Giant Retinal Tear

Key Points at a Glance

Giant retinal tear (GRT) is a rhegmatogenous retinal detachment with a full-thickness retinal tear of 90 degrees or more, accounting for approximately 1.5% of all rhegmatogenous retinal detachments. ¹⁾
60–80% are idiopathic; trauma and hereditary connective tissue diseases (Stickler syndrome, Marfan syndrome) are important underlying conditions.
Because the retinal flap is inverted, proliferative vitreoretinopathy (PVR) develops rapidly and frequently.
Standard treatment is vitrectomy (PPV) with perfluorocarbon liquid (PFCL) for retinal unfolding and stabilization, achieving anatomical reattachment rates of 80–90%. ¹⁾
The incidence of RD in the fellow eye reaches 30–35%, and prophylactic laser or cryotherapy can reduce RD risk by up to 86%. ³⁾
Pediatric GRT differs from adult GRT in that traumatic cases are more common, and vitreous separation is difficult due to the absence of posterior vitreous detachment.

1. What is Giant Retinal Tear?

Giant Retinal Tear (GRT) is a rhegmatogenous retinal detachment (RRD) associated with a full-thickness retinal tear extending 90 degrees (3 clock hours) or more. The tear usually occurs at the posterior border of the vitreous base posterior to the ora serrata. When the tear exceeds two quadrants (180 degrees), the posterior retinal flap tends to invert and fold over the optic disc or macula.

GRT accounts for approximately 1.5% of all rhegmatogenous retinal detachments ¹⁾, with a male predominance (72%). ¹⁾ Associated conditions include Marfan syndrome and Stickler syndrome ¹⁾, and it also occurs frequently in highly myopic eyes with lattice degeneration.

By etiology, 60–80% are idiopathic, and traumatic cases account for 16.1%. ⁴⁾ Bilateral involvement occurs in up to 20%, and the incidence of RD in the fellow eye reaches 30–35%. ³⁾

Equatorial Type

Most common GRT type: Tear located at the equator.

Posterior flap mobility: Moderate. Unfolding is relatively easy.

Posterior Equatorial Extension Type

Flap inversion is common: The tear edge extends posteriorly.

Folding risk: Inversion over the macula or optic disc is likely.

Pars Plana Type

Rarest type: Tear located near the pars plana.

Anterior approach: Surgical technique may be specialized in some cases.

Q What is the difference between GRT and GRD (giant retinal dialysis)?

GRT (Giant Retinal Tear) is a full-thickness retinal tear occurring at the posterior border of the vitreous base, caused by vitreous traction. In contrast, GRD (Giant Retinal Dialysis) is a condition where the retina is detached at the ora serrata itself, often traumatic, and differs in that vitreous remains attached posterior to the tear margin. Distinguishing them is important because treatment approaches also differ.

2. Main Symptoms and Clinical Findings

Yo-Chen Chang; Li-Yi Chiu; Tzu-En Kao; Wen-Hsin Cheng; Ting-An Chen; Wen-Chuan Wu. Management of Giant Retinal Tear with microincision vitrectomy and metallic retinal tacks fixation-a case report. BMC Ophthalmol. 2018 Oct 22; 18:272. Figure 1. PMCID: PMC6198422. License: CC BY.

a. Fundus examination revealed a 120 degree giant tear with large inverted flap of the 53-year-old man’s right eye. b, c and d. No recurrent retinal detachment was noted during follow up period and the retina was well fixated by retinal tacks and laser scar

Subjective Symptoms

GRT often follows a rapid course.

Rapid vision loss: In cases with macular detachment, vision may decline to counting fingers (CF) or light perception (LP).
Floaters: Occur due to dispersion of pigment particles into the vitreous.
Photopsia: Flashes of light due to retinal traction.
Visual field defect: Visual field loss opposite to the tear site.
Often lack prodromal symptoms: Due to acute onset, patients may delay seeking care.

Clinical Findings

Tobacco dusting (Shafer sign): Present in all cases. Pigment particles scattered in the anterior vitreous, strong evidence of retinal tear.
Inversion of the posterior flap: In giant retinal tears, the posterior retinal flap folds over the optic disc or macula, exposing the retinal pigment epithelium (RPE).
Rapid progression of PVR (proliferative vitreoretinopathy): Because RPE cells are released into the vitreous cavity, PVR tends to develop earlier than in other types of rhegmatogenous retinal detachment.
Characteristics of pediatric GRT: Posterior vitreous detachment (PVD) is absent, and the vitreous gel is more viscous, presenting findings different from those in adults. ²⁾
Abuse-related GRT: A case has been reported in a 4-week-old neonate with two GRTs (1–5 o’clock and 7–11 o’clock). ⁴⁾

3. Causes and Risk Factors

The development of GRT involves dynamic vitreous traction and predisposing fragility of the retina and vitreous.

PVR (proliferative vitreoretinopathy): The most important postoperative risk factor, occurring with a frequency of 0.8–31.57%. ¹⁾
Tear extent >150 degrees: A GRT extent exceeding 150 degrees is a poor prognostic factor. ¹⁾
High myopia: Often associated with lattice degeneration, making the posterior border of the vitreous base fragile.
Young age (≤35 years): Higher risk of surgical failure. ¹⁾
Male sex: Approximately 1.3 times higher risk than females; 72% of cases are male. ¹⁾
Stickler syndrome: A hereditary disorder with abnormal collagen synthesis, associated with a high lifetime risk of bilateral GRT and RRD. ³⁾
Trauma (blunt trauma): Shearing forces from blunt trauma can tear the posterior border of the vitreous base. ⁴⁾
Child abuse: Multiple GRT cases have been reported in a 4-week-old infant. ⁴⁾

Q If a GRT occurs in one eye, is the other eye also likely to develop it?

The incidence of RD in the fellow eye is as high as 30–35%. ³⁾ However, meta-analyses have shown that prophylactic laser or cryotherapy can reduce the risk of RD by up to 86%. ³⁾ In Stickler syndrome, 360-degree prophylactic laser is particularly recommended. For details, see the section “Latest Research and Future Prospects”.

4. Diagnosis and Examination Methods

The diagnosis of GRT is primarily based on fundus examination, combined with ancillary tests.

Slit-lamp biomicroscopy and indirect ophthalmoscopy: Confirmation of tobacco dusting (Shafer sign) and assessment of the extent of the tear and retinal detachment.
B-scan ultrasonography: A double linear echo sign (the folded retina appears as a double line) is characteristic of GRT. Useful when fundus view is poor due to opaque vitreous.
Differential diagnosis (GRT vs. GRD): GRT is a posterior tear due to vitreous traction, while GRD is a traumatic dialysis of the ora serrata; the approaches differ.
Fundus examination of the fellow eye: Essential to check for lattice degeneration, peripheral tears, and predisposing factors.
Pediatric and infant cases: Actively investigate for history of trauma or possible child abuse. ⁴⁾

Q How is pediatric GRT different from adult GRT?

In children, the proportion of traumatic GRT is higher (up to 32%) compared to adults, and because posterior vitreous detachment (PVD) is absent, separation of the vitreous from the retina is difficult. ²⁾ The presence of viscous vitreous gel makes vitrectomy surgery more complex than in adults. In infants, the possibility of injury from abuse should be considered. ⁴⁾

5. Standard Treatment

Pars Plana Vitrectomy (PPV)

Pars plana vitrectomy is the first-line treatment for GRT. ¹⁾ Vitrectomy was chosen in 34 of 36 studies ¹⁾, and MIVS (microincision vitrectomy surgery; 23G to 27G) is now widely used as the standard technique. ¹⁾

Key intraoperative points are as follows:

Introduction of perfluorocarbon liquid (PFCL): A heavy liquid used to press the inverted retinal flap from behind, unfold and stabilize it. This is a fundamental step in GRT surgery.
Endophotocoagulation: Apply 8 to 10 rows of photocoagulation along the edge of the retinal tear to seal the retina around the tear.
PFCL-tamponade exchange: Replace PFCL with silicone oil or gas tamponade to complete the surgery (direct PFCL-oil exchange technique may also be used).
Indications for lensectomy: Some cases require lensectomy to ensure anterior visualization or facilitate intraoperative maneuvers.

Choice of Tamponade

Silicone Oil

Most frequently used tamponade: Chosen in 22 studies. Provides sustained retinal support. ¹⁾

Risks: Watch for cataract and secondary glaucoma. Subsequent removal surgery is required.

Gas Tamponade

Indications: SF6 (primary) and C3F8 (reoperation) are used. ¹⁾

Precautions: Strict postoperative positioning is required. In neonatal cases, 15% C3F8 has been reported. ⁴⁾

PFCL

Intraoperative use: Used to unfold and stabilize the inverted retina. Replacement is required postoperatively.

Direct PFCL-oil exchange: A technique to directly replace PFCL with silicone oil while maintaining stability.

Treatment Outcomes

The following are key treatment outcomes (based on a systematic review integrating data from 751 eyes). ¹⁾

Parameter	Value
SSAS rate (primary surgical success)	65.51–100%
FAS rate (final anatomical reattachment)	Up to 100%
Visual improvement	Confirmed in 29/36 studies

Major Postoperative Complications

The frequencies of major complications that may occur postoperatively are shown below. ¹⁾

Complication	Frequency
Cataract	3.9–28.3%
IOP elevation	0.01–51.2%
PVR	0.8–31.57%

It has been reported that 77% of postoperative proliferative vitreoretinopathy occurs within one month after surgery¹⁾, making early follow-up particularly important.

Q How often does redetachment occur after GRT surgery?

Redetachment due to proliferative vitreoretinopathy has been reported to occur in up to 45% of cases. 77% of postoperative proliferative vitreoretinopathy occurs within one month after surgery.¹⁾ The anatomical success rate of primary surgery (SSAS) is 80–90% in most studies, but since PVR is the greatest cause of failure, strict follow-up during the first postoperative month is essential.

6. Pathophysiology and Detailed Mechanism

Dynamic vitreous traction at the vitreous base (White Without Pressure; WWOP area) plays a central role in the development of GRT.

Arrest of posterior vitreous detachment (PVD): When posterior vitreous detachment progresses, it stops at the posterior border of the vitreous base (posterior border of WWOP), concentrating local traction forces.
Tear formation at the posterior border of the vitreous base: Local traction penetrates the full thickness of the retina, forming a large tear of 90 degrees or more.
Release of RPE cells: The tear exposes the RPE to the vitreous cavity, releasing cells. This initiates proliferative vitreoretinopathy.
Progression of proliferative vitreoretinopathy: Released RPE cells and glial cells proliferate and contract, forming proliferative membranes on the retinal surface. This is the main cause of redetachment.
Mechanism of traumatic GRT: Rapid deformation of the eyeball due to blunt trauma generates shear forces, tearing the retina at the posterior border of the vitreous base. ⁴⁾

Sherief ST et al. (2022) reported a case of multiple GRTs (at 1–5 o’clock and 7–11 o’clock) in a 4-week-old neonate. It is presumed that rapid mechanical shear forces from trauma (abuse) caused extensive tears in the thin retina of the infant. ⁴⁾

7. Latest Research and Future Perspectives (Investigational Reports)

Evidence for prophylactic treatment of the fellow eye

The effectiveness of prophylactic laser and cryocoagulation in the fellow eye of patients with unilateral GRT has been quantified for the first time in a systematic review and meta-analysis.

Vasilakopoulou MP et al. (2025) showed that prophylactic treatment of the fellow eye reduces the risk of RD by 86% (OR 0.14; 95% CI 0.05–0.40). ³⁾ For laser alone, OR was 0.12; for laser plus cryocoagulation, OR was 0.17; the difference between the two modalities was not statistically significant (p=0.57).

In patients with Stickler syndrome, 360-degree prophylactic laser is particularly recommended. ³⁾ However, an important limitation of this meta-analysis is that no RCTs (randomized controlled trials) were available, and the results are based solely on observational studies. ³⁾

Findings from a Large-Scale Scoping Review

Quiroz-Reyes et al. (2024) conducted a scoping review of 36 studies involving 751 eyes and reported a vitrectomy technique usage rate of 89%, SSAS of 91.2%, and FAS of 96.7%. ¹⁾ The possibility of reducing postoperative epiretinal membrane (ERM) by ILM peeling was also suggested, but the lack of RCTs was pointed out as the major limitation. ¹⁾

Reports on surgical approaches for pediatric GRT are also increasing, and modifications of vitrectomy for pediatric eyes lacking posterior vitreous detachment are being discussed. ²⁾ In the future, prospective multicenter studies and RCTs are needed to build evidence.

8. References

Quiroz-Reyes MA, Babar ZU, Hussain R, et al. Management, risk factors and treatment outcomes of rhegmatogenous retinal detachment associated with giant retinal tears: scoping review. Int J Retina Vitreous. 2024;10:35.
Bhende PS, Kashyap H, Nadig RR. Surgical management of a case of giant retinal tear with closed funnel retinal detachment in a pediatric patient. Indian J Ophthalmol. 2024. doi:10.4103/IJO.IJO_1598_23.
Vasilakopoulou MP, Androudi S, Tsinopoulos I, et al. Prophylactic Laser and Cryotherapy in the Fellow Eye of Patients With Giant Retinal Tears: A Systematic Review and Meta-Analysis. Cureus. 2025;17(12):e99849.
Sherief ST, Dhoot AS, Schwartz S, et al. Multiple giant retinal tears due to inflicted injury in a neonate. Am J Ophthalmol Case Rep. 2022;26:101453.