Retinal detachment

Retinal detachment refers to the detachment of the inner layer of the retina (neurosensory retina) from the retinal pigment epithelium. The most frequent causes of retinal detachment are tears or holes in the retina (rhegmatogenous retinal detachment), risk factors for which include myopia, previous intraocular surgery, trauma, and/or posterior vitreous detachment. Less commonly, retinal detachment occurs without any retinal tears (nonrhegmatogenous retinal detachment). Nonrhegmatogenous retinal detachment is most often the result of vitreoretinal bands (e.g., proliferative diabetic retinopathy), subretinal/intraretinal tumors (e.g., choroidal melanoma), or a number of systemic and ocular causes that result in subretinal fluid accumulation. Small detachments typically present with photopsia, floaters, and/or visual field defects. Loss of vision may be severe if the retinal detachment is extensive and/or the macula is affected. The diagnosis is confirmed by fundoscopy. To prevent retinal detachment, laser photocoagulation in the direct vicinity of the retinal defect should be performed after diagnosis of retinal tears or holes. Extensive retinal detachment is a vision-threatening emergency and usually requires prompt surgery to prevent further detachment and restore sensory function. Visual prognosis depends particularly on the extent of retinal detachment (poor with macular involvement) and how much time passes before the retina is reattached.

• Detachment of the neurosensory retina, which contains the photoreceptor layer, from the retinal pigment epithelium.
• Disturbed metabolism of the photoreceptor layer leads to loss of retinal function (i.e., vision impairment)
• Separation of the retina from the choroid for more than 12 hours leads to retinal ischemia and retinal degeneration.

Symptoms ^[2][3]

Symptoms may be unilateral or bilateral depending on the underlying etiology.

• Prodromal symptoms: caused by posterior vitreous detachment
  • Sudden increase in floaters (shower of floaters)
  • Flashes of light (photopsia)
• Sudden, painless loss of vision: caused by retinal detachment
  • Typically described as a curtain or shadow either descending or ascending across the field of vision
  • May be partial (scotoma) or complete depending on the extent of retinal detachment and macular involvement

Most retinal detachments are preceded by a posterior vitreous detachment or a retinal tear, which manifest with photopsia and floaters. Photopsia is typically absent in individuals with exudative retinal detachment. ^[2][4]

Examination findings ^[3][5]

• Visual acuity: may be normal or significantly decreased depending on the extent and position of the retinal detachment
• Visual field examination: visual field defects corresponding to the site of detachment
• Pupillary examination: relative afferent pupillary defect in individuals with retinal detachments involving the fovea ^[4]

Individuals with retinal tears may have preserved visual acuity but, if left untreated, retinal tears can progress to retinal detachment and vision loss. ^[5]

General principles ^[3][5]

Immediately refer all patients with photopsia or sudden painless visual field defects to ophthalmology for same-day evaluation.

• Fundoscopy is required to confirm the diagnosis.
• If the fundus is obscured by hemorrhage, ocular ultrasound can be considered.
• Additional studies may be required to assess for complications or surgical planning.

Fundoscopy

• Perform a dilated eye examination of both eyes. ^[6]
  • Direct fundoscopy can detect central hemorrhages.
  • Indirect fundoscopy is used to evaluate the peripheral retina.
• Findings
  • The detached retina appears pale and opaque and masks the underlying choroidal vasculature. ^[6]
  • Additional findings are specific to the type of retinal detachment.

Examine both eyes in patients with suspected retinal detachment. ^[2]

Retinal detachment cannot be excluded based on direct fundoscopy alone because of its poor visualization of the peripheral retina. ^[3]

Point-of-care ocular ultrasound

• Indications: dense vitreous hemorrhage or cataract occluding the view of the fundus ^[5][6]
• Findings
  • A retinal detachment appears as a distinct hyperechoic membrane within the vitreous cavity. ^[3][7]
  • Vitreous hemorrhage may be seen as hyperechoic points within the vitreous cavity. ^[7]

Ocular ultrasound is operator-dependent and cannot detect retinal tears. ^[3][7]

Further testing

Additional studies performed by a specialist may include:

• Intraocular pressures ^[2]
• Electroretinography ^[8]
• Optical coherence tomography ^[9]

Differential diagnoses of retinal detachment ^[10][11]

• Retinoschisis
• Choroidal detachment

Differential diagnoses of photopsia ^[6]

• Posterior vitreous detachment
• Migraine aura
• Postural hypotension
• Optic nerve pathology (e.g., optic neuritis)
• Choroidal tumors
• Transient ischemic attacks

Differential diagnoses of floaters ^[6]

• Vitreous hemorrhage
• Uveitis
• Age-related macular degeneration
• Posterior vitreous detachment
• Asteroid hyalosis

The differential diagnoses listed here are not exhaustive.

Approach ^[3][5]

• Urgently refer to ophthalmology; retinal detachment is a vision-threatening emergency.
• Advise patients to reduce head and eye movements as much as possible until seen. ^[12]
• Further management depends on the type and severity of retinal detachment.

Rhegmatogenous retinal detachment ^[13]

• Retinal holes with little or no retinal detachment: laser photocoagulation or cryoretinopexy in the direct vicinity of the retinal defect ^[1]
• Extensive retinal detachment
  • Prompt surgical treatment is required.
  • Options include: ^[2][13][14]
    • Pneumatic retinopexy
    • Scleral buckling
    • Pars plana vitrectomy

Rhegmatogenous retinal detachment warrants prompt surgical intervention.

Nonrhegmatogenous retinal detachment ^[2]

• Tractional retinal detachment: vitrectomy with or without scleral buckling ^[2][15]
• Exudative (serous) retinal detachment ^[2]
  • Treatment of the underlying cause
  • Surgery is not usually required.

• Without treatment, progressive retinal detachment causes blindness, especially if the macula is involved.
• Proliferative vitreoretinopathy
• Toxic uveitis (due to endocular toxins) in long-standing retinal detachment
• Retinal detachment in the other eye

We list the most important complications. The selection is not exhaustive.

• Rhegmatogenous retinal detachment ^[2]
  • The smaller the area of detachment, the better the prognosis.
  • The prognosis is good if surgery is performed at an early stage and there is no macular involvement.
• Nonrhegmatogenous retinal detachment: significantly poorer prognosis