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ophtho.retinal-detachment.core.v1

Retinal detachment & acute PVD / retinal tear (vitreoretinal lens)

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VITREORETINAL-lens engine for the acute flashes-floaters-curtain spectrum (symptomatic PVD → retinal tear → rhegmatogenous RD), the reciprocal partner of ophtho.acute-vision-loss.core.v1 (which already routes its curtain/Shafer-sign macula-on RD trigger here). Non-rhegmatogenous causes recognised then routed OUT by engine_id (ophtho.diabetic-retinopathy.core.v1 for tractional, ophtho.ocular-trauma.core.v1 for traumatic/giant-tear, ophtho.uveitis.core.v1 for exudative VKH/posterior-uveitis). Not a duplicate — its job is the dilated-exam gate, the macula-on/off timing pivot, and the tear-prophylaxis / RRD-repair ladder. High-yield rule foregrounded: every symptomatic PVD needs a prompt dilated fundus exam because ~14% (95% CI 12-16%) harbour a retinal tear on first exam and ≈3.4% develop a delayed tear within 6 weeks of an initially "uncomplicated PVD" (Hollands JAMA 2009 RCE PMID 19934426). The macula-ON (same-day emergency, ~24 h) vs macula-OFF (≤6-day acuity benefit — Kim Retina 2013 PMID 23591530) distinction drives surgical timing. This is a procedural disease — the regimen_axes is modelled as a procedure/decision ladder with steps almost entirely non_pharm: urgent dilated-exam gate → symptomatic-tear laser/cryopexy prophylaxis → RRD repair (pneumatic retinopexy first-line for PIVOT-eligible — Hillier Ophthalmology 2019 PMID 30468761; scleral buckle phakic / PPV pseudophakic per SPR — Heimann Ophthalmology 2007 PMID 18054633) → positioning/activity restriction → exudative-cause-directed medical Rx. RxCUI prednisone 8640 is the ONLY pharmacologic entry (exudative VKH/posterior-uveitis branch only); it is the well-established RxNorm ingredient CUI (matching ophtho.acute-vision-loss.core.v1) and is flagged for live RxNav re-confirmation next session — no fabricated codes; all procedures encoded as non_pharm. Bayesian linkage (pre-test tear/RD prior given acute floaters+flashes ± vitreous haemorrhage ± subjective field loss; LR+/LR− for subjective visual reduction (LR 5.0, 95% CI 3.1-8.1), vitreous haemorrhage (summary LR 10, 95% CI 5.1-20), absence of vitreous pigment (LR− 0.23, 95% CI 0.12-0.43), ≥10 floaters (summary LR 8.1-36); decision thresholds — any symptomatic PVD → urgent dilated exam, macula-on → emergency repair window; cross-engine routing edges by engine_id; PVD-only-vs-tear and rhegmatogenous-vs-exudative pivots) is documented in the co-located _design-brief.md + _research-bundle.md; first-class TS LR fields remain schema-blocked (same constraint as the gold-template dossiers). Effect sizes (≥5): retinal-tear prevalence 14% (95% CI 12-16%) in acute symptomatic PVD and ≈3.4% delayed tear within 6 weeks (Hollands JAMA 2009 RCE PMID 19934426); subjective visual reduction LR 5.0 (95% CI 3.1-8.1), vitreous haemorrhage summary LR 10 (95% CI 5.1-20), absence of vitreous pigment LR− 0.23 (95% CI 0.12-0.43), ≥10 new floaters summary LR 8.1-36 (Hollands JAMA 2009 RCE PMID 19934426); PIVOT PnR vs PPV +4.9 ETDRS letters at 12 mo (79.9 vs 75.0, P=0.024) with primary anatomic success 80.8% vs 93.2% (P=0.045) but secondary success ~98.7%/98.6% (Hillier Ophthalmology 2019 PMID 30468761); PIVOT post-hoc foveal EZ discontinuity 7% (PnR) vs 24% (PPV), OR 4.20 (95% CI 1.46-12.12) (Muni JAMA Ophthalmol 2021 PMID 33885738); SPR pseudophakic primary anatomic success 53.4% (SB) vs 72.0% (PPV, P=0.002) and phakic SB BCVA −0.71 vs PPV −0.56 logMAR (P=0.0005) (Heimann Ophthalmology 2007 PMID 18054633); macula-off repair ≤6 days → mean 20/25 vs 20/50 with longer duration (P=0.003) (Kim Retina 2013 PMID 23591530).

Entry points (5)

  • symptom
    New-onset floaters and/or photopsia (flashes) — symptomatic posterior vitreous detachment until proven otherwise; ~14% harbour a retinal tear on first dilated exam (Hollands JAMA 2009 RCE, PMID 19934426)
    new_floaters_and_or_photopsia
  • symptom
    Progressive peripheral "curtain" / shadow / field defect ± central vision drop — rhegmatogenous retinal detachment; macula-on vs macula-off pivot drives timing (Hillier PIVOT Ophthalmology 2019, PMID 30468761)
    peripheral_curtain_or_shadow_field_defect
  • symptom
    Sudden shower of floaters with subjective visual reduction (± "raining soot") — high-risk for retinal tear / vitreous haemorrhage (subjective visual reduction LR 5.0; vitreous haemorrhage LR 10 — Hollands JAMA 2009 RCE, PMID 19934426)
    sudden_shower_of_floaters_with_reduced_vision
  • history
    Prior RD in fellow eye, high myopia, pseudophakia/post-cataract, lattice degeneration, Stickler/Marfan, or ocular trauma — elevated-prior detachment substrate (AAO PPP Posterior Vitreous Detachment / Retinal Detachment)
    fellow_eye_rd_or_high_myopia_or_pseudophakia
  • problem_list
    Proliferative diabetic retinopathy (tractional) or exudative substrate (Coats / intraocular tumour / VKH / malignant HTN / pre-eclampsia) — NON-rhegmatogenous detachment branch, routed by cause
    diabetic_or_exudative_substrate

Required inputs (17)

  • symptom_onset_and_durationrequired
    symptom • used at ENTRY
    Time since onset drives the macula-on emergency window (~24 h) and the macula-off ≤6-day acuity benefit (Kim Retina 2013 PMID 23591530; Hillier PIVOT Ophthalmology 2019 PMID 30468761)
  • visual_field_curtain_defectrequired
    symptom • used at ENTRY
    A progressing peripheral curtain/shadow is the cardinal RRD symptom and signals the detachment is advancing toward the macula (Hollands JAMA 2009 RCE PMID 19934426; AAO PPP Retinal Detachment)
  • subjective_central_vision_changerequired
    symptom • used at ENTRY
    Central acuity drop suggests macular involvement (macula-OFF) — the single most important prognostic and timing pivot; subjective visual reduction is also the strongest tear symptom (LR 5.0, Hollands JAMA 2009 RCE PMID 19934426)
  • floater_burden_and_characterrequired
    symptom • used at CONTEXT
    New onset of ≥10 floaters markedly raises tear risk (summary LR 8.1-36); a single Weiss-ring floater is typical uncomplicated PVD (Hollands JAMA 2009 RCE PMID 19934426)
  • photopsia_patternrequired
    symptom • used at CONTEXT
    Brief peripheral arcs/lightning on eye movement (vitreoretinal traction) differ from the fortification scotoma of migraine aura and the homonymous pattern of cortical ischaemia (AAO PPP PVD; Hollands JAMA 2009 RCE PMID 19934426)
  • dilated_fundus_examinationrequired
    imaging • used at INITIAL_WORKUP
    Urgent dilated fundus exam (indirect ophthalmoscopy + scleral depression) is the mandatory test in any symptomatic PVD to detect a tear/detachment — every symptomatic PVD needs it (Hollands JAMA 2009 RCE PMID 19934426; AAO PPP)
  • vitreous_haemorrhage_or_pigmentrequired
    imaging • used at INITIAL_WORKUP
    Vitreous haemorrhage (summary LR 10, 95% CI 5.1-20) and vitreous pigment / "tobacco dust" (Shafer sign) are the highest-yield tear pointers; absence of vitreous pigment is the best negative finding (LR− 0.23) (Hollands JAMA 2009 RCE PMID 19934426)
  • macula_on_vs_off_statusrequired
    imaging • used at INITIAL_WORKUP
    Macula attached (macula-ON) = same-day surgical emergency before the fovea detaches; macula-OFF = wider window but ≤6-day repair still better (Hillier PIVOT Ophthalmology 2019 PMID 30468761; Kim Retina 2013 PMID 23591530)
  • b_scan_ultrasound_if_no_fundus_view
    imaging • used at BRANCHING_WORKUP
    When dense vitreous haemorrhage or media opacity prevents a fundus view, B-scan ultrasound detects an occult detachment/tear and prevents a missed RRD (AAO PPP Posterior Vitreous Detachment)
  • refractive_status_high_myopiarequired
    history • used at CONTEXT
    High myopia and a long axial length substantially raise RRD and lattice/tear risk and lower the re-examination threshold (AAO PPP Retinal Detachment)
  • pseudophakia_or_recent_cataract_surgeryrequired
    history • used at CONTEXT
    Pseudophakia/aphakia raises RRD risk and changes repair selection (PPV favoured in pseudophakic SPR-type RRD — Heimann Ophthalmology 2007 PMID 18054633)
  • prior_rd_or_fellow_eye_or_family_historyrequired
    history • used at CONTEXT
    Prior RD, fellow-eye RD, lattice, Stickler/Marfan or family history substantially raises prior and triggers fellow-eye surveillance (AAO PPP Retinal Detachment)
  • ocular_traumarequired
    history • used at RED_FLAGS
    Trauma causes giant retinal tears, dialyses and traumatic RD and mandates an open-globe / trauma pathway — route to ophtho.ocular-trauma.core.v1
  • diabetes_proliferative_retinopathyrequired
    history • used at CONTEXT
    Proliferative diabetic retinopathy causes TRACTIONAL RD — pneumatic retinopexy is contraindicated; route to ophtho.diabetic-retinopathy.core.v1 for tractional ownership
  • exudative_systemic_cause
    history • used at CONTEXT
    Exudative RD (Coats, intraocular tumour, VKH, malignant hypertension, pre-eclampsia) is treated by cause, not by rhegmatogenous repair — shifting subretinal fluid + no tear + systemic cause is the exudative pivot
  • pregnancy
    history • used at CONTEXT
    Pre-eclampsia/eclampsia causes exudative serous RD that usually resolves with blood-pressure/delivery management (observation, not surgery); also gates any pharmacologic/anaesthetic decisions
  • red_painful_eye_or_systemic_features
    symptom • used at RED_FLAGS
    A painful red eye, hypopyon, or systemic illness reframes toward endophthalmitis / posterior uveitis / a non-RD emergency — route to the acute-vision-loss / uveitis pathway

12-phase flow (12)

  1. 1FRAME
    Frame the acute flashes-floaters-curtain spectrum as a TIME-CRITICAL vitreoretinal problem: symptomatic PVD → retinal tear → rhegmatogenous detachment, with the macula-on emergency window dominating timing. ~14% of symptomatic acute PVD have a tear on first dilated exam (Hollands JAMA 2009 RCE PMID 19934426). Tractional (diabetic) and exudative RD are recognised and routed by cause, not re-authored here. Reciprocal partner of ophtho.acute-vision-loss.core.v1.
    advance: vitreoretinal-timing framing set; macula-on window and symptomatic-PVD-needs-exam rule foregrounded
  2. 2ENTRY
    Capture the symptom triad up front: new floaters / photopsia, a progressing peripheral curtain/shadow, and any central-vision change; record symptom onset and duration (drives the macula-on ~24 h clock and macula-off ≤6-day acuity benefit — Kim Retina 2013 PMID 23591530).
    inputs: symptom_onset_and_duration, visual_field_curtain_defect, subjective_central_vision_change
    actions: workup.acute_vision_loss
    advance: symptom triad + onset/duration + macula-suspect status recorded
  3. 3CONTEXT
    Build the detachment prior: floater burden (≥10 floaters → tear LR 8.1-36 — Hollands JAMA 2009 RCE PMID 19934426), photopsia pattern (vs migraine aura / cortical), high myopia, pseudophakia/post-cataract, prior/fellow-eye RD or family history (Stickler/Marfan), proliferative diabetic retinopathy (tractional branch), exudative systemic cause, pregnancy. This phase assigns the pretest tear/RD probability and the rhegmatogenous-vs-tractional-vs-exudative branch.
    inputs: floater_burden_and_character, photopsia_pattern, refractive_status_high_myopia, pseudophakia_or_recent_cataract_surgery, prior_rd_or_fellow_eye_or_family_history, diabetes_proliferative_retinopathy, exudative_systemic_cause, pregnancy
    actions: workup.acute_vision_loss
    advance: pretest tear/RD prior assigned; rhegmatogenous vs tractional vs exudative branch chosen
  4. 4RED_FLAGS
    Time-critical screen: (1) any symptomatic PVD → MANDATORY prompt dilated fundus exam to exclude a tear (the high-yield rule — Hollands JAMA 2009 RCE PMID 19934426); (2) macula-ON RRD or imminent macular threat → same-day vitreoretinal surgical emergency; (3) trauma / giant retinal tear → route to ophtho.ocular-trauma.core.v1; (4) painful red eye / hypopyon / systemic illness → reframe toward endophthalmitis/uveitis, route to ophtho.acute-vision-loss.core.v1. Recognised and time-stamped here.
    inputs: ocular_trauma, red_painful_eye_or_systemic_features
    actions: workup.acute_red_eye
    advance: symptomatic-PVD-needs-exam, macula-on, trauma and red-eye flags screened and time-critical action initiated
  5. 5INITIAL_WORKUP
    The mandatory test: urgent dilated fundus examination (indirect ophthalmoscopy + scleral depression) of the symptomatic eye AND the fellow eye. Document: a retinal tear/break, vitreous haemorrhage (tear LR 10) and vitreous pigment / Shafer "tobacco dust" sign (absence is the best negative — LR− 0.23) (Hollands JAMA 2009 RCE PMID 19934426), and the macula-ON vs macula-OFF status (the timing pivot). OCT confirms foveal status when the macula is borderline.
    inputs: dilated_fundus_examination, vitreous_haemorrhage_or_pigment, macula_on_vs_off_status
    actions: panel.cbc, panel.inflammation
    advance: dilated exam (both eyes) complete; tear/RD presence + vitreous-haemorrhage/pigment + macula status documented
  6. 6BRANCHING_WORKUP
    Branch by exam: (a) tear/break present + symptomatic → prophylactic laser/cryopexy candidate (the proven-benefit category — Wilkinson Cochrane 2014 PMID 25191970); (b) RRD present → macula-on (emergency) vs macula-off (≤6-day window) → repair-technique selection; (c) no fundus view (dense vitreous haemorrhage) → B-scan ultrasound to exclude occult RRD/tear; (d) tractional configuration + PDR → ophtho.diabetic-retinopathy.core.v1; (e) shifting subretinal fluid + no tear + systemic cause → exudative work-up (route to uveitis/medical cause). PVD-only with NO tear after a thorough exam → counsel + scheduled re-examination (≈3.4% delayed tear within 6 weeks — Hollands JAMA 2009 RCE PMID 19934426).
    inputs: b_scan_ultrasound_if_no_fundus_view
    actions: panel.cmp
    advance: tear vs RRD vs PVD-only vs tractional vs exudative resolved; technique branch or re-exam plan set
  7. 7DIFFERENTIAL
    Terminal differential with pivot findings: rhegmatogenous RD (tear + vitreous pigment + shifting curtain + corrugated mobile retina pivot) vs symptomatic retinal tear without detachment (tear + flashes/floaters, retina still attached pivot) vs PVD WITHOUT tear (Weiss ring + no pigment/haemorrhage + clean dilated exam pivot — LR− 0.23) vs vitreous haemorrhage (loss of red reflex + diabetic/PVD + B-scan pivot) vs retinoschisis (smooth dome, absolute scotoma, bilateral inferotemporal, immobile pivot) vs tractional RD (PDR + concave taut traction + no tear pivot — diabetic) vs exudative RD (smooth shifting subretinal fluid + NO tear + systemic cause pivot — Coats/tumour/VKH/malignant-HTN/pre-eclampsia) vs CRVO/CRAO (fundus vascular signs + no curtain pivot — route to ophtho.acute-vision-loss.core.v1) vs migraine aura (bilateral fortification scotoma, builds & marches over ~20-30 min, fully resolves pivot) vs ophthalmic-artery/retinal TIA (transient monocular grey-out, vascular risk, fully recovered pivot — route to acute-vision-loss).
    advance: single best diagnosis selected; rhegmatogenous vs tractional vs exudative explicitly resolved; PVD-only vs tear pivot stated
  8. 8RISK_STRATIFICATION
    Stratify sight-threat: macula-ON RRD (highest urgency — same-day surgery before foveal detachment), macula-OFF RRD (urgent but ≤6-day window for best acuity — Kim Retina 2013 PMID 23591530), symptomatic tear (urgent prophylaxis to prevent progression to RRD — Wilkinson Cochrane 2014 PMID 25191970), PVD-only (scheduled re-exam, delayed-tear ≈3.4%). Layer modifiers: high myopia, pseudophakia, fellow-eye/prior RD, giant retinal tear, proliferative vitreoretinopathy (PVR — the dominant redetachment driver), trauma. NEWS2/qSOFA overlay only if a systemic exudative cause (e.g., malignant HTN, pre-eclampsia, sepsis-related) co-exists.
    inputs: macula_on_vs_off_status, refractive_status_high_myopia
    actions: calc.news2, calc.qsofa
    advance: sight-threat tier + modifier overlay assigned
  9. 9TREATMENT
    Procedure ladder (mostly non-pharmacologic): (1) urgent dilated-exam GATE — never skip in symptomatic PVD (Hollands JAMA 2009 RCE PMID 19934426); (2) SYMPTOMATIC retinal tear → prophylactic laser retinopexy / cryopexy to wall off the tear before it detaches (proven-benefit category — Wilkinson Cochrane 2014 PMID 25191970); (3) RRD repair — PnR first-line for PIVOT-eligible RRD (superior acuity, less metamorphopsia, lower morbidity — Hillier PIVOT Ophthalmology 2019 PMID 30468761), scleral buckle (phakic benefit) / PPV (pseudophakic, complex, media opacity) per SPR (Heimann Ophthalmology 2007 PMID 18054633); (4) post-procedure positioning + activity restriction (non_pharm); (5) exudative-cause-directed medical therapy where a real drug applies (e.g., systemic corticosteroid for VKH-type exudative RD — RxNav-verified); tractional (diabetic) RD is NOT pneumatic and is owned by ophtho.diabetic-retinopathy.core.v1.
    inputs: macula_on_vs_off_status, symptom_onset_and_duration, pregnancy
    advance: tear prophylaxis or RRD repair (or exudative-cause therapy) selected and definitive ownership routed where applicable
  10. 10DISPOSITION
    Macula-ON RRD → same-day emergent vitreoretinal surgery. Macula-OFF RRD → urgent surgery, target ≤ ~6 days from symptom onset for best acuity (Kim Retina 2013 PMID 23591530). Symptomatic tear → same-day/next-day laser/cryopexy then close follow-up. PVD-only no tear → discharge with strict return precautions + scheduled re-examination (delayed tear ≈3.4% within 6 weeks — Hollands JAMA 2009 RCE PMID 19934426). Tractional/exudative → route to the owning engine. Trauma/giant tear → ophtho.ocular-trauma.core.v1.
    inputs: macula_on_vs_off_status
    advance: disposition + routed engine_id (where applicable) documented
  11. 11MONITORING
    Post-repair: anatomic reattachment, intraocular pressure, tamponade positioning compliance, and re-detachment surveillance — primary anatomic success ~80.8% (PnR) vs 93.2% (PPV) with ~98.7%/98.6% secondary success in PIVOT (Hillier Ophthalmology 2019 PMID 30468761); long-term redetachment is low and similar for PnR vs PPV (Chen PIVOT post-hoc Ophthalmol Retina 2024 PMID 39182651). Watch for proliferative vitreoretinopathy (the dominant cause of redetachment). PVD-only: scheduled re-exam; counsel that new/worsening floaters, flashes, or any curtain mandates immediate re-presentation.
    inputs: visual_field_curtain_defect
    advance: reattachment confirmed or re-exam completed; PVR / redetachment surveillance active
  12. 12FOLLOWUP
    Fellow-eye surveillance is the long-tail deliverable: prior/contralateral RD, high myopia, pseudophakia, lattice and Stickler/Marfan substantially raise fellow-eye risk (AAO PPP Retinal Detachment) — schedule dilated fellow-eye exams and counsel lifelong symptom awareness. Post-RRD refraction/cataract follow-up (PPV accelerates cataract in phakic eyes — Hillier PIVOT Ophthalmology 2019 PMID 30468761). Tractional/exudative causes → long-term disease control owned by the routed engine (diabetic-retinopathy / uveitis / systemic cause). Low-vision rehabilitation for irreversible macula-off loss.
    inputs: prior_rd_or_fellow_eye_or_family_history
    advance: fellow-eye surveillance + symptom-awareness counselling documented; disease-specific follow-up handed to the routed engine_id