OcuLearning › Retina

Retinal Tear / Break

URGENT — Retina

Symptoms

  • photopsias (flashes): bright, brief flickers typically in the peripheral field
  • floaters: sudden appearance of "cobwebs", "hairs", or a "film" that moves with the eye
  • blurred vision: may occur if there is associated vitreous hemorrhage
  • history: often follows an acute posterior vitreous detachment (pvd)

Clinical Findings

Clinical signs

  • shafer sign ("tobacco dust"): brown pigmented RPE cells in the anterior vitreous
  • horseshoe tear: flap of retina pulled forward by vitreous traction (high risk)
  • operculated hole: a "plug" of retina completely pulled free from the surface
  • vitreous hemorrhage: ranging from mild "dust" to dense blood

Chronic features

  • pigmented borders: a ring of pigment around a hole suggests it is old and stable
  • subretinal fluid (srf): localized fluid around the break (the start of a detachment)

Etiology

Mechanism

  • vitreoretinal traction: the vitreous gel pulls on areas of firm attachment during a PVD
  • lattice degeneration: localized thinning of the retina that is prone to holes or tears

Risk factors

  • high myopia (longer eye = thinner retina), trauma, and previous intraocular surgery
  • family or personal history of retinal detachment

Red Flags

  • shafer sign (pigment): ~90% correlation with a retinal break
  • horseshoe tear: extremely high risk of progressing to retinal detachment if untreated
  • vitreous hemorrhage + acute pvd: 50–70% risk of an underlying tear
  • symptomatic fluid: localized detachment surrounding a fresh tear

Investigations

Exam protocol

  • dilated fundus exam with 360° scleral depression is mandatory for both eyes
  • slit lamp: check the anterior vitreous specifically for pigment cells

Imaging

  • b-scan ultrasound: essential if vitreous hemorrhage prevents a clear view of the retina
  • wide-field photography: useful for documentation and patient education

Treatment

Retinopexy

  • laser retinopexy: 1–3 rows of confluent burns around the break to create a scar
  • cryotherapy: cold probe used if the break is too peripheral or media is too hazy for laser

Conservative management

  • atrophic holes: small, round holes in lattice may often be observed if asymptomatic
  • lifestyle: avoid heavy lifting or high-impact activities for 2 weeks post-treatment

Clinical Pearl

"Tobacco dust" (Shafer sign) in the anterior vitreous = retinal tear until proven otherwise. Pigmented cells in the vitreous come from the RPE after a full-thickness break. A symptomatic tear without treatment leads to retinal detachment in ~50% within days to weeks.

Differential Diagnosis

  • • lattice degeneration (thinning without a full-thickness break)
  • • vitreous hemorrhage from other causes (e.g., diabetic retinopathy)
  • • retinoschisis (splitting of retinal layers; usually less urgent)
  • • "white without pressure" (benign peripheral retinal appearance)

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