Retinal Detachment
Retinal 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 Rhegmatogenous RD (most common): 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
- PVD: 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
- Pars plana vitrectomy (PPV): 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
- Pneumatic retinopexy: 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 |