By virtue of its nature, a comprehensive ophthalmology practice promises a broad variety of pathology and problem complexity. The ability to recognize diagnoses that warrant referral to a specialist strengthens the comprehensive ophthalmologist’s clinical acumen.
The following is a list of common diagnoses that are best managed with the assistance of a retina specialist. It is by no means exhaustive; however, this list encompasses some of the most common indications for referral.
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 Occlusions
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.
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About the author: Christina Antonopoulos, MD, is a vitreoretinal fellow at Boston University School of Medicine.