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Retina and Vitreous

 

This guideline summarises the most common retina and vitreous problems that may require referral from Primary Care.

 

Red Flags

  • Sudden onset reduced visual acuity
     
  • Photophobia
     
  • Patient describing ‘grey veil’, ‘shadow’ or ‘dark curtain’ in their vision
     
  • Papilloedema or other features of raised intracranial pressure
     
  • Irregular, dilated or non-reactive pupil
     
  • Double vision
     
  • Abnormal neurological assessment
     
  • Trauma including penetrating injury
     
  • Systemically unwell patient
     
  • Severe eye pain
     
  • Headache with concerning features (see linked page)
     
  • Vomiting

*This list is not exhaustive


 

Floaters/posterior vitreous detachment

Common, but its symptoms and signs may mimic those of retinal detachment. Patients with uncomplicated, asymptomatic PVD usually need no treatment.


Common symptoms can include new floaters or a sudden increase in the number of floaters, and photopsia (ocular flash) often described like a camera flash going off. It is painless.

 

Referral Instructions

  • <1 week, or if any red flags, refer to Eye Casualty

  • >1 week, but less than 3 months, with no red flags, refer to Ophthalmology Urgent Clinic

  • >3 months and no associated reduction in visual acuity or other red flags, ask patient to have Optometrist review and then refer to Ophthalmology as necessary. Warn patients of retinal detachment signs (black shadow or curtain effect) and red flags.



 

Retinal detachment

Results in progressive loss of vision and can lead to permanent visual loss in the affected eye1.


Retinal detachment should be considered if there is one or more of1:

  • New onset of floaters.
     
  • New onset of flashes.
     
  • Sudden-onset painless and usually progressive visual field loss. ‘Black shadow’ or ‘curtain effect’ sometimes described.
     
  • A reduction in visual acuity, blurred or distorted vision, causing persistent and progressive visual loss

 

Referral Instructions

  • If retinal detachment suspected, or any red flags, refer urgently to Eye Casualty.



 

Age related macular degeneration (ARM)

Common in those over 50. Affects the central vision. Does not cause total blindness but can make things like reading and recognising faces more difficult.

Symptoms can include2:

  • Distortion of vision, where straight lines appear crooked or wavy
     
  • Painless loss, or blurring, of central or near-central vision
     
  • A black or grey patch affecting the central field of vision (scotoma)
     
  • Difficulty reading, driving, or seeing fine detail (such as facial features)
     
  • Flickering or flashing lights (photopsia)
     
  • Difficulty adjusting from bright to dim lighting
     
  • Visual hallucinations (associated with severe visual loss).

 

Referral Instructions

  • If any sudden change in visual acuity, or any other red flags, refer to Eye Casualty
     
  • If no red flags advise patient to see Optometrist. A referral to Ophthalmology can be made following this if required.

(Please note an NHS eye test is not a universal entitlement in England, some patients will have to pay for their eye test privately.)



 

Amaurosis fugax

Temporary, painless, loss of vision typically lasting seconds to minutes.


Referral Instructions

  • Refer to TIA clinic
     
  • If there is any uncertainty consider discussion with AcuteGP or Neurologist of the day, contacted via RCHT switchboard.


 

Retinal Vessel Occlusion 

1.Retinal artery occlusion: Branch/Central

Typically, can present with painless and sudden loss of vision, or reduction in visual field, usually in only one eye. Central retinal artery occlusion: Clinical features – GPnotebook

  • ·Management
    • Consider giant cell arteritisif inflammatory markers elevated, but do not delay urgent referral whilst awaiting blood results.

 

  • ·Referral Instructions
    • Any clinical suspicion of stroke admit via 999 stroke pathway
    • If sudden visual loss, reduction in visual acuity, or any other red flags above Refer urgently to Eye Casualty.

 

2.Retinal vein occlusion:

May present as a painless loss of vision, usually over a period of hours or days. Can involve Branch vessels (BRVO) or less commonly Central (CRVO).

  • ·Management
    • Optimise atherosclerotic risk factors.

 

  • ·Referral Instructions
    • If sudden visual loss, reduction in acuity or any red flags Refer urgently to Eye Casualty.


 

Diabetic retinopathy

All diabetic patients should be on DRS database and are usually referred through them.

  • ·Referral Instructions
    • Check patient is under diabetic eye screening programme.  If yes, no need to refer. If no, please refer to them.
    • Any red flag features refer urgently to Eye Casualty


 

Macular hole

Symptoms appear gradually over days/weeks3. These can include distorted vision, reduction in visual acuity.

If vision 6/60 for more than 12 months unlikely to respond to surgery. Surgery not suitable for very frail

  • ·Referral Instructions
    • Urgent Ophthalmology clinic - VR surgery done in Plymouth
    • If any red flag features, then urgent Eye Casualty Referral


 

Epiretinal membrane

Scar tissue can grow across the macula. As the membrane contracts, it causes distortion of the retinal tissue. This can distort central vision, e.g. straight lines appear wavy, and reading is difficult.

 

VA 6/9 or better unlikely to have surgery, needs monitoring by optometrist

  • ·Referral Instructions
    • Routine Ophthalmology clinic - VR surgery done in Plymouth


 

Retinal pigment/choroidal naevus

Typically, a darkly pigmented lesion found in the back of the eye.

 

Check old notes to see if seen before. Benign looking ones are photographed and referred to optometrist for annual monitoring

  • ·Referral Instructions
    • Refer to Optometrist for review initially. They will refer on to Ophthalmology as required
    • Any red flag features, urgent referral to Eye Casualty.


 

Vitreous haemorrhage

Painless bleeding into the vitreous humour, usually unilateral. Vitreous haemorrhage varies from mild, with symptoms such as floaters, to complete loss of vision. Most cases resolve after treatment and vision is restored to its previous level.

  • ·Referral Instructions
    • Refer urgently to Eye Casualty. 


 

Advice and Guidance

Please send advice and guidance requests to Ophthalmology via eRS


 

Supporting Information

For Professionals

 

For Patients

 

References

 

Page review information

Date reviewed:        27 January 2026

Next review due:     27 January 2028

Sifter name:            Dr Kate Northridge

Contributor:             Mr Ashish Patwardhan, Consultant Ophthalmologist RCHT