Retinal Detachment

See Also

Posterior Vitreous Detachment

Definitions

Retinal Detachment
1. Retinal neurosensory layer separates from the underlying pigmented epithelium

Epidemiology

Incidence (U.S.): 10 per 100,000 per year (most over age 50 years old)
Lifetime risk: 1 in 300 patients
Age over 50 years old (peaks 60 to 70 years old)

Pathophysiology

Retina is normally fixed to underlying epithelium by negative fluid pressure
In Retinal Detachment, Retina detaches from underlying epithelium
1. Affected Neurons are separated from the Choroid, their vascular supply
2. Vision Loss in affected Neurons is permanent if not corrected within 24 to 72 hours
3. Retinal Detachments often start localized but may progress to larger area without treatment
4. Even a fully Detached Retina, will still be fixed to the region of the Optic Nerve Head and the ora serrata

Types

Rhegmatogenous Retinal Detachment (most common)
1. Posterior Vitreous Detachment is initiating event
  1. Peripheral Retina (at the globe's equator) is thinnest, allowing for tear as vitreous separates
  2. Vitreous seeps via tear in Retina under the Neuronal layer into the subretinal space
  3. Posterior Vitreous Detachment confers 10-15% risk of progression to Retinal Detachment
  4. Other precipitating events include Trauma or focal Retinal thinning (latice degeneration)
2. Common age >50-60 years old (with related increased traction at vitreous attachments)
3. Vitreous pulls on Retina causing brief flashing lights (Photopsias)
4. Vitreous Detachment will result in shadows forming on the Retina (visual Floaters)
Exudative Retinal Detachment or serous Retinal Detachment
1. Subretinal inflammation or mass lesion attracts increased fluid into subretinal space
2. Causes include sarcoid Uveitis, Severe Hypertension and neoplasms
Tractional Retinal Detachment
1. Fibrosis due to Trauma, infection, inflammation or Retinopathy
2. Most commonly due to traction from neovascularization (e.g. proliferative Diabetic Retinopathy)

Risk Factors

Most common risks
1. Myopia (Near-sightedness, due to egg-shaped globe)
  1. Myopia with >3 diopter Refractive Error confers 10x increased risk
2. Eye Trauma
  1. Rarely complicated by Retinal Detachment (0.2 in 10,000 per year)
3. Coagulopathy
4. Older age (especially age > 50-60 years)
5. Prior Cataract surgery (decreases vitreous via liquefaction): 0.1 to 1% risk
6. History of prior Retinal Detachment in the contralateral eye
7. Prior Retinal Detachment (10% risk of Retinal Detachment in other eye within 4 years)
Other risk factors
1. Diabetic Retinopathy
2. Retinopathy of Prematurity
3. Congenital Cataracts
4. Congenital Glaucoma
5. Retinal Detachment Family History

Symptoms

Classic triad: Flashes, Floaters and Visual Field Defect
Unilateral Photopsia (Light Flashes)
1. Each light flash lasts <1 second
2. Occurs with vitreous pulling on the Retina (see above)
3. Occurs with either Vitreous Detachment or Retinal Detachment
  1. Suggests Retinal Detachment or signficant bleeding if accompanied by Vision Loss
4. Extraocular Movement may be provocative
Unilateral increase in number of Floaters
1. Occurs with Vitreous Detachment (see above)
Acute, painless Vision Loss
1. Develops peripherally and progresses centrally
2. Develops over a course of hours to days
3. Ultimately may involve the Macula (Macula-Off Retinal Detachment)
  1. Significantly worse prognosis for Vision in the affected eye
  2. Persistent severe Vision Loss even with surgery
Altered Visual Field
1. Light gray shadow or curtain Sensation falls over affected region of eye (typically from lateral edge)
2. Shadow location does not move with a change in gaze
3. Vision may be cloudy, or completely lost as in cases associated with severe bleeding
4. Progresses as Retina peels away from the underlying Choroid
5. Metamorphopsia (wavy distortion of Vision)

Signs

Visual Field Exam by Confrontation
1. Visual Field Deficits may be subtle
Funduscopic Exam with Pupil Dilation (direct and indirect)
1. Careful exam by a skilled examiner focused on the peripheral Retina
2. Affected Retina will have the pale billowing appearance of a parachute
3. Vitreous bleeding may occur if small Retinal vessels are torn
Afferent Pupillary Defect
1. Typically normal pupil response unless severe Retinal Detachment

Differential Diagnosis

Imaging
Ocular Ultrasound

Indications
1. Emergency Department evaluation of Retinal Detachment
2. Ophthalmoscopy (Fundoscopy) is non-diagnostic
Findings
1. Hyperechoic Retina floats freely within vitreous chamber, and moves with Extraocular Movement
Efficacy
1. in non-dilated Eye Exam, Ocular Ultrasound has better sensitivity
  1. Test Sensitivity: 97-100%
  2. Test Specificity: 83-100%
2. Bedside Ultrasound in ED has high accuracy with training (Test Sensitivity 91%, Test Specificity 96%)
  1. Jacobsen (2016) West J Emerg Med 17(2): 196-200 +PMID: 26973752 [PubMed]

Management

Emergent, immediate ophthalmology referral
1. Normal Visual Acuity with suspected new Retinal Detachment confers a higher urgency
2. Goal is to intervene early to maintain that Visual Acuity
  1. Macula-on (fovea sparing) Retinal Detachment repair within 3 days
  2. Macula-off Retinal Detachment repair within 6 to 7 days
Ophthalmology management
1. Retina fixed in place (pneumatic retinopexy)
  1. Air or gas injected into the posterior vitreous cavity
  2. The gas tamponades the loose segment of Retina back in place
  3. Forces out trapped fluid beneath the Retinal tear (or that fluid is removed with vitrectomy)
2. Reattachment of Retina
  1. Ophthalmologist locates the Retinal tear
  2. Cryotherapy, diathermy or laser photocoagulation applied to Retinal tear
  3. Reattaches, or tacks down the Retina
3. Reduce vitreous tension at attachment to Retina (may not be required)
  1. Scleral buckling involves the suturing of constricting silicone band to external Sclera
  2. Results in indentation of Sclera, decreasing globe diameter, and decreasing vitreous traction
  3. Allows ocular wall to recontact the Retina at the site of the Retinal break
    1. On recontact, Retinal epithelium resorbs subretinal fluid, and reattaches within days
4. Posterior vitrectomy (with Scleral buckling)
  1. Intraocular procedure to extract vitreous gel from the Retinal break region
  2. Followed by pneumatic retinopexy (see above) to hold the Retina in place
  3. Posterior vitrectomy is performed with Scleral buckling in Macula-Off Retinal Detachment

Prognosis

Surgical Repair has a good prognosis in Macula-on (fovea sparing) Retinal Detachment
1. Overall surgery is successful in 95% of cases if performed within 3 days of onset
2. Vision 20/40 or better in 75 to 80% of cases unless central Macula involvement
Predictors of worse outcome
1. Delayed repair (>3 days for Macula-on, >6 to 7 days for Macula off)
2. Detachment involving Macula (Macula-off)
  1. Vision 20/40 in <60% of patients even with prompt repair

Complications

Proliferative vitreoretinopathy
1. Fibrosis forms within weeks of repair
Retinal Detachment in contralateral eye (25% risk)

Prevention

Sports Eye Protection
Posterior Vitreous Detachment
1. May require laser "tacking" of Retina
2. Aggressively follow patients with new onset
3. Higher risk if increase in Floaters present
Contralateral eye Retinal Detachment
1. Periodic Eye Exams by ophthalmology in those with Retinal Detachment history

References

Sales, Patel and Patel (2019) Crit Dec Emerg Med 33(12): 3-13
Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
Trobe (2012) Physicians Guide to Eye, p. 151-3
Yu and Jasani (2024) Crit Dec Emerg Med 38(1): 27-34
Banker (2001) Ophthalmol Clin North Am 14(4):695-704 [PubMed]
Gariano (2004) Am Fam Physician 69:1691-8 [PubMed]
Gelston (2020) Am Fam Physician 102(9):539-45 [PubMed]
Gelston (2013) Am Fam Physician 88(8):515-9 [PubMed]