of improvement.

Expert's Opinion

Impression and recommendation:
1. The above referenced patient suffered from posterior vitreous detachment.
Posterior vitreous detachment (PVD) is a common condition which occurs in about 75% of people over the age of 65. As people get older the vitreous, a jelly-like substance inside the eye changes, and this causes the separation of the vitreous jell from the retinal surface, namely, the PVD. The occurrence of PVD is even more common in patients with myopia, as is the patient. So, the answer to question 1- what do you consider to be the cause of the vitreous detachment is- this is just a normal aging process of the vitreous, which is very common at the patient's age, and there is no need to search for another cause.
2. It is very difficult to tell clinically, and also by ultrasound whether complete detachment of the vitreous has occurred. Thus it is difficult to answer the first part of question 2- will the vitreous detachment stabilize or will it fully detach. Usually, however, there is complete detachment of the posterior detachment and stabilization of the situation. Around the first days of PVD there is an increased risk (about 15%) for retinal tear formation. If left untreated, these can lead to retinal detachment. Since it is now 3 weeks post the PVD the chances for retinal tear occurrence are much lower. No precautions need or can be taken to promote improvement of the situation. Nothing done or not done by the patient will change the natural history of the situation. Sport activities, including skiing, tennis, swimming, and all other sports or other activities can be resumed.
3. No treatment is available which is proven for PVD. I guess that by now the patient was examined at 3 weeks after the commencement of the PVD, and if this is the case, there is no need for further follow up, unless there will be increase in floaters, flashed or light or decrease in visual acuity.
I would like to add that it is not surprising at all that even though the patient had laser treatment she still experiences symptoms: the laser is performed just to lower the chances of development of retinal detachment and does not change the flashes and or floaters. The flashes will improve with time. The floaters will not disappear but there will be adjustment of the brain and the patient will not notice them, or notice them very rarely, which she will look on a very light background.
In summary, no treatment is needed.
I would be happy to see this patient in my practice if he wishes to travel to the Israel, however, it seems to me that she should continue her follow up by a retina specialist in her country. I can recommend Prof. Francesco Bandello, from the Department of Ophthalmology in the university of Udine or Prof. Paolo Lanzetta from the same department.

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