Retinal Tear

A retinal tear is a full thickness break in the neurosensory retina, usually caused by vitreoretinal traction during posterior vitreous detachment. It is the precursor of rhegmatogenous retinal detachment.

• Types: horseshoe (flap) tear (traction on a retinal flap, highest risk), operculated hole (a piece of retina detached with the vitreous), round atrophic holes (inside lattice or in thin retina, low risk), dialysis (circumferential tear at the ora serrata, usually after trauma), and giant tear (over 90 degrees).
• Risk factors: acute PVD, myopia, lattice degeneration, previous cataract surgery, trauma, family history, Stickler and Marfan syndromes, and previous retinal detachment in the fellow eye.
• Without treatment, symptomatic horseshoe tears progress to detachment in about 30 to 50 percent of eyes.

• Floaters (new, with a shower of dots), flashes of light, and sometimes a pigmented or red cloud with vitreous haemorrhage.
• Asymptomatic in many atrophic holes.
• Retina: flap tear with surrounding vitreous traction, often at the superotemporal quadrant; pigment in vitreous (Shafer sign); associated vitreous haemorrhage; subretinal fluid may be present around the tear (localised detachment).
• Absence of field loss unless detachment develops.

• Dilated fundus examination with indirect ophthalmoscopy and scleral indentation, with careful drawing of the tear and any subretinal fluid; 360-degree peripheral examination of both eyes.
• Widefield imaging and optical coherence tomography for the macula; B-scan ultrasound if the view is poor.
• Classify as symptomatic or asymptomatic, with or without detachment, and assess the high risk features (horseshoe tear, superior location, large size, vitreous traction, subretinal fluid, aphakia, high myopia, fellow eye detachment).

• Symptomatic tears and high risk lesions require prompt treatment (within 24 to 48 hours) to prevent detachment:
  • Laser retinopexy (indirect ophthalmoscope or slit lamp delivery): 2 to 3 rows of confluent burns surrounding the tear (about 200 to 400 milliwatts, 0.1 to 0.2 seconds, 200 to 500 micrometres) to create a chorioretinal adhesion, which matures by about 10 to 14 days (full strength at about 2 weeks).
  • Cryopexy (transconjunctival freezing to a whitening of the retina), preferred when the tear is anterior, with media opacity (vitreous haemorrhage), or the pupil is poorly dilated.
• Tears with progressing subretinal fluid: scleral buckle, pneumatic retinopexy or vitrectomy; small localised cuffs are demarcated with laser.
• Asymptomatic round atrophic holes and asymptomatic lattice without tears: observe (prophylactic laser only in selected high risk eyes: fellow eye detachment, family history of detachment, aphakia, Stickler syndrome).
• Post-treatment: avoid heavy straining and high impact sport for 2 weeks; review at 2 weeks and 6 weeks, then 3 months; re-treat if new tears or leaking subretinal fluid.
• Counsel on warning symptoms (new floaters, flashes, shadow, vision loss) with same day review, because new tears can occur in about 5 to 10 percent after treatment.
• Examine the fellow eye.