Small Retinal Hemorrhages Research Articles

Susac syndrome: A rare presentation

Susac syndrome is an autoimmune microangiopathy characterized by a triad of encephalopathy, sensori-neural hearing loss and varying degrees of branch retinal artery occlusion. A young male patient is described with features of focal neurological lesions and small superficial retinal haemorrhages and areas of retinal arteriolar endothelial inflammation appearing as Gass plaques. Susac syndrome presents with varying features involving brain, inner ear and retina. Fundus Fluorescein angiography should be performed in all patients with an unexplained encephalopathy to look for characteristic arteriolar wall changes.

Histopathologic Observations of Eyes in Exenterated Orbits After Neoadjuvant Intra-Arterial Cytoreductive Chemotherapy for Adenoid Cystic Carcinoma of the Lacrimal Gland.

To assess whether exenteration specimens obtained after neoadjuvant intra-arterial cytoreductive chemotherapy (IACC) for adenoid cystic carcinoma of the lacrimal gland demonstrate significant ocular histopathologic alterations that might preclude future pursuit of globe-preserving therapy. Retrospective histopathologic analysis of globes in IACC-treated exenteration specimens among the same cohort of patients whose survival outcomes have been reported. Twenty patients had specimens available. Nineteen globes revealed no abnormalities of the iris, ciliary body, lens, retinal pigment epithelium, choroid, or chorioretinal vasculature. Eighteen globes showed no optic nerve abnormalities. One globe from a patient who refused exenteration until adenoid cystic carcinoma recurrence supervened demonstrated optic nerve edema with a peripapillary hemorrhage and cotton wool spot, as well as hemorrhage and necrosis within an extraocular muscle. Eighteen globes showed no retinal abnormalities attributable to intra-arterial chemotherapy. Three globes showed incidental retinal findings: 2 globes contained 1 to 2 small peripheral retinal hemorrhages and 1 had a pigmented retinal hole. Seven demonstrated mild, chronic extraocular muscle inflammation, and 13 had unremarkable musculature. The single patient who received IACC via the internal carotid rather than the external carotid artery developed ophthalmic artery occlusion with orbital apex syndrome prior to exenteration, and diffuse necrosis and hemorrhage were evident histopathologically. Neoadjuvant IACC does not cause significant histopathologic damage to key ocular structures or compromise visual function in patients receiving intra-arterial chemotherapy through the external carotid artery. However, delivering chemotherapy through the internal carotid artery may result in visually significant thrombotic vascular events. The generally benign histopathological findings in these exenteration specimens support the concept of IACC delivery through the external carotid system as the cornerstone of a future globe-preserving strategy for lacrimal gland adenoid cystic carcinoma.

ANATOMICAL CHANGES ON SEQUENTIAL MULTIMODAL IMAGING IN PERIFOVEAL EXUDATIVE VASCULAR ANOMALOUS COMPLEX.

To report a series of 21 patients with perifoveal exudative vascular anomalous complex (PEVAC) and to investigate the anatomical changes over time. We conducted a retrospective study. Clinical data of consecutive patients, presenting at the Rotterdam Eye Hospital between 2014 and 2019, were analyzed. The data collected included best-corrected visual acuity, fundus photography, optical coherence tomography (OCT), OCT-angiography, fluorescence angiography, and indocyanine green angiography. We included 21 patients with a PEVAC lesion with a mean follow-up of 24.3 ± 13.8 months (range, 9-46 months). Patients with PEVAC were on average 75.3 ± 11.1 years (range, 53-90 years). The large perifoveal vascular aneurysmal abnormality was associated with small retinal hemorrhages in six patients and hard exudates in three patients. The PEVAC lesion was associated with intraretinal cystic spaces on OCT in 15 patients. Twelve of 21 patients showed no changes in cystic spaces on OCT during follow-up: 9 patients had stable cystic spaces and 3 patients had no cystic spaces. In contrast, in 9 of 21 patients, we observed changes in cystic spaces on OCT during follow-up. In two patients, cystic spaces appeared during follow-up, and in seven patients, there was a spontaneous resolution of cystic spaces. In three of these seven patients, the PEVAC lesion completely disappeared. Two patients, with stable intraretinal cystic spaces on OCT, were treated with intravitreal injections of anti-vascular endothelial growth factor without improvement. Perifoveal exudative vascular anomalous complex is an idiopathic perifoveal retinal vascular abnormality that is associated with intraretinal cystic spaces. These intraretinal cystic spaces associated with a PEVAC lesion, and even the PEVAC lesion itself, can have a spontaneous resolution over time.

The Expanded Spectrum of Perifoveal Exudative Vascular Anomalous Complex

To expand our understanding of the uncommon entity, referred to as perifoveal exudative vascular anomalous complex (PEVAC) by describing multimodal imaging findings, including optical coherence tomography angiography (OCT-A). Retrospective cohort study. Patients diagnosed with PEVAC were identified at 4 retina referral centers worldwide and underwent complete ophthalmologic examination including structural OCT, OCT-A, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Demographics and clinical findings were analyzed at baseline and at available follow-ups. Fifteen eyes (15 patients, mean age 73 ± 13 years) were included. Six of 15 eyes were diagnosed with coincident age-related macular degeneration (AMD) and 2 with myopic macular degeneration. On fundus examination PEVAC presented as a large perifoveal isolated aneurysm, unifocal in 12 of 15 eyes, associated with small retinal hemorrhages and intraretinal exudation. On structural OCT, PEVAC appeared as a round hyperreflective lesion with hyporeflective lumen, typically surrounded by intraretinal cystic spaces. Dye angiography demonstrated a well-defined hyperfluorescent lesion with variable leakage on FA and without leakage on ICGA. OCT-A showed flow signal correlating with the aneurysmal lesion connecting to retinal capillary plexuses. Seven patients were followed for 13.0 ± 10.5months with no evidence of functional/anatomic changes. Three patients underwent anti-vascular endothelial growth factor (VEGF) intravitreal injections without improvement. Two eyes were associated with a type 3 neovascularization eccentric to PEVAC. PEVAC is an isolated, perifoveal, aneurysmal abnormality, occurring in otherwise healthy patients who may manifest other macular disease including AMD and myopic macular degeneration. PEVAC did not typically respond to anti-VEGF therapy, and may be associated with type 3 neovascularization.

Fundus imaging in newborn children with wide-field scanning laser ophthalmoscope.

Current fundus imaging in newborn babies requires mydriatics, eye specula and corneal contact. We propose that a scanning laser ophthalmoscope (SLO) allows ultra wide-field imaging with reduced stress for the child. This prospective observational single centre study was conducted in Landspítali, University Hospital, Reykjavik, Iceland. In this study, a noncontact wide-field SLO (Optomap 200Tx) was used to image the retina in healthy full-term newborns without the use of mydriatics or eye specula. The child was held by one of the parents, while one of the researchers supported the child's head in front of the SLO camera for alignment and opened the eye with either a finger or a cotton tip. Fifty-nine participants were recruited (34 females). The mean age was 16days, and the mean gestational age was 40±1weeks at the time of imaging. Ultra-wide-field (200°) images were obtained of 44 participants. Twenty-seven participants (61%) had at least one ultra wide-field image with the optic disc and vessel segments in all quadrants of the fundus visible and in focus. No retinal pathology was found in the participants with the exception of one participant with small retinal haemorrhages. Scanning laser ophthalmoscope (SLO) ultra-wide-field fundus imaging is feasible in healthy full-term newborns without corneal contact, eye speculum or mydriatics. This approach could be an improvement for retinal imaging in newborn infants. Eye movement of the infant, whether asleep or awake, influenced which part of the fundus was captured, but focus and image quality were generally good.

Small retinal haemorrhages accompanied by macular soft drusen: prevalence, and funduscopic and angiographic characteristics

PurposeTo investigate the prevalence and clinical significance of small retinal haemorrhages accompanied by macular soft drusen in exudative age-related macular degeneration (AMD).MethodsThis observational case series included patients who had first...

Valsalva retinopathy following esophagogastroduodenoscopy under propofol sedation: A case report

We report a case of Valsalva retinopathy associated with esophagogastroduodenoscopy (EGD) under propofol sedation. A 43-year-old woman who had no previous history of systemic or ocular disease presented with a complaint of decreased vision in her left eye, which developed one day after EGD under propofol sedation. According to the referring physician, the patient had experienced multiple sustained Valsalva maneuvers during EGD. The fundus examination of the left eye showed a large preretinal hemorrhage surrounded by multiple small retinal hemorrhages in the posterior pole. One month later, fundus examination revealed a floating organized vitreous hemorrhage. The pars plana vitrectomy was performed to treat persistent vitreous hemorrhage. One month after vitrectomy, fundus examination showed normal retina and the patient's vision recovered to 20/20. Valsalva maneuver can occur during EGD under sedation, and Valsalva retinopathy should be considered as a possible cause. Valsalva retinopathy should be included in the differential diagnosis when a patient complains of blurred vision following EGD.

Teaching Neuro Images : Combined retinal and cerebral hyperperfusion syndrome after carotid thromboendarterectomy

A 62-year-old man presented with mild left hemiparesis, headache, and blurred vision of his right eye. Ten days before, he had undergone thromboendarterectomy because of subtotal stenosis of his right internal carotid artery. MRI revealed confluent white matter edema together with focal hemorrhage consistent with cerebral hyperperfusion syndrome (CHS; figure 1). Likewise, funduscopy showed small retinal hemorrhages confined to the right eye (figure 2). Under careful blood pressure control, symptoms and brain edema fully resolved within weeks. CHS occurs in around 3% of patients undergoing carotid thromboendarterectomy and can induce severe neurologic deficits.1 Rarely, hyperperfusion also involves the ipsilateral eye.2

Retinal Vasculature

See related article, pp 706–711 Ong et al1 studied 2907 participants in the Atherosclerosis Risk in Communities Study, who were free of diabetes mellitus, stroke, or coronary artery disease at baseline, and were followed for 13 years. Using retinal photographs and a simplified classification of hypertensive retinopathy, they found that even among patients who were well-controlled on antihypertensive medication, moderate/severe retinopathy carried a nearly 3-fold increase in the risk of stroke. Retinal signs of vascular pathology include an increased light reflex of the retinal arterioles (copper wiring or silver wiring, thought to occur as a result of atherosclerotic vessel wall thickening) and other arteriolar changes, including focal arteriolar narrowing, arteriovenous nicking, and microaneurysms. Retinal cotton-wool spots and exudates are the visible manifestations of small retinal infarctions and retinal hemorrhages, respectively, and represent the retinal consequences of the underlying arteriolar disease. All these findings predict an increased risk of vascular disease, and in particular, the risk of stroke,2 but the kind of stroke predicted differs with the retinal …

Three‐dimensional analysis of HSV colour space to distinguish small retinal haemorrhages, hard exudates and photocoagulation marks from dust artefacts

AbstractPurpose To detect early diabetic retinopathy, we employed three‐dimensional analysis of HSV colour spaces.Methods Six patients with diabetic retinopathy and small haemorrhages, hard exudates and photocoagulation marks were evaluated using fundus photography, which revealed dust artefacts in the fundi of some patients. We constructed an experimental device similar to the optical system of a fundus camera and made the artificial eyes of the fundus painted four kinds of colours: khaki, sunset, rose and sunflower. The dust artefacts were photographed under each artificial eye using the experimental device. We analysed all images using Scilab 5.4.0 and SIVP 0.5.3 software, which changed the RGB colour space into an HSV colour space. The software interpreted each value of HSV colour space as a three‐dimensional graph, which was modified using a Gaussian filter.Results We calculated the difference between manifestation and perimanifestation areas and dust artefact and periartefact areas using average HSV values. V values for the manifestations were haemorrhage, 0.06±0.03; hard exudate, −0.12±0.06 and photocoagulation marks, 0.07±0.02. V values for the dust artefacts, visualized under the human eye and the artificial eyes, were human eye, 0.19±0.03; khaki, 0.41±0.02; sunset, 0.43±0.04; rose, 0.47±0.11 and sunflower, 0.59±0.07. Ratios of the dust artefact to manifestation areas in the human eye were haemorrhage, 3.17; hard exudate, −1.58 and photocoagulation, 2.71.Conclusion The HSV colour space displayed good capability to distinguish small retinal haemorrhages, hard exudates and photocoagulation marks from dust artefacts.

The eye and the heart

The vasculature of the eye and the heart share several common characteristics. The easily accessible vessels of the eye are therefore—to some extent—a window to the heart. There is interplay between cardiovascular functions and risk factors and the occurrence and progression of many eye diseases. In particular, arteriovenous nipping, narrowing of retinal arteries, and the dilatation of retinal veins are important signs of increased cardiovascular risk. The pressure in the dilated veins is often markedly increased due to a dysregulation of venous outflow from the eye. Besides such morphological criteria, functional alterations might be even more relevant and may play an important role in future diagnostics. Via neurovascular coupling, flickering light dilates capillaries and small arterioles, thus inducing endothelium-dependent, flow-mediated dilation of larger retinal vessels. Risk factors for arteriosclerosis, such as dyslipidaemia, diabetes, or systemic hypertension, are also risk factors for eye diseases such as retinal arterial or retinal vein occlusions, cataracts, age-related macular degeneration, and increases in intraocular pressure (IOP). Functional alterations of blood flow are particularly relevant to the eye. The primary vascular dysregulation syndrome (PVD), which often includes systemic hypotension, is associated with disturbed autoregulation of ocular blood flow (OBF). Fluctuation of IOP on a high level or blood pressure on a low level leads to instable OBF and oxygen supply and therefore to oxidative stress, which is particularly involved in the pathogenesis of glaucomatous neuropathy. Vascular dysregulation also leads to a barrier dysfunction and thereby to small retinal haemorrhages.

Determination of the Optimal Color Space from Eight Types of Color Spaces for Distinguishing Small Retinal Hemorrhages from Dust Artifacts

To determine the optimal color space from eight types of color spaces for distinguishing small retinal hemorrhages from dust artifacts in cases of early diabetic retinopathy. We constructed an experimental device, which comprised an illumination optical system and a photographic optical system separated by a mirror having a hole. This device included a canon EOS 50D camera, an EF 50 mm f/1.8–2 camera lens, a Speedlite 270EX flash, an object lens, four double-convex lenses, three aperture stops, and six artificial eyes. The hemispherical eye ground was made of polythene terephthalate, which was painted with six matt color sprays: red, coffee, ocher, yellow, ivory, and orange. Five fragments of house dust on the object lens and the two lenses were photographed under each artificial eye. The RGB color space, measured by Paint Shop Pro from pictures, was changed into seven types of color spaces: XYZ, CMY, HSL, HSV, HSI, L*a*b*, and L*u*v*. The L*u*v* color space was the optimal one as it demonstrated the highest sensitivity and the best reproducibility. This result demonstrated that this color space could distinguish small hemorrhages from dust artifacts. Next, we analyzed the L*u*v* color space and compared the following three types of house dust positions: “on an object lens,” “on a photographic optical system,” and “on an illumination optical system.” The house dust position “on an object lens” had the highest sensitivity and the best reproducibility. However, the positions “on a photographic optical system” and “on an illumination optical system” had high sensitivity and good reproducibility only under certain conditions. In addition, no differences were found among the six types of fundus colors.

Determination of the optimal colour space for distinguishing small retinal haemorrhages from dust artefacts

AbstractPurpose To determine the optimal colour space from eight types of colour spaces for the purpose of distinguishing small retinal haemorrhages from dust artefacts in cases of early diabetic retinopathy.Methods We constructed an experimental device, which comprised an illumination optical system and a photographic optical system separated by a mirror having a hole. The device included a canon EOS 50D camera, an EF 50 mm f/1.8‐2 camera lens, a Speedlite 270EX flash, an object lens, four double‐convex lenses, three aperture stops and six artificial eyes. The eye ground was a hemisphere made of polythene terephthalate painted with six matt colour sprays: red, white brown, ochre, yellow, ivory and orange. Five fragments of house dust on the object lens and the two lenses were photographed under each artificial eye. The RGB colour space, measured by Paint Shop Pro from pictures, was changed into seven kinds of colour spaces: XYZ, CMY, HSL, HSV, HSI, L*a*b* and L*u*v*.Results The evaluation values of the following three colour spaces were favourable: the L*u*v* colour space (L*, 5.7±1.1; u*, 8.5±1.8 and v*, 6.7±1.1), the HSV colour space (hue, 2.0±0.5; saturation, 9.5±3.7 and value, 6.7±0.7) and the HSL colour space (hue, 2.0±0.5; saturation, 7.8±2.5 and lightness, 6.8±0.8). The other colour spaces did not show a good result.Conclusion The L*u*v* colour space is highly sensitive; therefore, it is most effective in distinguishing small haemorrhages from dust artefacts. The HSV and HSL colour spaces were highly sensitive in terms of saturation, lightness and value. Using Scilab and SIVP software, we are currently researching methodology that applies the use of colour spaces such as L*u*v* and HSV for automatic distinction.

Basic Research for Distinguishing Small Retinal Hemorrhages from Dust Artifact by using Hue, Lightness, and Saturation Color Space

Basic Research for Distinguishing Small Retinal Hemorrhages from Dust Artifact by using Hue, Lightness, and Saturation Color Space

Vitreoretinal traction in impending branch retinal vein occlusion: A pathogenetic role?

A 25-year-old woman noticed floaters in her left visual field since a few days earlier. She was positive for the heterozygous A1298C mutation on MTHFR gene, betafibrinogen gene –455G/A polymorphism, and 4G/5G plasminogen activator inhibitor-1 (PAI-1). Blood test and a systemic workup did not reveal any abnormality. Blood pressure was 120/80 mmHg. Visual acuity was 20/20 in both eyes. Following a complete ophthalmologic examination an impending upper temporal branch retinal vein occlusion (BRVO) was diagnosed ( Fig. 1). The patient was followed for one month without any particular treatment. Visual acuity remained unchanged and ophthalmic examination demonstrated improvement in the retinal vascular configuration with complete resolution of retinal hemorrhages, venous tortuosity and congestion ( Fig. 2). BRVO is the second most common vascular disorder of the retina, after diabetic retinopathy. It typically occurs at an arteriovenous (AV) crossing, where the retinal arteriole and venule share a common adventitial sheath (1). Although the pathogenesis of BRVO is not clear, there is evidence suggesting a multifactorial process including genetic, environmental and local factors. Mechanical narrowing of venous lumen may alter the normal blood flow downstream of the AV crossing, leading to turbulent flow. The preexisting endothelial vascular damage from different systemic Figure 1: Findings at first presentation of the patient. A) Fundus photograph of the left eye showing a moderate tortuous and engorged upper temporal retinal vein (white arrows), with some small flame-shaped retinal hemorrhages along the territory of the affected vessel (black arrows). B) Fluoresceingraphy disclosed delayed venous filling and a localised partial obstruction in the venous lumen near optic nerve (arrow). C) SD-OCT directed to the site of obstruction revealed a vitreovascular traction (arrow) and tissue elevation (asterisks) by an obliquely directed posterior hyaloids. D) SD-OCT dense protocol of false-color maps provided qualitative information of perivascular edema, showing an intense red colour at the involved blood vessel segment. A B

Evaluation of a partial retinal surface tear by optical coherence tomography

Differential diagnosis of retinal hemorrhage and partial tear of the retinal surface may be difficult in some cases. A 62-year-old woman was mistakenly followed-up for small retinal hemorrhages for more than 1 year. Blocked fluorescence specific to retinal hemorrhage was not observed by fluorescein angiography (FAG). Optical coherence tomography (OCT) clearly showed defects of the retinal surface indicating partial tears of the surface at the vitreo-retinal juncture and not hemorrhage. OCT is a useful and noninvasive device for the differential diagnosis of retinal hemorrhage and partial tear of the retinal surface.

Method for distinguishing small retinal hemorrhages from dust artifacts using HLS color space

Abstract Purpose Many ophthalmologists consider it is difficult to distinguish the small retinal hemorrhages of early diabetic retinopathy from dust artifacts on fundus cameras. To distinguish these, we analyzed the HLS color spaces for both findings. Methods Five patients with diabetic retinopathy had photographs of their fundi taken. Paint Shop Pro v. 8.0 was used to measure HLS color spaces of both hemorrhagic area and the area around hemorrhage in two locations of the photograph. In the darkroom, the experimental devise had four kinds of color papers on its ceiling: red, yellow, brown and black. Ten fragments of house dust on magnifier were each photographed using flash with each color paper. Three kinds of color lighting bulbs were hung from the ceiling without color papers. The ten fragments of house dust on the camera’s object lens were photographed under each color lighting bulb. Paint Shop Pro 8.0 was used to measure the HLS color spaces of dust artifact and the area around the dust artifact. Results The evaluation space of house dust was calculated using the HLS data obtained from magnifier. The hue was red, −116.6±33.1; black, 52.6±24.8; and yellow, 16.9±4.1. The lightness was black, −24.0±5.1; red, −14.5±2.0; brown, −11.5±2.4; and yellow, −8.3±1.4. The saturation was black, −163.8±84.5 and yellow, 45.6±21.6. The evaluation space of house dust was calculated using the HLS data obtained from the camera’s object lens. The hue was yellow, 7.9±1.7 and red, −3.3±1.4. The lightness was yellow, 10.0±2.3; red, 6.4±1.5; and brown, 5.7±2.6. Conclusion The lightness of the HLS color space could help to distinguish dust from hemorrhage in all color spectra. However, hue and saturation could only distinguish dust from hemorrhage in some conditions.

A Phase I Study of Visilizumab, a Humanized Anti-CD3 Monoclonal Antibody, in Severe Steroid-Refractory Ulcerative Colitis

To evaluate the safety and biological activity of visilizumab (a humanized anti-CD3 monoclonal antibody) and to determine a maximum tolerated dose in patients with severe ulcerative colitis that had not responded to 5 days of treatment with intravenous corticosteroids. In this open-label phase 1 study, 32 subjects received visilizumab at a dose of 10 or 15 microg/kg, administered intravenously on 2 consecutive days. Clinical response was defined as a Modified Truelove and Witts Severity Index <10 with a minimum decrease of 3 points; remission was <4 points. Endoscopic remission was a Mayo endoscopic subscore of 0 or 1. Eight patients received 15 microg/kg visilizumab. Because of dose-limiting toxicities (T-cell recovery >30 days in 2 of 8 patients), the dose was reduced to 10 microg/kg in 24 patients. On day 30, 84% of patients demonstrated a clinical response, 41% achieved clinical remission, and 44% achieved endoscopic remission. Forty-five percent of patients did not require salvage therapies or colectomy during the first year postdose. Mild to moderate symptoms of cytokine release occurred in 100% and 83% of patients in the 15- and 10-microg/kg dose groups, respectively. All patients exhibited a rapid decrease in circulating CD4(+) T-cell counts, which returned to baseline values by day 30 in 26 of 30 evaluable patients (86%). There were no serious infections. Visilizumab had an acceptable safety profile at the 10-microg/kg dose level and may be clinically beneficial in patients with severe intravenous corticosteroid-refractory ulcerative colitis.

Optic disc, foveal, and extrafoveal damage due to surgical separation of the vitreous.

To evaluate the morphologic outcomes resulting from surgical vitreoretinal separation in young adult primates. Vitrectomy and mechanical separation of the vitreous from the internal limiting lamina (ILL) of the posterior retina and surface of the optic disc were performed on 25 young adult cynomolgus monkey eyes in vivo. Lectin histochemical studies were used to evaluate the vitreoretinal interface. Morphologic outcomes were tabulated. In 11 of 25 eye regions, residual vitreous remained attached to the ILL in some of the regions. Localized ILL breaks or separation of the ILL from the neural retina was noted in 9 eyes. Retinal tissue loss, including avulsion of the ganglion cell, inner plexiform, or inner nuclear layers, was observed in 7 eyes. Avulsion of axon bundles in the optic disc was noted in 9 eyes. Significantly, partial- or full-thickness foveal tears were noted in 11 eyes. Based on the surgeons' intraoperative observations, small superficial optic disc or retinal hemorrhages were observed in 3 of 25 eyes. None of the eyes on which a vitrectomy alone was performed showed ILL damage, or retinal or optic disc tissue loss. Damage may occur to the optic disc, fovea, and extrafoveal retina as a result of surgical separation of the vitreous from the retina in young adult primates. These data support the contention that surgically induced damage at the level of the vitreoretinal interface may help explain the visual field defects noted after surgery to close full-thickness macular holes. These data also support the need for developing additional modalities to assist in vitreous separation, thereby reducing the risk of traumatic complications associated with purely mechanical procedures.

Symptoms predictive for the later development of retinal breaks.

To identify symptoms in patients with isolated posterior vitreous detachment predictive for the later development of retinal breaks. Two hundred eighty consecutive patients seen with symptoms of posterior vitreous detachment were prospectively asked to complete a questionnaire detailing their symptoms. At the time of presentation and follow-up, all patients had a full ophthalmologic examination including slitlamp biomicroscopy with Goldmann 3-mirror contact lens after maximal pupil dilatation. Two hundred fifty patients with an isolated posterior vitreous detachment were included and reexamined 6 weeks after the onset of symptoms. If small retinal or vitreous hemorrhages were detected, patients were reexamined after 2 weeks. In 13 patients (5.2%) a retinal break was detected at reexamination. Logistic regression analysis with backward elimination revealed that symptoms of flashes in combination with clouds or multiple (>10) small dots at the time of the initial examination or an increase of floaters after the initial examination were statistically significantly (P<.001) related to the development of new breaks. These symptoms had a predictive value for the presence or absence of a new retinal break of 75.0% and 99.6%, respectively. Specific symptoms can identify patients at risk for the development of new retinal breaks after an initial examination in which no abnormalities were found and may obviate the need for follow-up appointments of patients not at risk.