Harvey's Garden

Retinal detachment

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aliases

3 min read

Epidemiology & Risk Factors

  • Types:
    • Rhegmatogenous: Most common; full-thickness retinal break allows vitreous fluid into subretinal space.
    • Tractional: Fibrous bands pull retina away (e.g., Proliferative Diabetic Retinopathy [PDR], ROP).
    • Exudative (Serous): Fluid accumulation without tears (e.g., severe HTN, AMD, choroidal melanoma).
  • Risk Factors:
    • Severe myopia (axial elongation thins peripheral retina).
    • Prior cataract extraction (pseudophakia).
    • Posterior Vitreous Detachment (PVD).
    • Ocular trauma.
    • History of lattice degeneration or prior RD in contralateral eye.

Clinical Features

  • History:
    • Painless, sudden or progressive monocular visual loss.
    • Prodromal flashes of light (photopsia) and shower of floaters (“black spots”, “cobwebs”).
    • Progresses to a dark “curtain/shadow coming down” over visual field (starts peripherally, advances centrally).
  • Physical Exam:
    • Visual Acuity (VA): Normal if macula spared; severely impaired if macula detached (“macula-off”).
    • Visual field testing: Dense peripheral scotoma corresponding to detachment location.
    • Relative Afferent Pupillary Defect (RAPD / Marcus Gunn pupil): Present in extensive/complete detachment.

Diagnosis

  • Initial & Confirmatory: Dilated indirect ophthalmoscopy (Best Initial & Gold Standard).
    • Classic finding: Elevated, wrinkled, pale/gray, undulating retina bulging into the vitreous humor with loss of normal underlying choroidal vasculature.
  • Adjunct Imaging:
    • Ocular B-scan Ultrasound: Indicated when fundus view is obscured (e.g., dense cataract, coexisting vitreous hemorrhage); shows high-amplitude mobile retinal membrane anchored at the optic disc and ora serrata.
  • Key Labs: None routinely indicated.

Differential Diagnostics

  • Posterior Vitreous Detachment (PVD):
    • Presents with flashes and floaters, but lacks a fixed visual field defect (“curtain”). Fundus shows flat, attached retina; may visualize a Weiss ring (fibrous ring floating above optic nerve).
  • Vitreous Hemorrhage:
    • Acute painless floaters/vision loss, but exam reveals obscured fundus/loss of red reflex and visible RBCs in the vitreous cavity rather than an undulating retinal flap.
  • Amaurosis Fugax (Transient Monocular Visual Loss):
    • Painless “curtain pulled down” that is transient (resolves completely within 5–15 min); caused by retinal emboli (carotid artery disease), with normal fundus between episodes.
  • Central Retinal Artery Occlusion (CRAO):
    • Sudden, profound, painless vision loss; fundoscopy reveals diffuse retinal pallor with a cherry-red spot at the fovea and “boxcarring” of retinal arterioles.
  • Central Retinal Vein Occlusion (CRVO):
    • Subacute/acute painless vision loss; fundoscopy displays extensive “blood and thunder” appearance (diffuse flame hemorrhages, tortuous veins, cotton-wool spots, disc edema).

Management

  • Immediate Actions:
    • Emergent Ophthalmology referral.
    • Strict bed rest; position pt head-down or leaning toward the side of detachment (minimizes gravitational progression).
    • Keep pt NPO for possible urgent surgical intervention.
  • Surgical Strategy (Stratified by Macular Status):
    • “Macula-ON”: True surgical emergency; requires intervention within 24 hours to prevent detachment from spreading to the fovea and causing irreversible central blindness.
    • “Macula-OFF”: Semi-urgent repair (typically within 7–10 days); central vision is already compromised, urgency is slightly reduced without worsening long-term functional recovery.
  • Definitive Procedural Modalities:
    • Retinal breaks without extensive detachment: Laser photocoagulation or cryopexy.
    • Active detachment:
      • Pneumatic retinopexy: Intravitreal gas bubble injection + head positioning (best for uncomplicated superior breaks).
      • Scleral buckling: External indenting band placed around the globe.
      • Pars plana vitrectomy (PPV): Internal removal of vitreous traction + internal gas/oil tamponade.

Complications

  • Permanent visual acuity loss or blindness.
  • Proliferative Vitreoretinopathy (PVR): Recurrent tractional detachment due to scar tissue formation (most common cause of surgical failure).
  • Secondary open-angle or angle-closure glaucoma (post-procedural gas expansion or silicone oil migration).
  • Accelerated cataract progression (following vitrectomy).

Graph View

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