Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

posterior vitreous detachment without break/tear

1st line – prophylactic treatment

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ACUTE
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posterior vitreous detachment without break/tear
1st line – 

prophylactic treatment

Posterior vitreous detachment (PVD) cannot be monitored with sufficient certainty because posterior vitreoschisis can mask the diagnosis. Prophylactic treatment such as laser cerclage dramatically reduces the risk of subsequent detachment.

retinal hole/tear without detachment

1st line – observation/reassurance ± prophylactic treatment

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ACUTE
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retinal hole/tear without detachment
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asymptomatic
1st line – 

observation/reassurance ± prophylactic treatment

Asymptomatic retinal breaks without detachment may be monitored. Prophylactic treatment such as laser cerclage dramatically reduces the risk of subsequent detachment.

1st line – cryopexy or laser retinopexy

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ACUTE
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retinal hole/tear without detachment
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symptomatic
1st line – 

cryopexy or laser retinopexy

In symptomatic patients, the breaks are sealed using cryopexy or laser retinopexy.

rhegmatogenous RD

1st line – scleral buckle and/or vitrectomy

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ACUTE
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rhegmatogenous RD
1st line – 

scleral buckle and/or vitrectomy

Perform scleral buckle or vitrectomy alone or in combination. The breaks are sealed using cryopexy or laser retinopexy.

Scleral buckling and vitrectomy have similar outcomes on several measures when repairing simple rhegmatogenous RD (e.g., primary retinal reattachment rate, post-operative visual acuity, and anatomical success).[48] [ Cochrane Clinical Answers logo ] ​ More people experience cataract development, cataract progression, and new/iatrogenic breaks with vitrectomy than with scleral buckling, whereas fewer people experience choroidal detachment with vitrectomy.[48] [ Cochrane Clinical Answers logo ]

1st line – pneumatic retinopexy

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ACUTE
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rhegmatogenous RD
1st line – 

pneumatic retinopexy

Pneumatic retinopexy is indicated for the repair of uncomplicated rhegmatogenous RD (e.g., small breaks in the superior two-thirds of the fundus).[49]​ Observational data suggest a success rate between 54% and 77% after a single procedure.[50][51][52]​ Success is lower in eyes with inferior breaks, marked vitreoretinal traction, and multiple breaks, but may be superior in phakic eyes than in pseudophakic eyes.[53]​ Failure of pneumatic retinopexy does not appear to impact upon final visual acuity following a subsequent procedure.[50]​ Pneumatic retinopexy is associated with fewer post-operative complications than scleral buckle, but it has lower reattachment and higher recurrence rates.[54]

tractional RD

1st line – vitrectomy

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ACUTE
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tractional RD
1st line – 

vitrectomy

Pars plana vitrectomy is considered the most suitable treatment option in the presence of significant traction. Care must be taken to avoid creating iatrogenic retinal breaks. The intraoperative use of triamcinolone helps to visualise the vitreous for detachment and removal, thereby reducing the incidence of iatrogenic retinal tears/detachment.[57]

The breaks are sealed using cryopexy or laser retinopexy.

Consider – scleral buckle

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ACUTE
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tractional RD
Consider – 

scleral buckle

Additional treatment recommended for SOME patients in selected patient group

In tractional RD secondary to PVD, a scleral buckle procedure may be used in conjunction with vitrectomy.

exudative RD

1st line – treat underlying cause

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ACUTE
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exudative RD
1st line – 

treat underlying cause

Treatment should focus on the underlying aetiology.

Inflammatory conditions may require topical and/or systemic corticosteroids.

Infections require appropriate antimicrobial therapy.

In patients with diabetes, optimise hypertensive and glycaemic control.

Consider – retinotomy + drainage

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ACUTE
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exudative RD
Consider – 

retinotomy + drainage

Additional treatment recommended for SOME patients in selected patient group

In select cases, use retinotomy to drain the sub-retinal fluid.

haemorrhagic RD

1st line – retinotomy ± retinal inversion

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ACUTE
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haemorrhagic RD
1st line – 

retinotomy ± retinal inversion

In haemorrhagic RD, the thickness of the sub-macular blood informs decision-making.

Blood is either removed or repositioned away from the fovea. Blood may be drained or evacuated by retinotomy or retinal inversion (for large clots).

Delay may lead to irreversible damage.

Consider – tissue plasminogen activator (tPA) + gas bubble tamponade

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ACUTE
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haemorrhagic RD
Consider – 

tissue plasminogen activator (tPA) + gas bubble tamponade

Additional treatment recommended for SOME patients in selected patient group

tPA injection with a gas bubble tamponade can 'push' the blood out from the sub-macular space into an inferior location where the photoreceptor damage is less noticeable to the patient. This requires an appropriately positioned patient.

Cataract may result from tPA given intravitreally or through direct venous cannulation.

Consult a specialist for guidance on dose.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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