1.Retinal Tear/Break or Rhegmatogenous Detachment -
Retinal tears are particularly common in the setting of acute posterior
vitreous detachments, trauma or in highly myopic eyes with lattice
degeneration. Retinal breaks can potentially allow liquefied vitreous
into the subretinal space, leading to a rhegmatogenous retinal
detachment. If a retinal break or tear is suspected based on a clinical
history of new floaters/photopsias, and/or a careful peripheral exam
with scleral depression reveals one or more breaks, it is important
that the location(s) be documented. A referral should then be made for
laser retinopexy, the urgency depending primarily on both the
symptomatology and location of the break(s). If a rhegmatogenous
detachment is diagnosed, the patient requires urgent referral to a
retina specialist for operative repair.
2.Intraocular Foreign Body
Any patient who has sustained penetrating globe trauma must be
carefully evaluated for the presence of an intraocular foreign body.
Several modalities are useful in assessing for a posterior segment
intraocular foreign body, namely B-scan ultrasound, frontal and lateral
skull plain films and non-contrast enhanced orbital CT scan. Foreign
bodies may be metallic, glass or organic material. If an intraocular
foreign body is suspected, urgent referral must be made to a retina
specialist for removal. Pars plana vitrectomy provides for cautious
removal of the foreign body, with the assistance of a rare earth magnet
or forceps extraction, depending on whether the material is
ferromagnetic or not.
3. Post-Operative, Post-Traumatic or Endogenous Infectious
Endophthalmitis-
A diagnosis of endophthalmitis made on the basis of profound
intraocular inflammation in the setting of recent intraocular surgery
(e.g., cataract extraction or glaucoma filtration surgery), penetrating
globe trauma or known sepsis or endocarditis requires urgent referral
to a retinal specialist. The recommended management of such patients
involves performing a limited vitreous biopsy (or needle tap) and
intravitreal injection of antibiotic and, if indicated, antifungal
agents.
4. Proliferative Diabetic Retinopathy with High-Risk Characteristics -
Diabetic patients with proliferative diabetic retinopathy (PDR) with
high-risk characteristics carry the highest risk of severe visual loss.
High-risk PDR is defined as:
• Mild disc neovascularization with vitreous
hemorrhage;
• Moderate to severe disc neovascularization
with or without vitreous hemorrhage; and
• Moderate (1/2 disc area) neovascularization
elsewhere with vitreous hemorrhage.
Referral for evaluation and management of anterior
and posterior segment neovascularization is crucial to avoid
development of proliferative vitreoretinopathy and
tractional and/or rhegmatogentous retinal detachment.
5. Clinically Significant Macular Edema or Recalcitrant -
Diabetic Macular Edema Cases of clinically significant diabetic macular
edema (CSDME) or suspected diabetic macular edema should be referred
for evaluation and potential focal laser treatment. Persistent diabetic
macular edema that remains after initial management with laser
photocoagulation often requires treatment with modified grid laser
treatment, intravitreal triamcinolone injections, intravitreal
anti-VEGF agents or a combination of these therapies. A pars plana
vitrectomy with membrane peel may be indicated in the case of CSDME
associated with posterior hyaloid traction.
6. Exudative Age-Related Macular Degeneration -
Patients with a documented history of non- exudative macular
degeneration with new-onset metamorphopsia and/or scotomata or a
clinical exam demonstrating subretinal or intraretinal fluid or
hemorrhage suggestive of a choroidal neovascular membrane should be
referred urgently to a retina specialist for evaluation with
fluorescein angiography, optical coherence tomography and initiation of
intravitreal anti-VEGF therapy (Avastin or Lucentis). These patients
need to establish care with a retina specialist, as the initial
follow-up of the clinical response to anti-VEGF therapy is initially
quite frequent (every four to six weeks).
7. Retinal Vein Occlusion -
Central retinal vein and branch retinal vein occlusions are variably
symptomatic, depending on the degree of ischemia and macular edema that
is induced. All cases warrant evaluation by a retina specialist to
assess the level of macular perfusion and edema and determine the
appropriate management, which may include focal laser photocoagulation,
intravitreal anti-VEGF agents or triamcinolone. Such cases require
close follow-up by either a comprehensive ophthalmologist or specialist
for detection of sequelae of retinal vein occlusions, namely posterior
and anterior segment neovascularization.
