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ophtho.retinal-detachment.core.v1PRODUCTION
ophtho.retinal-detachment.core.v1

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

general_internal_medicineacutesubacuteadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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.

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vitreoretinal-timing framing set; macula-on window and symptomatic-PVD-needs-exam rule foregrounded

Patient inputs (17)

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)

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)

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/aphakia raises RRD risk and changes repair selection (PPV favoured in pseudophakic SPR-type RRD — Heimann Ophthalmology 2007 PMID 18054633)

Prior RD, fellow-eye RD, lattice, Stickler/Marfan or family history substantially raises prior and triggers fellow-eye surveillance (AAO PPP Retinal Detachment)

Proliferative diabetic retinopathy causes TRACTIONAL RD — pneumatic retinopexy is contraindicated; route to ophtho.diabetic-retinopathy.core.v1 for tractional ownership

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)

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)

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)

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 (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 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)

Trauma causes giant retinal tears, dialyses and traumatic RD and mandates an open-globe / trauma pathway — route to ophtho.ocular-trauma.core.v1

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)

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

Pre-eclampsia/eclampsia causes exudative serous RD that usually resolves with blood-pressure/delivery management (observation, not surgery); also gates any pharmacologic/anaesthetic decisions

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

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningmacula_on_rrd_emergency_24h
    Rhegmatogenous RD with the MACULA still ON (central vision intact) — same-day surgical emergency to repair before the fovea detaches (Hillier PIVOT Ophthalmology 2019 PMID 30468761; AAO PPP Retinal Detachment)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtraumatic_rd_open_globe_context
    RD with a history of significant ocular trauma — possible occult open globe, giant tear or dialysis; the trauma pathway takes precedence
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_pvd_needs_urgent_dilated_exam
    New floaters/photopsia or a change in known PVD symptoms — every symptomatic PVD needs a prompt dilated fundus exam because ~14% harbour a retinal tear (Hollands JAMA 2009 RCE PMID 19934426)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregiant_retinal_tear_or_traumatic_rd
    Giant retinal tear (≥3 clock hours) or traumatic RD / retinal dialysis in an open-globe or trauma context — complex repair, route by engine_id
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereproliferative_vitreoretinopathy_redetachment
    Recurrent detachment with star folds / rigid retina / fixed folds — proliferative vitreoretinopathy (PVR), the dominant cause of redetachment after RRD repair (Hillier PIVOT Ophthalmology 2019 PMID 30468761)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefellow_eye_or_high_risk_substrate
    Prior RD, fellow-eye RD, high myopia, pseudophakia/aphakia, lattice, or Stickler/Marfan — substantially elevated RD prior and fellow-eye risk (AAO PPP Retinal Detachment)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateexudative_tumour_or_systemic_cause
    Smooth, shifting subretinal fluid with NO retinal break and a systemic/ocular cause (intraocular tumour, Coats, VKH/posterior uveitis, malignant HTN, pre-eclampsia/eclampsia) — exudative RD, NOT a rhegmatogenous repair
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute flashes-floaters-curtain → tear prophylaxis → RRD repair (procedure ladder)
axis: retinal_detachment_procedure_ladderstep 1 - Step 1 — Urgent dilated-fundus-exam GATE (never skip in symptomatic PVD)
Selected step "Step 1 — Urgent dilated-fundus-exam GATE (never skip in symptomatic PVD)" — Any new floaters and/or photopsia, a peripheral curtain, or a change in known PVD symptoms — symptomatic PVD
  • urgent_dilated_fundus_examination_with_scleral_depression_both_eyes
    first line
    mandatory_diagnostic_gate
    triggers: symptomatic_pvd, new_floaters_or_flashes, curtain_defect
    Hollands JAMA 2009 RCE (PMID 19934426) — ~14% of symptomatic acute PVD harbour a retinal tear on the first dilated exam (95% CI 12-16%); a clean exam still carries ≈3.4% delayed tear within 6 weeks, so a scheduled re-exam is mandated. Vitreous haemorrhage (LR 10) and vitreous pigment (Shafer sign) up-triage; absence of vitreous pigment is the best negative finding (LR− 0.23).

outpatient playbook — drug actions (1)

  1. 1. Prednisone (exudative VKH-type RD only)
    rxcui 8640
    1 mg/kg then taper • PO • once daily
    trigger: Confirmed exudative uveitic (VKH/posterior uveitis) serous RD
    Cause-directed medical therapy for exudative uveitic RD; ownership to ophtho.uveitis.core.v1

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Retinal detachment & acute PVD / retinal tear (vitreoretinal lens)** (ophtho.retinal-detachment.core.v1).
Phenotype framing: 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).
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute flashes-floaters-curtain → tear prophylaxis → RRD repair (procedure ladder)** — step "Step 1 — Urgent dilated-fundus-exam GATE (never skip in symptomatic PVD)".
1. urgent_dilated_fundus_examination_with_scleral_depression_both_eyes (mandatory_diagnostic_gate, first line) — Hollands JAMA 2009 RCE (PMID 19934426) — ~14% of symptomatic acute PVD harbour a retinal tear on the first dilated exam (95% CI 12-16%); a clean exam still carries ≈3.4% delayed tear within 6 weeks, so a scheduled re-exam is mandated. Vitreous haemorrhage (LR 10) and vitreous pigment (Shafer sign) up-triage; absence of vitreous pigment is the best negative finding (LR− 0.23).

Setting playbook (outpatient) — Confirm tear vs RRD vs PVD-only on dilated exam, deliver tear prophylaxis or arrange RRD repair, and run fellow-eye surveillance — the long-tail deliverable (Hollands JAMA 2009 RCE PMID 19934426; AAO PPP Retinal Detachment)
2. Prednisone (exudative VKH-type RD only) 1 mg/kg then taper PO once daily — Confirmed exudative uveitic (VKH/posterior uveitis) serous RD (Cause-directed medical therapy for exudative uveitic RD; ownership to ophtho.uveitis.core.v1)

Non-pharmacologic actions:
- Prophylactic laser retinopexy / cryopexy for a symptomatic tear (Wilkinson Cochrane 2014 PMID 25191970)
- Arrange PnR (PIVOT-eligible) / scleral buckle (phakic) / PPV (pseudophakic, complex) per RRD configuration (Hillier PIVOT Ophthalmology 2019 PMID 30468761; Heimann SPR Ophthalmology 2007 PMID 18054633)
- Tamponade positioning + activity/air-travel restriction counselling post-procedure
- Scheduled fellow-eye dilated surveillance in high myopia / pseudophakia / prior RD; lifelong symptom-awareness counselling
- Observe asymptomatic breaks/lattice (no prophylaxis) with symptom-awareness counselling (Wilkinson Cochrane 2014 PMID 25191970)

AVOID / contraindication checks:
- Never skip urgent dilated exam in symptomatic PVD (Hollands JAMA 2009 RCE PMID 19934426 — ~14% have a tear; missed tear progresses to blinding RRD)
- Do not pneumatic retinopexy tractional diabetic RD (no rhegmatogenous break; route to ophtho.diabetic retinopathy.core.v1)
- Do not treat asymptomatic breaks or lattice prophylactically (Wilkinson Cochrane 2014 PMID 25191970 — no RCT support; treat only SYMPTOMATIC tears)
- No air travel or altitude with intraocular gas bubble (expansile gas → dangerous IOP rise)
- Exudative RD from pre eclampsia usually observe not operate (resolves with BP/delivery management; obstetric co management)
- Systemic corticosteroid pregnancy and renal gating (calc.ckd_epi_2021; exudative VKH branch only)

Monitoring

Regimen monitoring:
- macula on RRD same day surgery window (Hillier PIVOT Ophthalmology 2019 PMID 30468761)
- macula off RRD target repair within 6 days for best acuity (Kim Retina 2013 PMID 23591530)
- post repair anatomic reattachment IOP positioning compliance (Hillier PIVOT Ophthalmology 2019 PMID 30468761)
- proliferative vitreoretinopathy redetachment surveillance (dominant redetachment driver)
- PVD only scheduled re examination delayed tear 3.4pct within 6 weeks (Hollands JAMA 2009 RCE PMID 19934426)
- fellow eye dilated surveillance in high myopia pseudophakia prior RD (AAO PPP Retinal Detachment)

Setting (outpatient) monitoring:
- Post-retinopexy tear stability + post-RRD reattachment, IOP and PVR surveillance (Hillier PIVOT Ophthalmology 2019 PMID 30468761)
- PVD-only: re-examination as scheduled; immediate return on symptom change (≈3.4% delayed tear within 6 wk — Hollands JAMA 2009 RCE PMID 19934426)

Follow-up plan: 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.
- Close-out criterion: fellow-eye surveillance + symptom-awareness counselling documented; disease-specific follow-up handed to the routed engine_id

Monitoring phase: 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.

Disposition

Current setting: outpatient — Confirm tear vs RRD vs PVD-only on dilated exam, deliver tear prophylaxis or arrange RRD repair, and run fellow-eye surveillance — the long-tail deliverable (Hollands JAMA 2009 RCE PMID 19934426; AAO PPP Retinal Detachment)

Disposition criteria:
- Discharge with documented fellow-eye surveillance schedule and symptom-awareness counselling
- Refraction/cataract follow-up post-repair (PPV accelerates phakic cataract — Hillier PIVOT Ophthalmology 2019 PMID 30468761)
- Hand tractional/exudative long-term control to the routed engine_id

Escalation triggers (move to higher acuity):
- New subretinal fluid / progression of a treated tear to RRD → urgent vitreoretinal repair
- Redetachment / PVR → reoperation (PPV ± buckle ± silicone oil)
- New fellow-eye symptoms → same-day dilated exam

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Rhegmatogenous RD with the MACULA still ON (central vision intact) — same-day surgical emergency to repair before the fovea detaches (Hillier PIVOT Ophthalmology 2019 PMID 30468761; AAO PPP Retinal Detachment)
- [LIFE_THREATENING] RD with a history of significant ocular trauma — possible occult open globe, giant tear or dialysis; the trauma pathway takes precedence
- [SEVERE] New floaters/photopsia or a change in known PVD symptoms — every symptomatic PVD needs a prompt dilated fundus exam because ~14% harbour a retinal tear (Hollands JAMA 2009 RCE PMID 19934426)

Citations

- Hollands et al, JAMA 2009 — Rational Clinical Examination "Acute-onset floaters and flashes: is this patient at risk for retinal detachment?" + AAO Preferred Practice Pattern (Posterior Vitreous Detachment, Retinal Breaks & Lattice Degeneration / Retinal Detachment, current cycle) + Hillier et al, Ophthalmology 2019 — PIVOT RCT (pneumatic retinopexy vs vitrectomy) + Heimann et al, Ophthalmology 2007 — SPR study (scleral buckling vs primary vitrectomy) + Wilkinson, Cochrane 2014 — interventions for asymptomatic retinal breaks & lattice (symptomatic-vs-asymptomatic pivot) + Kim et al, Retina 2013 — macula-off symptom-duration timing [PMID:19934426](https://pubmed.ncbi.nlm.nih.gov/19934426/)
- Cited evidence (PMID 30468761) [PMID:30468761](https://pubmed.ncbi.nlm.nih.gov/30468761/)
- Cited evidence (PMID 33885738) [PMID:33885738](https://pubmed.ncbi.nlm.nih.gov/33885738/)
- Cited evidence (PMID 34520841) [PMID:34520841](https://pubmed.ncbi.nlm.nih.gov/34520841/)
- Cited evidence (PMID 35953261) [PMID:35953261](https://pubmed.ncbi.nlm.nih.gov/35953261/)

Last reconciled with current guidelines: 2026-05-17.
References
  • Hollands et al, JAMA 2009 — Rational Clinical Examination "Acute-onset floaters and flashes: is this patient at risk for retinal detachment?" + AAO Preferred Practice Pattern (Posterior Vitreous Detachment, Retinal Breaks & Lattice Degeneration / Retinal Detachment, current cycle) + Hillier et al, Ophthalmology 2019 — PIVOT RCT (pneumatic retinopexy vs vitrectomy) + Heimann et al, Ophthalmology 2007 — SPR study (scleral buckling vs primary vitrectomy) + Wilkinson, Cochrane 2014 — interventions for asymptomatic retinal breaks & lattice (symptomatic-vs-asymptomatic pivot) + Kim et al, Retina 2013 — macula-off symptom-duration timing — PMID:19934426
  • Cited evidence (PMID 30468761) — PMID:30468761
  • Cited evidence (PMID 33885738) — PMID:33885738
  • Cited evidence (PMID 34520841) — PMID:34520841
  • Cited evidence (PMID 35953261) — PMID:35953261