• Oct 2014
    AAO Retina PPP Panel, Hoskins Center for Quality Eye Care

    Introduction

    These are summary benchmarks for the Academy’s Preferred Practice Patterns® (PPP) guidelines. The Preferred Practice Patterns series of guidelines has been written on the basis of three principles.

    • Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
    • Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
    • Each recommendation should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects the best evidence available.

    Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. They physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

    The Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

    For each major disease condition, recommendations for the process of care, including the history, physical exam and ancillary tests, are summarized, along with major recommendations for the care management, follow-up, and education of the patient. For each PPP, a detailed literature search of PubMed and the Cochrane Library for articles in the English language is conducted. The results are reviewed by an expert panel and used to prepare the recommendations, which they rated in two ways.

    The panel first rated each recommendation according to its importance to the care process. This “importance to the care process” rating represents care that the panel thought would improve the quality of the patient’s care in a meaningful way. The ratings of importance are divided into three levels.

    • Level A, defined as most important
    • Level B, defined as moderately important
    • Level C, defined as relevant but not critical

    The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The “ratings of strength of evidence” also are divided into three levels.

    • Level I includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
    • Level II includes evidence obtained from the following:
      • Well-designed controlled trials without randomization
      • Well-designed cohort or case-control analytic studies, preferably from more than one center
      • Multiple-time series with or without the intervention
    • Level III includes evidence obtained from one of the following:
      • Descriptive studies
      • Case reports
      • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review) 

    PPPs are intended to serve as guides in patient care, with greatest emphasis on technical aspects. In applying this knowledge, it is essential to recognize that true medical excellence is achieved only when skills are applied in such a manner that the patients’ needs are the foremost consideration. The AAO is available to assist members in resolving ethical dilemmas that arise in the course of practice. (AAO Code of Ethics)

    Initial and Follow-up Evaluation

    Initial Exam History (Key elements)

    • Symptoms of PVD
    • Family history of RD, related genetic disorders
    • Prior eye trauma
    • Myopia
    • History of ocular surgery including refractive lens exchange and cataract surgery

    Initial Physical Exam (Key elements)

    • Confrontation visual field examination, and assessing for the presence of a relative afferent pupillary defect
    • Examination of the vitreous for hemorrhage, detachment, and pigmented cells
    • Examination of the peripheral fundus with scleral depression. The preferred method of evaluating peripheral vitreoretinal pathology is with indirect ophthalmoscopy combined with scleral depression.

    Ancillary Tests

    • Optical coherence tomography may be helpful to evaluate and stage the PVD
    • Perform B-scan ultrasonography if peripheral retina cannot be evaluated. If no abnormalities are found, frequent follow-up examinations are recommended.

    Surgical and Postoperative Care if Patient Receives Treatment

    • Inform patient about the relative risks, benefits, and alternatives to surgery
    • Formulate a postoperative care plan and inform patient of these arrangements
    • Advise patient to contact ophthalmologist promptly if they have a substantial change in symptoms such as floaters, visual field loss, or decreased visual acuity

    Follow-up History

    • Visual symptoms
    • Interval history of eye trauma, including intraocular surgery

    Follow-up Physical Exam

    • Visual acuity
    • Evaluation of the status of the vitreous, with attention to the presence of pigment, hemorrhage, or syneresis
    • Examination of the peripheral fundus with scleral depression
    • Optical coherence tomography if vitreomacular traction is present
    • B-scan ultrasonography if the media are opaque

    Patient Education

    • Educate patients at high risk of developing retinal detachment about the symptoms of PVD and retinal detachment and the value of periodic follow-up exams
    • Instruct all patients at increased risk of retinal detachment to notify their ophthalmologist promptly if they have a substantial change in symptoms such as increase in floaters, loss of visual field, or decrease in visual acuity

    Care Management:

    Management Options

    Type of Lesion Treatment*
    Acute symptomatic horseshoe tears Treat promptly
    Acute symptomatic operculated tears Treatment may not be necessary
    Acuite symptomatic dialyses Treat promptly
    Traumatic retinal breaks Usually treated
    Asymptomatic horseshoe tears (without subclinical RD) Often can be followed without treatment
    Asymptomatic operculated tears Treatment is rarely recommended
    Asymptomatic atrophic round holes Treatment is rarely recommended
    Asymptomatic lattice degeneration without holes Not treated unless PVD causes a horseshoe tear
    Asymptomatic lattice degeneration with holes Usually does not require treatment
    Asymptomatic dialyses No consensus on treatment and insufficient evidence to guide management
    Eyes with atrophic holes, lattice degeneration, or symptomatic
    horseshoe tears where the fellow eye has had a  RD
    No consensus on treatment and insufficient evidence to guide management
    PVD = Posterior vitreous detachment; RD = retinal detachment
    * There is insufficient evidence to recommend prophylaxis of asymptomatic retinal breaks for patients undergoing cataract surgery.