In the second part of the fifth installment of Clinical Conversations in Retina, Daniel Epshtein, OD, FAAO, and Alison Bozung, OD, FAAO, continue the discussion of retinal emergencies.
In part I, Dr. Epshtein and Dr. Bozung considered treatments for acute retinal arterial occlusions. In this subsequent part, they explore treating retinal occlusions with longer onset and retinal detachments.
Managing retinal occlusion patients with onset for a week
In cases where a patient may have had an onset of acute vision loss for a longer period of time, such as a week or more, it is still important to ask questions regarding giant cell arteritis (GCA) and general stroke symptoms. For patients who do not have health insurance or have difficulty accessing care, sending them to an emergency room may help expedite the process of their treatment.
Since many individuals prefer to avoid the emergency room (ER), Dr. Epshtein lists cardiologists as another possible course of action if a patient has one. Many cardiologists are accustomed to adding patients to their schedules on late notice.
As it is difficult to quickly receive referrals, appointments, and treatments, patients can also be sent to their primary healthcare provider to initiate the work-up process.
Treating retinal detachments
Understanding the type of retinal detachment influences the type and urgency of treatment.
Retinal detachments can be classified as:
- Rhegmatogenous: Tend to have a wrinkled appearance with a retinal break
- Tractional: Most commonly occurs secondary to proliferative diabetic retinopathy
- Exudative: Occurs due to conditions like infections or inflammatory disease
Patients who have been experiencing vision loss for several months may not be considered immediate emergencies, but it is still important for them to receive treatment in the near future. Of note, patients with retinal tears, flashes of light, and floaters are dealt with more urgently to ascertain the retinal status and prevent the worsening of their condition.
Treating macula-on and macula-off detachments
Historically, eyecare professionals (ECPs) have considered macula-on detachments to require surgery the day of, while macula-off detachments require surgery within a week. Ongoing studies suggest that operating on macula-off detachments within 48 to 72 hours of central vision loss may actually result in similar outcomes when compared to macula-on detachments.
As a result, Dr. Bozung recommends expedient referrals for recent macula-off detachments as much as possible. The time of fovea detachment can usually be pinpointed by understanding when central vision was lost, so this may be a pertinent question to ask macula-off retinal detachment patients.
Referring patients with retinal detachments
Macular detachment should generally be seen by a retina surgeon within a few days and repaired within the next week to a week and a half. For macula-off detachments, surgeons may prefer to wait until they are able to have their regular team to ensure the best possible outcome.
Macula-on and fovea-on detachments are considered emergencies, so they should see a retinal surgeon immediately. Further, patients should be warned against eating prior to the surgical evaluation to avoid any delays.
There are other factors that can help diagnose retinal detachment and the timing of its onset. ECPs can look out for the presence of proliferative vitreoretinopathy (PVR), which indicates detachment may have begun some time ago. Demarcation lines also suggest a more chronic retinal detachment.
Conclusion
Understanding patients’ level of access to healthcare allows ECPs to recommend a course of action that allows treatment to be obtained the quickest.
Treating retinal detachments depends on the status of the macula and the type of detachment. Macula-on and very recently macula-off (within 1 to 3 days) retinal detachments are considered emergencies and should be referred to a retinal surgeon urgently.
