Retinal Detachment

Key Features

Essentials of Diagnosis

• Loss of vision in one eye that is usually rapid, possibly with "curtain" spreading across field of vision

• No pain or redness

• Detachment seen by ophthalmoscopy

General Considerations

• Most cases are due to development of one or more peripheral retinal tears or holes (rhegmatogenous retinal detachment); this usually results from posterior vitreous detachment, related to degenerative changes in the vitreous

• Generally occurs in persons over 50 years of age

• Nearsightedness and cataract extraction are the two most common predisposing causes

• May also be caused by penetrating or blunt ocular trauma

• Once there is a defect in the retina, fluid vitreous is able to pass under the sensory retina and, with the added effects of vitreous traction and gravity, progressive retinal detachment results

• Tractional retinal detachment occurs when there is preretinal fibrosis, such as in proliferative retinopathy due to diabetic retinopathy or retinal vein occlusion or as a complication of rhegmatogenous retinal detachment

• Exudative retinal detachment results from accumulation of subretinal fluid, such as in wet ("neovascular") age-related macular degeneration or secondary to choroidal tumor

Clinical Findings

• Rhegmatogenous retinal detachment usually starts in the superior temporal area, spreading rapidly to cause visual field loss that starts inferiorly and expands upward but can occur at other locations

• Premonitory symptoms of the predisposing vitreous degeneration and vitreo-retinal traction include

  • Recent onset of or increase in floaters (moving spots or strands like cobwebs in the visual field)

  • Photopsias (flashes of light)

• Central vision remains intact until the central macula becomes detached

Diagnosis

• Retina may be elevated in the vitreous cavity with an irregular surface

• One or more retinal tears or holes are usually found on retinal examination with scleral depression, which is a technique to examine the peripheral retina using a cotton tip swab or blunt instrument to push on, or depress, the external eye to evaluate the peripheral retina through a dilated pupil

• A macular hole, usually caused by traction from the vitreous or scar tissue on the retinal surface (epiretinal membrane), causes reduction of central vision

• In idiopathic cases, the hole occurs from localized retinal traction with retinal separation at the fovea, whereas in macular hole due to trauma or nearsightedness, there is a risk of progression to total retinal detachment

• In tractional retinal detachment, there is irregular retinal elevation adherent to scar tissue on the retinal surface, sometimes extending into the vitreous

• In exudative retinal detachment, the retina is dome-shaped and the subretinal fluid shifts position with changes in posture

• Ocular ultrasonography assists the detection and characterization of retinal detachment

Treatment

• Laser photocoagulation to the retina or cryotherapy to the sclera

  • Treats rhegmatogenous retinal detachments

  • Closes all of the ...