Retinal Detachment Summary

Definition

  • Separation of neurosensory retina from RPE
  • Fluid accumulation in subretinal space
  • Preventable cause of vision loss

The 4 F's

  • Floaters: Mobile dots/lines/haze
  • Flashes: Brief recurrent light perceptions
  • Field loss: Dark curtain/shadow
  • Fall in VA: If macula detaches

Types

  • Rhegmatogenous: Most common (tear/break)
  • Exudative: Fluid leakage (inflammation/malignancy)
  • Tractional: Vitreous contraction (diabetic retinopathy)

Risk Factors

  • Myopia
  • Previous eye surgery/trauma
  • Family/personal history
  • Diabetes (proliferative retinopathy)

Management

  • URGENT ophthalmology referral
  • Tears: Laser/cryotherapy
  • Detachment: Vitrectomy, scleral buckling, pneumatic retinopexy

Fundoscopy Findings

  • Loss of red reflex
  • Vitreous opacities
  • Pale, opaque retinal folds

Retinal Detachment

Separation of neurosensory retina from retinal pigment epithelium - a preventable cause of vision loss

Definition & Overview

Retinal detachment refers to the separation of the inner neurosensory retina from the underlying retinal pigment epithelium, which allows fluid to accumulate in the subretinal space.

CRITICAL: Retinal detachment is a preventable cause of vision loss. Prompt recognition and referral may allow early surgical repair before the macula is detached, which reduces the risk of permanent visual impairment. If left untreated, symptomatic retinal detachment invariably results in permanent loss of vision.

Types of Retinal Detachment

Rhegmatogenous (Most Common)

  • As the vitreous shrinks and partly separates from the retinal surface
  • A retinal tear or break may develop
  • Fluid passes through break into subretinal space

Exudative

  • Caused by leakage of fluid into the subretinal space
  • Often due to inflammation or malignancy
  • No retinal break present

Tractional

  • Most commonly seen in proliferative diabetic retinopathy
  • Abnormal vasculature causes contraction of the vitreous
  • Vitreous then pulls on the underlying retina

Note: Trauma can cause any type of retinal detachment through various mechanisms including direct retinal injury, vitreous hemorrhage, or inflammatory response.

Risk Factors

Ocular Factors

  • Myopia (increases risk of posterior vitreous detachment)
  • Family history or previous history of retinal break/detachment
  • Previous cataract surgery
  • Proliferative diabetic retinopathy

Trauma & Inflammation

  • Eye trauma (especially blunt trauma e.g., boxing, paintball injury)
  • Inflammatory conditions (uveitis, scleritis)
  • Posterior vitreous detachment

Other Factors

  • Malignancy (choroidal melanoma or ocular metastasis)
  • Congenital eye disease (glaucoma, cataract)
  • Retinopathy of prematurity
  • Advanced age

Clinical Features - The 4 F's

Floaters

  • Perception of mobile dots, lines, or haze
  • Caused by blood and pigment cells entering the vitreous cavity
  • These cast shadows on the retina

Flashes

  • Perception of light often seen as recurrent, brief flashes
  • Caused by traction on the retina as the vitreous pulls away
  • Typically in peripheral vision

Field Loss

  • May be described as a dark curtain or shadow
  • Starts in the periphery and progresses towards the centre
  • Progresses as the detachment extends

Fall in Visual Acuity

  • If the macula detaches, central visual acuity may be severely reduced
  • Indicates poor prognosis for visual recovery
  • EMERGENCY situation requiring immediate intervention

Important: Any patient presenting with new onset flashes and/or floaters requires urgent ophthalmological assessment to exclude retinal tear or detachment.

Fundoscopy Findings

Direct Observation

  • Loss of red reflex in affected area
  • Vitreous opacities (hemorrhage, pigment cells)
  • Detached retinal folds (appear pale, opaque and wrinkled in larger detachments)
  • Retinal vessels appear dark against pale retina

Additional Signs

  • Retinal breaks/tears (often horseshoe-shaped)
  • Subretinal fluid shifting with position changes (in exudative detachment)
  • Vitreous hemorrhage (may obscure view of retina)
  • Pigment in vitreous ("tobacco dust")

Examination tip: In cases where the view is obscured by vitreous hemorrhage, B-scan ultrasound can be used to confirm the diagnosis and assess the extent of detachment.

Management

Initial Response

URGENT OPHTHALMOLOGY REFERRAL for any suspected retinal detachment. Time is vision - macular involvement significantly worsens prognosis.

Specialist Treatment Options

Retinal Tears/Breaks (Prophylaxis)

  • Laser therapy (photocoagulation)
  • Cryotherapy
  • Creates scar adhesion between retina and RPE
  • Seals the hole and prevents fluid access into subretinal space
  • Prevents progression to retinal detachment

Established Retinal Detachment

Surgical techniques aim to:

  • Close retinal tears/holes
  • Reduce vitreous traction
  • Reattach the retina

Surgical Procedures

Procedure Mechanism Indications
Vitrectomy Removal of vitreous gel to relieve traction, followed by fluid-gas exchange Complex detachments, vitreous hemorrhage, PDR
Scleral Buckling External indentation of sclera to oppose RPE to neurosensory retina Rhegmatogenous RD, particularly in young patients
Pneumatic Retinopexy Intravitreal gas bubble to tamponade retinal break Selected uncomplicated superior retinal breaks

Post-operative care: Patients may require specific positioning (e.g., face down) for several days to weeks to ensure the gas bubble tamponades the retinal break effectively.

Prognosis & Follow-up

Visual Outcomes

  • Macula-on: Excellent prognosis (90%+ retain good vision)
  • Macula-off: Variable recovery, often incomplete
  • Time to surgery critical for visual preservation

Long-term Considerations

  • Regular ophthalmological follow-up
  • Increased risk of detachment in fellow eye
  • Possible complications: cataract, glaucoma, PVR
  • Patient education about warning symptoms

Key message: Patient education about the symptoms of retinal detachment is crucial, as early recognition and treatment dramatically improve visual outcomes.