Retinal detachment

Background

Retinal detachement

• Average age of onset ~55

Types

1. Rhegmatogenous (rhegma means "tear")
   • As vitreous separates from retina the traction creates a hole in retina
     • Fluid goes through the hole and peels the retina off like wallpaper
2. Exudative
   • Fluid accumulates beneath the retina without a retinal tear
   • Associated with neoplasm, inflammatory conditions, hypertension, preeclampsia
3. Tractional
   • Acquired fibrocellular bands in the vitrous contract and detach the retina
   • Associated with DM, sickle cell, trauma
4. Distinguish between mac-off and mac-on

• Other risk factors:
  • Aging
  • Previous retinal detachment
  • Family history of retinal detachment
  • Extreme myopia
  • Eye surgery, cataract removals

Clinical Features

• Abrupt onset of new "floaters" or flashes of light
  • Vitreous tugs on the retina before separation
• Visual acuity loss (filmy, cloudy, or curtain-like) or visual field loss
  • May be mild or dramatic

Differential Diagnosis

Acute Vision Loss (Noninflamed)

• Arteritic anterior ischemic optic neuropathy
• Amaurosis fugax
• Central retinal artery occlusion (CRAO)^†
• Central retinal vein occlusion (CRVO)^†
• High altitude retinopathy
• Open-angle glaucoma
• Optic neuritis
• Posterior Reversible Encephalopathy Syndrome (PRES)
• Retinal detachment^†
• Temporal arteritis^†
• Traumatic optic neuropathy
• Vitreous hemorrhage
• Stroke^†

^†Emergent Diagnosis

Acute onset flashers and floaters

• Ocular causes
  • Floaters and/or flashes
    • Posterior Vitreous Detachment
    • Retinal tear or Retinal Detachment
    • Posterior Uveitis
  • Predominantly floaters
    • Vitreous Hemorrhage secondary to proliferative retinopathy
    • Sympathetic ophthalmia
  • Predominantly flashes
    • Oculodigital stimulation
    • Rapid eye movements
    • Neovascular age-related macular degeneration
• Nonocular causes
  • Migraine aura (classic)
  • Migraine aura (acephalgicmigraine)
  • Occipital lobe disorders
  • Postural hypotension

Evaluation

• Examination
  • Visual acuity and visual fields
  • Fundoscopic exam with dilation
• [Ocular ultrasound]]

Management

• Urgent ophtho referral within 24hr (pneumatic retinopexy, scleral buckle, or vitrectomy)
• In macular off retinal detachment, visual acute is significantly decreased if reattachment does not occur within 6 days.
• Position patient relative to area of retinal detachment so retina lies flat:
  • Superior detachment = lay patient's head in supine position
  • Inferior detachment = elevate head up
  • Different from face-down recovery position after pneumatic retinopexy (so that bubble covers retinal break)
  • May know where retinal detachment is by a couple of clues:
    • Good fundoscopy
    • US beam orientation
    • Visual Field Defects examples:
      • Superior detachment may have inferior visual field defect
      • Temporal detachment may have nasal visual field defect

See Also

• Acute Onset Flashers and Floaters
• Ocular ultrasound

References

Authors

Ross Donaldson