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Late Detection of Retinal Breaks After Acute Posterior Vitreous Detachment
REFERENCES
1. Miglior S, Torri V, Zeyen T, et al. Intercurrent factors associated with the development of open-angle glaucoma in the European glaucoma prevention study. Am J Ophthalmol 2007;144:266 –275. 2. The European Glaucoma Prevention Study Group. The European Glaucoma Prevention Study design and baseline description of the participants. Ophthalmology 2002;109:1612– 1621. 3. de Voogd S, Ikram MK, Wolfs RC, et al. Is diabetes mellitus a risk factor for open-angle glaucoma? The Rotterdam Study. Ophthalmology 2006;113:1827–1831. 4. Leske MC, Wu SY, Hennis A, et al. Risk factors for incident open-angle glaucoma. The Barbados Eye Studies. Ophthalmology 2007. Forthcoming. 5. Le A, Mukesh BN, McCarty CA, Taylor HR. Risk factors associated with the incidence of open-angle glaucoma: the visual impairment project. Invest Ophthalmol Vis Sci 2003;44:3783–3789.
Late Detection of Retinal Breaks After Acute Posterior Vitreous Detachment EDITOR:
toms of PVD at initial visit with a second look four to six weeks later. MAHESH UPARKAR SUNDARAM NATARAJAN
Mumbai, India
REFERENCES
1. Coffee RE, Westfall AC, Davis GH, Mieler WF, Holz ER. Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis. Am J Ophthalmol 2007;144:409 – 413. 2. van Overdam KA, Bettink-Remeijer MW, Mulder PG, van Meurs JC. Symptoms predictive for the later development of retinal breaks. Arch Ophthalmol 2001;119:1483–1486. 3. Sharma MC, Regillo CD, Shuler MF, Borrillo JL, Benson WE. Determination of the incidence and clinical characteristics of subsequent retinal tears following treatment of the acute posterior vitreous detachment-related initial retinal tears. Am J Ophthalmol 2004;138:280 –284. 4. Uchino E, Uemura A, Ohba N. Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol 2001; 119:1475–1479. 5. Byer NE. What happens to untreated asymptomatic retinal breaks, and are they affected by posterior vitreous detachment? Ophthalmology 1998;105:1045–1049.
WE READ WITH INTEREST THE ARTICLE BY COFFEE AND
associates1. Their retrospective review was admirably supplemented with an exhaustive meta-analysis of literature discussing the incidence and clinical characteristics of delayed onset retinal breaks after acute symptomatic posterior vitreous detachment. However, we demur on certain nebulous aspects of their discussion. Among study subjects with follow-up, the incidence of delayed onset retinal breaks was low at 1.5% and usually detected within the first two months of follow-up. These could very easily have been breaks missed at initial examination as shown in a prospective study by van Overdam and associates.2,3 The definition of posterior vitreous detachment (PVD), as used in this study after observation of a Weiss ring suggests detachment of vitreous around the optic nerve. However fundus examination may not adequately detect PVD, even in healthy older individuals, as shown in optical coherence tomography studies.4 We surmise that the delayed onset retinal breaks within the six week period of observation as observed by Coffee and associates may be a part of ongoing PVD and would deserve additional care if persistently symptomatic, especially within the first six weeks.5 The retrospective nature of the study and the rarity of late onset breaks may have limited the scope of discussion for the authors. However, their insight and sincerity is laudable. We concur with the authors’ suggestion for assiduous examination of high-risk patients presenting with sympVOL. 145, NO. 1
REPLY WE APPRECIATE THE ASTUTE CRITICISM OF UPARKAR AND
Natarajan in their correspondence regarding our study. We would like to respond to the points that they have raised. Uparkar and Natarajan emphasize that the delayed retinal breaks described in our study could have been present at the time of the initial exam, but simply were missed. This is a valid point because it is always possible to overlook clinical findings. However, the incidence of delayed retinal breaks in our meta-analysis was quite low, even considering factors such as vitreous hemorrhage that would limit fundus examination at initial presentation. This suggests that retinal breaks are missed extremely rarely by experienced examiners. Recognition of this possibility does not change the conclusions of the study. Ophthalmologists should remain mindful of risk factors such as vitreous hemorrhage, lens status, myopia, trauma, or other confounding factors and use their own clinical judgment when considering whether to recommend an early follow-up examination. The second point raised by Uparkar and Natarajan related to the ability of clinicians to diagnose a complete posterior vitreous detachment (PVD) on clinical examination. We recognize that even though a Weiss ring may be present on ophthalmoscopic examination, this may not necessarily indicate a complete PVD. While results of OCT testing may be superior to biomicroscopic examina-
CORRESPONDENCE
183
1. Miglior S, Torri V, Zeyen T, et al. Intercurrent factors associated with the development of open-angle glaucoma in the European glaucoma prevention study. Am J Ophthalmol 2007;144:266 –275. 2. The European Glaucoma Prevention Study Group. The European Glaucoma Prevention Study design and baseline description of the participants. Ophthalmology 2002;109:1612– 1621. 3. de Voogd S, Ikram MK, Wolfs RC, et al. Is diabetes mellitus a risk factor for open-angle glaucoma? The Rotterdam Study. Ophthalmology 2006;113:1827–1831. 4. Leske MC, Wu SY, Hennis A, et al. Risk factors for incident open-angle glaucoma. The Barbados Eye Studies. Ophthalmology 2007. Forthcoming. 5. Le A, Mukesh BN, McCarty CA, Taylor HR. Risk factors associated with the incidence of open-angle glaucoma: the visual impairment project. Invest Ophthalmol Vis Sci 2003;44:3783–3789.
Late Detection of Retinal Breaks After Acute Posterior Vitreous Detachment EDITOR:
toms of PVD at initial visit with a second look four to six weeks later. MAHESH UPARKAR SUNDARAM NATARAJAN
Mumbai, India
REFERENCES
1. Coffee RE, Westfall AC, Davis GH, Mieler WF, Holz ER. Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis. Am J Ophthalmol 2007;144:409 – 413. 2. van Overdam KA, Bettink-Remeijer MW, Mulder PG, van Meurs JC. Symptoms predictive for the later development of retinal breaks. Arch Ophthalmol 2001;119:1483–1486. 3. Sharma MC, Regillo CD, Shuler MF, Borrillo JL, Benson WE. Determination of the incidence and clinical characteristics of subsequent retinal tears following treatment of the acute posterior vitreous detachment-related initial retinal tears. Am J Ophthalmol 2004;138:280 –284. 4. Uchino E, Uemura A, Ohba N. Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol 2001; 119:1475–1479. 5. Byer NE. What happens to untreated asymptomatic retinal breaks, and are they affected by posterior vitreous detachment? Ophthalmology 1998;105:1045–1049.
WE READ WITH INTEREST THE ARTICLE BY COFFEE AND
associates1. Their retrospective review was admirably supplemented with an exhaustive meta-analysis of literature discussing the incidence and clinical characteristics of delayed onset retinal breaks after acute symptomatic posterior vitreous detachment. However, we demur on certain nebulous aspects of their discussion. Among study subjects with follow-up, the incidence of delayed onset retinal breaks was low at 1.5% and usually detected within the first two months of follow-up. These could very easily have been breaks missed at initial examination as shown in a prospective study by van Overdam and associates.2,3 The definition of posterior vitreous detachment (PVD), as used in this study after observation of a Weiss ring suggests detachment of vitreous around the optic nerve. However fundus examination may not adequately detect PVD, even in healthy older individuals, as shown in optical coherence tomography studies.4 We surmise that the delayed onset retinal breaks within the six week period of observation as observed by Coffee and associates may be a part of ongoing PVD and would deserve additional care if persistently symptomatic, especially within the first six weeks.5 The retrospective nature of the study and the rarity of late onset breaks may have limited the scope of discussion for the authors. However, their insight and sincerity is laudable. We concur with the authors’ suggestion for assiduous examination of high-risk patients presenting with sympVOL. 145, NO. 1
REPLY WE APPRECIATE THE ASTUTE CRITICISM OF UPARKAR AND
Natarajan in their correspondence regarding our study. We would like to respond to the points that they have raised. Uparkar and Natarajan emphasize that the delayed retinal breaks described in our study could have been present at the time of the initial exam, but simply were missed. This is a valid point because it is always possible to overlook clinical findings. However, the incidence of delayed retinal breaks in our meta-analysis was quite low, even considering factors such as vitreous hemorrhage that would limit fundus examination at initial presentation. This suggests that retinal breaks are missed extremely rarely by experienced examiners. Recognition of this possibility does not change the conclusions of the study. Ophthalmologists should remain mindful of risk factors such as vitreous hemorrhage, lens status, myopia, trauma, or other confounding factors and use their own clinical judgment when considering whether to recommend an early follow-up examination. The second point raised by Uparkar and Natarajan related to the ability of clinicians to diagnose a complete posterior vitreous detachment (PVD) on clinical examination. We recognize that even though a Weiss ring may be present on ophthalmoscopic examination, this may not necessarily indicate a complete PVD. While results of OCT testing may be superior to biomicroscopic examina-
CORRESPONDENCE
183