Retina Case Study – 45 YOM with Acute Loss of Vision

March 26, 2009

45 YOM presented this weekend with acute loss of vision in the right eye. Occasional floaters, but no trauma. Successful cataract surgery 2 years ago. Noted progressive, painless, loss of vision over the past 1-2 days. Vision loss started in the periphery and moved centrally. Excellent historian. Past medical history was not contributory, healthy and no history of diabetes. Your differential?

My colleague was on call and went in to examine the patient. Our differential was retinal detachment, vascular occlusion or vitreous hemorrhage. The patient was found to have a dense vitreous hemorrhage. It was now 10:30 PM on Saturday night. B-scan was unremarkable. I asked the patient to follow-up with me this week. Would you have done anything differently at this point?

The patient returned 48 hours later. He reported some slight clearing, but there was still no view of the peripheral retina. B-scan was inconclusive in that there were no gross abnormalities such as retinal detachment. At this point, my differential is retinal tear with vitreous hemorrhage, retinal detachment or the dreaded posterior vitreous detachment (PVD) with no obvious tear.  What is my next move, observation, Tissue plasminogen activator (tPA) or vitrectomy?

I have been in practice for 16 years as a retinal physician.  I used to think this scenario was routine and easy to manage, but I really feel this is one of the more difficult cases.  I highly suspect a tear or even a detachment, but have no concrete evidence that there is a retinal detachment.  To restate, I have no clear indication for surgery, i.e. vitrectomy.  On the other hand, if you don’t operate, are you willing to take the chance of a retinal detachment developing and possibly involving the macula?

I have become most comfortable operating in this scenario believing it is far more beneficial than observation, although seemingly less conservative.  I feel that you have far more to gain by operating.  If a retinal tear or detachment is usually the cause, why wait for a retinal detachment to develop?

I operated this morning and found a tear without detachment and a low lying detachment with dialysis.

Looking forward to your comments,

Randall V. Wong, M.D.
Retinal Specialist

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