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Retinal Detachment

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Overview

Retinal detachment (RD) is when the retina peels away from its underlying layer of tissue leading to a painless loss of vision. Most retinal detachments follow a posterior vitreous detachment (PVD). Early recognition and management can restore vision; however, involvement of the macula or late intervention can lead to permanent visual loss.

Retinal detachment can be classified into the following:

  • Rhegmatogenous retinal detachment – most common
    • This is retinal detachment that follows a retinal break usually due to PVD
  • Non-rhegmatogenous retinal detachment can be:
    • Exudative (serous/secondary) retinal detachment:
      • Damage to underlying retinal pigment epithelium allows fluid leakage into the subretinal space pushing the retina away
    • Tractional – uncommon:
      • Vitreous fibres contract and pull the retina away

Epidemiology

  • Incidence increases with advancing age
  • Mean age of presentation is 60 years
  • Traumatic retinal detachment is more common in younger individuals
  • Men and women are similarly affected

Risk Factors

  • Increasing age
  • Posterior vitreous detachment
  • Eye trauma
  • Previous eye surgery
  • Myopia
  • Family history
  • Previous history in other eye

Presentation

Patients often have preceding flashing lights or floaters before a painless loss of vision. The loss of vision is described as similar to a veil or curtain coming down, usually starting in the peripheral vision and moving centrally.

  • Infants may present with a white pupillary reflex
  • Children may not comment on visual disturbances 

Examination findings are as follows:

  • Visual acuity:
    • May be normal if the macula is still attached
    • If poor, then this suggests the macula has detached
  • Relative afferent pupillary defect:
    • Present if the macula is detached or the optic nerve is involved
  • Loss of red reflex

Differential Diagnoses

Central retinal vein occlusion (CRVO)

Amaurosis fugax

  • This can also present with vision loss similar to a ‘curtain coming down’
  • Flashes and floaters are not seen
  • Patients generally have a history of atherosclerotic disease, hypercoagulability, or vasculitis

Posterior vitreous detachment

  • Sudden onset of flashes and floaters
  • Fundoscopy may show a Weiss ring
  • The flashes and floaters may precede retinal detachment
  • The presence of vision loss suggests an associated retinal detachment

Investigations

  • Fundoscopy:
    • Absent red reflex
    • A detached retina may be visible
    • Retinal tears may be seen
  • Slit-lamp examination:
    • Shows retinal detachment/breaks
  • Indirect ophthalmoscopy:
    • Shows retinal detachment/breaks

Management

  • Immediate referral (within 24 hours) to ophthalmology
  • Management involves different surgical techniques:
    • Retinal tears are corrected with laser photocoagulation
    • Retinal reattachment can be done with vitrectomy, scleral buckling, or pneumatic retinopexy 

Complications

  • Loss of vision
  • Retinal detachment in the other eye
  • Visual impairment due to photoreceptor damage

Prognosis

  • If untreated, retinal detachments lead to a loss of vision
  • Retinal reattachment is successful in around 80% of cases

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