Retinal Detachment

Practice Essentials
Retinal detachment (see the image below) refers to separation of the inner layers of the retina from the
underlying retinal pigment epithelium (RPE, choroid). Next to central retinal artery occlusion, chemical
burns to the eye, and endophthalmitis, it is one of the most time-critical eye emergencies encountered in
the emergency setting.

Retinal detachment. Courtesy of Kresge

Eye Institute, Detroit, Michigan.

Signs and symptoms

Symptoms of retinal detachment may include the following:

Photopsia (common initially)

Visual field defect (developing over time; may help localize detachment)
Floaters
The history should include inquiries into the following:

History of trauma
Previous ophthalmologic surgery
Previous eye conditions (eg, uveitis and vitreous hemorrhage)
Duration of visual symptoms and visual loss
Physical examination should include the following:

Checking of visual acuity

External examination for signs of trauma and checking of the visual field
Assessment of pupil reaction
Measurement of intraocular pressure in both eyes
Slit-lamp biomicroscopy
Examination of the vitreous for signs of pigment or tobacco dust
Examination of the dilated fundus with ophthalmoscopy (preferably indirect)
See Presentation for more detail.

Diagnosis
Retinal detachment occurs by 3 basic mechanisms and thus is classified into the following 3 main types:

Rhegmatogenous retinal detachment (the most common type) This results when a hole, tear, or
break in the neuronal layer allows fluid from the vitreous to seep between and separate sensory and RPE
layers

Traction retinal detachment This results from adhesions between the vitreous gel/fibrovascular
proliferation and the retina

Exudative (serous) retinal detachment This results from exudation of material into the subretinal
space from retinal vessels (as in hypertension, central retinal venous occlusion, vasculitis, or
papilledema)
Laboratory tests are not helpful in detecting retinal detachment, but basic blood work may be useful if the
patient requires surgical intervention.
Unless globe rupture, orbital/facial bone fractures, or intraocular foreign bodies are suspected, diagnostic
imaging is not warranted.
See Overview and Workup for more detail.

Management
General treatment measures include the following:

Nil per os (NPO) status in anticipation of retinal surgery

In trauma cases, protection of the globe with a metallic eye shield
Avoidance of any pressure on the globe
Limitation of activity to a minimum until further evaluation
Treatment of any unstable vital signs in preparation for possible emergency surgery
Consideration of referral to a retina specialist (eg, whenever a macula-on retinal detachment is
suspected)
Specific techniques for treating retinal detachments include the following:

Scleral buckling
Pars plana vitrectomy
Pneumatic retinopexy
Retinal detachment repair is usually done on an outpatient basis.
See Treatment and Medication for more detail.

Background
Next to central retinal artery occlusion, chemical burns to the eye, and endophthalmitis, a retinal
detachment is one of the most time-critical eye emergencies encountered in the ED. Retinal detachment
(RD) was first recognized in the early 1700s by de Saint-Yves, but clinical diagnosis remained elusive until
Helmholtz invented the ophthalmoscope in 1851.
Tragically, retinal detachments were uniformly blinding until the 1920s when Jules Gonin, MD, pioneered
the first repair of retinal detachments in Lausanne, Switzerland. Today, with the advent of scleral buckling
and small-gauge pars plana vitrectomy, in addition to laser and cryotherapy techniques, rapid ED diagnosis
and treatment of a retinal detachment truly can be a vision-saving opportunity.

Pathophysiology
Eye anatomy is shown in the image below.

Anatomy of the eye.

Retinal detachment refers to separation of the inner layers of the retina from the underlying retinal pigment
epithelium (RPE, choroid). The choroid is a vascular membrane containing large branched pigment cells
sandwiched between the retina and sclera. Separation of the sensory retina from the underlying RPE
occurs by the following 3 basic mechanisms:

A hole, tear, or break in the neuronal layer allowing fluid from the vitreous cavity to seep in
between and separate sensory and RPE layers (ie, rhegmatogenous RD)

Traction from inflammatory or vascular fibrous membranes on the surface of the retina, which
tether to the vitreous

Exudation of material into the subretinal space from retinal vessels such as in hypertension,
central retinal venous occlusion, vasculitis, or papilledema
Retinal detachments may be associated with congenital malformations, metabolic disorders, trauma
(including previous ocular surgery),[1] vascular disease, choroidal tumors, high myopia or vitreous disease,
or degeneration.
Of the 3 types of retinal detachment, rhegmatogenous RD is the most common, deriving its name from
rhegma, meaning rent or break. Vitreous fluid enters the break and separates the sensory retina from the
underlying RPE, resulting in detachment.[2]
Exudative or serous detachments occur when subretinal fluid accumulates and causes detachment without
any corresponding break in the retina. The etiologic factors are often tumor growth or inflammation. These
types of retinal detachment do not usually require surgical intervention. Correction of the underlying
disorder typically leads to resolution of these detachments.
Tractional retinal detachment occurs as a result of adhesions between the vitreous gel/fibrovascular
proliferation and the retina. Mechanical forces cause the separation of the retina from the RPE without a
retinal break. Advanced adhesion may result in the eventual development of a tear or break. The most
common causes of tractional retinal detachment are proliferative diabetic retinopathy, sickle cell disease,
advanced retinopathy of prematurity, and penetrating trauma.
Retinal detachments are shown in the images below.

Retinal detachment. Courtesy of Kresge

Eye Institute, Detroit, Michigan.

Retinal detachment. Courtesy of Kresge

Eye Institute, Detroit, Michigan.

Retinal detachment. Courtesy of Kresge

Eye Institute, Detroit, Michigan.

Retinal detachment. Courtesy of Kresge

Eye Institute, Detroit, Michigan.

Retinal detachment. Courtesy of Kresge

Eye Institute, Detroit, Michigan.

Retinal detachment. Courtesy of Kresge

Eye Institute, Detroit, Michigan.

Epidemiology
Frequency
United States
Although 6% of the general population are thought to have retinal breaks, most of these are asymptomatic
benign atrophic holes, which are without accompanying pathology and do not lead to retinal detachment.
The annual incidence is approximately one in 10,000 or about 1 in 300 over a lifetime. [2] Other sources
suggest that the age-adjusted incidence of idiopathic retinal detachments is approximately 12.5 cases per
100,000 per year, or about 28,000 cases per year in the US. [3]
Certain groups have higher prevalence than others. Patients with high myopia (>6 diopters) and individuals
with aphakia (ie, cataract removal without lens implant) have a higher risk. Cataract extraction complicated
by vitreous loss during surgery can have an increased detachment rate of up to 10%.
International
The most common worldwide etiologic factors associated with retinal detachment are myopia (ie,
nearsightedness), aphakia, pseudophakia (ie, cataract removal with lens implant), and trauma.
Approximately 40-50% of all patients with detachments have myopia, 30-40% have undergone cataract
removal, and 10-20% have encountered direct ocular trauma. Traumatic detachments are more common in
young persons, and myopic detachment occurs most commonly in persons aged 25-45 years. Although no

studies are available to estimate incidence of retinal detachment related to contact sports, specific sports
(eg, boxing) have an increased risk of retinal detachment.

Mortality/Morbidity
Estimates reveal that 15% of people with retinal detachments in one eye develop detachment in the other
eye. Risk of bilateral detachment is increased (25-30%) in patients who have had bilateral cataract
extraction.

Race
There exists no racial predilection for retinal detachment incidence.

Sex
There exists no gender predilection for retinal detachment incidence.

Age
As the population ages, retinal detachments (RDs) are becoming more common. Retinal detachment
usually occurs in persons aged 40-70 years. However, paintball injuries in young children and teens are
becoming increasingly common causes of eye injuries, including traumatic retinal detachments.

History
Initial symptoms commonly include the sensation of a flashing light (photopsia) related to retinal traction
and often accompanied by a shower of floaters and vision loss.
Over time, the patient may report a shadow in the peripheral visual field, which, if ignored, may spread to
involve the entire visual field in a matter of days. Vision loss may be described as cloudy, irregular, or
curtainlike.
Retinal tissue is stimulated by light but also responds to mechanical disturbances. Flashing lights usually
are caused by separation of the posterior vitreous. As the vitreous gel separates from the retina, it
stimulates the retinal tissue mechanically, resulting in the release of phosphenes and the sensation of light.
Pathologic stimulation of the retina and production of phosphenes cause photopsia.
If a retinal detachment involves the macula, acuity may be severely reduced.
The location of the light sensation in the patient's visual field has no correlation to the location of a retinal
tear.
Floaters are a very common visual symptom in the population; thus, distinguishing their etiology requires
eliciting a detailed history. The sudden onset of large floaters in the center of the visual axis may indicate
posterior vitreous detachment (PVD). The patient observes a circular floater when the vitreous detaches
from its annular ring surrounding the optic nerve (referred to as Weiss ring). More ominous and concerning
is the description of hundreds of tiny black specks appearing before the eye, as this maybe be indicative of
a vitreous hemorrhage, resulting from disruption of a retinal vessel caused by a retinal tear or mechanical
traction of a vitreoretinal adhesion. A few hours after the initial shower of black spots, the patient can note
cobwebs that result from blood forming irregular clots. Generally, the new onset of floaters associated with
flashing lights is highly suggestive of a retinal tear.
While symptoms of photopsia and floaters are not helpful in locating the position of the retinal tear or
detachment, the visual field defect can be helpful in locating the detachment.
Bullous (ie, large ballooning) detachments produce dense visual field defects (ie, blackness), and flat
detachments produce relative field defects (ie, grayness).

Inquire about history of trauma, including whether it occurred several months before the symptoms or
coincided with the onset of symptoms. Documentation of head or ocular trauma may be subject to legal
investigation, especially in children.
Note previous surgery, including cataract extraction, intraocular foreign body removal, and retinal
procedures.
Question the patient about previous conditions, such as uveitis, vitreous hemorrhage, amblyopia,
glaucoma, and diabetic retinopathy. Query about family history of eye disease because, although RDs
usually are sporadic events, certain pedigrees may be prone to detachment.
Determine length of time there has been visual symptoms and visual loss. This can help determine the
appropriate timing of treatment

Physical
Check visual acuity at near and distance, correcting for refractive error.
Conduct an external examination for signs of trauma, checking the visual field (usually a confrontation field
examination is adequate). Visual fields can help isolate the location of the retinal detachment.
Check pupil reaction (a fixed dilated pupil may indicate previous trauma; a positive Marcus-Gunn pupil can
occur with any disturbance of the afferent pupillomotor pathway, including retinal detachment).
Check intraocular pressure measurement in both eyes (relative hypotony of >4-5 mm Hg less than the
fellow eye is common).
Administer slit-lamp biomicroscopy
Examine the vitreous for signs of pigment or tobacco dust (ie, Shafer sign), which is suggestive for a retinal
tear in 70% of cases with no previous eye disease or surgery.
Conduct a dilated fundus examination with ophthalmoscopy (panoptic ophthalmoscope may be used).
Indirect ophthalmoscopy is the definitive means of diagnosing retinal detachment. Direct funduscopy may
detect vitreous hemorrhage and large detachment of the posterior pole, but it is inadequate for complete
examination because of the lower magnification and illumination, lack of stereopsis, and limited view of the
peripheral retina. Obvious detachment is observed as marked elevation of the retina, which appears gray
with dark blood vessels that may lie in folds. The detached retina may undulate and appear out of
focus.Shallow detachments are much more difficult to detect; thus, comparing the suspected area with an
adjacent normal quadrant is helpful to detect any change in retinal transparency. A pigmented or
nonpigmented line may demarcate the limit of a detachment.

Differential Diagnoses

Migraine with or without aura

Posterior uveitis

Posterior vitreous detachment

Retinal Artery Occlusion

Retinal artery occlusion

Retinal vein occlusion

Vitreous Hemorrhage

Vitreous syneresis

Laboratory Studies
Laboratory tests are not helpful in detecting retinal detachment and are not warranted in the acute care of
the patient. However, if the patient requires surgical intervention, it may be useful to have basic blood work
(BMP, PT/PTT, INR, HbA1C). This is especially important in diabetics and those on systemic anticoagulation.

Imaging Studies
Unless globe rupture, orbital/facial bone fractures or intraocular foreign bodies are suspected, imaging
techniques, such as CT scans or MRIs, are not warranted to evaluate for retinal detachments.

Prehospital Care
When the patient or their family member contacts their physician, they should be advised to:

Keep the patient NPO (absolutely no solid foods or fluids) in anticipation of retinal
surgery
In cases of associated trauma, protect the globe with metallic eye shield
Avoid any pressure on the globe and to limit activity to a minimum until further
evaluation

Emergency Department Care

ED treatment of retinal detachment consists of evaluating the patient and treating any
unstable vital signs, preparing the patient for possible emergency surgery. Please see the
examination guidelines as stated above.
Patient follow up should be based upon macula status: Whenever a macula-on retinal
detachment is suspected, a retina specialist should evaluate the patient within 24 hours.
All patients should be instructed to limit strenuous physical activity. Upon discharge from the
ED, patients should be provided with the name and contact information for a retina specialist
located close to their home.
There exists a multitude of techniques for treating retinal detachments, including scleral
buckling, pars plana vitrectomy, and pneumatic retinopexy. The retinal detachment repair is
usually done on an outpatient basis.

Consultations
Ideally, patients with RD should be quickly referred to a retina specialist. The timing of surgical intervention
is typically based on the status of the macula.

Further Inpatient Care

Immediate ophthalmologic referral is mandatory for patients with retinal detachment.

Transfer
Emergent transfer to a facility with an available retina specialist is rarely indicated, as majority of cases can
be evaluated within 24 hours. In some cases, transfer to a facility with an available ophthalmologist or
retinal specialist is in the patient's best interest after initial ophthalmologic evaluation. Make these decisions
in accordance with the patient's wishes and the direction of the ophthalmology consultant.

Complications
Loss of vision to hand motion or light perception is a frequent complication of retinal detachments that
involve the macula.

Prognosis
As the retina is neuro-sensitive tissue, visual prognosis can be difficult to predict. Generally, a retinal
detachment without macular involvement tends to have a better final visual prognosis.

Dapus :

Apr 28, 2014, Hemang K Pandya, Asheesh Tewari, Francisco Talavera, Robert E O'Connor,
Gregory L Larkin, Douglas Lavenburg (http://emedicine.medscape.com/article/798501overview#showall)