Pictorial case study

Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire.

The case
A 69-year-old woman presented in the surgery with a five-day history of noticing black floaters in her right eye with occasional flashes of light. Her vision was otherwise unaffected and she had no other symptoms. She had not suffered any trauma. She was otherwise well and taking only a proton-pump inhibitor for acid reflux symptoms.

On examination in the surgery there was no abnormality to be seen on ophthalmoscopy. However, a good view of the retina was not obtained as the pupils were not dilated.

What is the diagnosis, management and differential diagnosis?

Diagnosis and management
The initial diagnosis was posterior vitreous haemorrhage or a retinal tear. As there was the possibility of a retinal tear she was referred urgently to an ophthalmologist who saw her the next day. On formal examination with pupillary dilation a small retinal tear was noted. This was treated successfully by laser photocoagulation two days later.

Retinal tear is more common in severe myopes and following surgery

Retinal tear is rare. It is more common in severe myopes; following cataract surgery or YAG laser capsulotomy; if there is a family history of retinal detachment or if there is a history of retinal detachment in the other eye; or, uncommonly, following trauma. It is more common in Caucasians, and more common in men than women. It is serious, as if left untreated it may lead to retinal detachment, which in turn may cause loss of vision.

Retinal tears occur when the vitreous becomes more liquid. With movements of the eye, pockets of liquid move around the vitreous cavity, which cause the vitreous to pull on the retina. Over time, the vitreous can separate from the retina. If it is securely attached to the retina, then the detachment may cause the retina to tear. Vitreous detachment and retinal tears are interpreted by the brain as flashes or large spots on the retina.

Retinal holes or tears can be treated with either lasers or cryotherapy under a local anaesthetic.

Possible different diagnoses

  • Posterior vitreous detachment.
  • Retinal detachment.

Differential diagnosis
Retinal detachment:

  • Relatively rare; affects one in 10,000 people.
  • More likely to affect short-sighted, middle-aged people.
  • Shadow spreading across vision.
  • Bright flashing lights or dark spots.

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