Letters Flashes, floaters, and a field defect

Risk of missing a retinal tear in patients with vitreous detachment

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7572 (Published 23 December 2013) Cite this as: BMJ 2013;347:f7572
  1. Edward Nicholas Herbert, consultant retinal surgeon1
  1. 1Musgrove Park Hospital, Taunton TA1 5DA, UK
  1. enherbert{at}doctors.org.uk

Khan and colleagues highlight that up to one in six patients with acute symptomatic posterior vitreous detachment have a resultant retinal tear and that dilated funduscopy is needed in all cases.1 Untreated tears can result in retinal detachment and sight loss. It is important to ensure that whoever performs funduscopy is adequately trained and uses the appropriate techniques. Most vitreoretinal negligence cases result from a missed or delayed diagnosis of retinal detachment.2

I conducted a survey of the Britain and Eire Association of Vitreo-Retinal Surgeons in 2009. Seventy seven per cent of respondents thought that slit lamp biomicroscopy (90D lens or equivalent) on its own did not constitute a minimum acceptable standard and that an additional technique—either three mirror biomicroscopy or binocular indirect ophthalmoscopy with indentation—is needed. The American Academy of Ophthalmology lists indented indirect ophthalmoscopy as essential.

One study showed that an experienced retinal surgeon would miss one in 10 tears with 90D biomicroscopy alone if indented ophthalmoscopy was not done,3 and that less experienced observers were more likely to miss signs associated with retinal tears.4 The report on the community optometry scheme in Cardiff suggested that nearly a quarter of breaks were missed.5

I am not convinced that assessing fields with a hatpin or looking for a Weiss ring with an ophthalmoscope in general practice would be helpful. The important thing is to recognise the symptoms and refer to someone appropriately trained in a short time frame for a proper assessment. In the era of any willing provider there is a high risk of permanent avoidable visual loss if those providing this service are not suitably trained or experienced and do not perform a full examination.


Cite this as: BMJ 2013;347:f7572


  • Competing interests: None declared.


View Abstract