Retinal Detachment
Chapter notes (PDF)PDFRetinal detachment is a sight-threatening emergency where the neurosensory retina separates from the retinal pigment epithelium, presenting with flashes, floaters, and a visual field defect progressing to visual loss if the macula detaches.
Key Facts
- Retinal detachment (RD) is an ophthalmological emergency; incidence approximately 10-15 per 100,000/year in the UK
retinal break
vitreous fluid enters subretinal space
detachment
- Symptoms: sudden onset flashes (photopsia), floaters (vitreous debris/pigment), visual field defect ("curtain/shadow"), reduced visual acuity if macula involved
- Risk factors: posterior vitreous detachment (PVD), high myopia (>-6D), previous RD in other eye, cataract surgery, family history, trauma
- Macula-on detachment: EMERGENCY - surgery within 24 hours to prevent macular involvement
- Macula-off detachment: urgent surgery (within 7 days); visual prognosis depends on duration
- Treatment: scleral buckle, vitrectomy (pars plana), pneumatic retinopexy, cryotherapy/laser to retinal break
- Posterior vitreous detachment (PVD): common cause of flashes and floaters; 10-15% have an associated retinal tear → urgent fundoscopy required
Overview
Key Facts
Retinal detachment is a surgical emergency. Prompt diagnosis and treatment (especially before macula detaches) significantly improves visual outcome.
Epidemiology
- Incidence: 10-15 per 100,000/year
- Peak age: 60-70 (PVD-related); also younger myopes
- Bilateral in 10% (lifetime risk in fellow eye)
- Male > female
Aetiology
- Rhegmatogenous (most common ~90%): retinal break (tear or hole) allows vitreous fluid to enter subretinal space
- Usually precipitated by PVD
- Tractional: fibrovascular membranes pull retina off RPE (proliferative diabetic retinopathy, ROP)
- Exudative/serous: fluid accumulates beneath retina without a break (uveitis, tumour, pre-eclampsia)
Pathophysiology
posterior vitreous separates from retina with age; vitreous traction on retina
retinal tear
vitreous fluid enters through tear
retinal detachment
Detached retina loses contact with RPE
photoreceptor ischaemia
cell death
permanent visual loss if prolonged (especially if macula involved for >24 hours)
Clinical Presentation
Symptoms
- Flashes (photopsia): light flashes in peripheral vision (vitreous traction on retina)
- Floaters: sudden shower of new floaters (vitreous haemorrhage or pigment cells - "tobacco dust"/Shafer's sign)
- Visual field defect: curtain or shadow spreading across vision (corresponds to location of detachment)
- Reduced visual acuity: if macula involved ("macula-off")
Signs
- Reduced visual acuity (macula-off)
- RAPD (relative afferent pupillary defect) if extensive detachment
- Elevated retina visible on fundoscopy (billowing grey membrane)
- Retinal tear visible
- Vitreous haemorrhage (may obscure view)
- Reduced red reflex
Red Flags
- Sudden new flashes and floaters → urgent fundoscopy (same day)
Visual field defect
macula-on RD
emergency surgery within 24 hours
Loss of central vision
macula-off RD
urgent surgery
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Posterior vitreous detachment | Flashes and floaters, no field defect, retina attached | Dilated fundoscopy |
| Vitreous haemorrhage | Sudden floaters, reduced vision, no view of retina | B-scan USS |
| Retinal vein occlusion | Sudden visual loss, retinal haemorrhages | Fundoscopy, OCT |
| Choroidal detachment | Post-surgery, dark mound on fundoscopy | B-scan USS |
| Retinoschisis | Visual field defect, splitting of retinal layers | OCT |
Diagnosis / Investigation
Bedside
- Visual acuity: critical (documents macula status)
- RAPD: present in extensive detachment
- Dilated fundoscopy (indirect ophthalmoscopy): identify break, extent of detachment, macula status
Bloods
- Not needed
Imaging
- B-scan ultrasound: if fundal view obscured (vitreous haemorrhage, dense cataract)
- OCT: for subtle macular detachment
Special Tests
- Slit lamp with contact lens: detailed retinal break identification
- Wide-field imaging: map extent of detachment
Management
Emergency Management
- Macula-on RD: surgery within 24 hours (preserve macular function)
- Macula-off RD: surgery within 7 days (some centres sooner)
- Positioning: may be advised to position to prevent progression (e.g. lie on side to prevent superior detachment involving macula)
Surgical/Interventional
most common approach; remove vitreous
drain subretinal fluid
laser/cryotherapy to retinal breaks
gas (SF6, C3F8) or silicone oil tamponade
- Scleral buckle: silicone band applied externally to indent sclera → closes retinal break; often used in young phakic patients
inject gas bubble intravitreally
patient positions to tamponade break
cryo/laser (for simple superior detachments)
- Laser retinopexy/cryotherapy: for retinal tears without detachment (prophylactic treatment to prevent RD)
Post-operative
- Posturing: head position to keep gas bubble against retinal break (may be required for days-weeks)
- No flying until gas absorbed (typically 2-8 weeks depending on gas type; gas expands at altitude → IOP rise)
- Follow-up: monitor for re-detachment, PVR (proliferative vitreoretinopathy)
Referral Criteria
- New flashes and floaters: same-day ophthalmology assessment
- Retinal tear without detachment: urgent laser/cryotherapy
- Retinal detachment: emergency surgical referral
- Symptoms in fellow eye: urgent assessment
Prognosis
- Macula-on RD (repaired promptly): 90% anatomical success; >80% achieve good visual acuity
- Macula-off RD: anatomical success similar but visual recovery limited by duration of macular detachment
- Re-detachment rate: 5-10% (may require further surgery)
- PVR (proliferative vitreoretinopathy): scar tissue formation → re-detachment; most common cause of surgical failure (~5%)
- Fellow eye risk: 10% lifetime risk of RD in other eye
- Prophylactic laser for retinal tears reduces RD risk from ~50% to <5%
Other Relevant Information
Types of Retinal Detachment
| Type | Mechanism | Cause | Treatment |
|---|---|---|---|
| Rhegmatogenous | Retinal break | PVD, myopia, surgery | Surgery (PPV, buckle) |
| Tractional | Fibrovascular traction | PDR, ROP | Vitrectomy |
| Exudative | Subretinal fluid without break | Uveitis, tumour | Treat cause |
Urgency of Retinal Detachment Repair
| Status | Timing |
|---|---|
| Retinal tear (no detachment) | Within 24 hours (laser/cryo) |
| Macula-on RD | Within 24 hours (surgery) |
| Macula-off <7 days | Within 7 days |
| Macula-off >7 days | Within 7-14 days |