- Clinical science
Retinal detachment refers to the detachment of the inner layer of the retina (neurosensory retina) from the retinal pigment epithelium. The most frequent causes of retinal detachment are tears or holes in the retina (rhegmatogenous retinal detachment), risk factors for which include myopia, previous intraocular surgery, trauma, and/or posterior vitreous detachment. Less commonly, retinal detachment occurs without any retinal tears (non-rhegmatogenous retinal detachment). Non-rhegmatogenous retinal detachment is most often the result of vitreoretinal bands (e.g., proliferative diabetic retinopathy), subretinal/intraretinal tumors (e.g., choroidal melanoma), or a number of systemic and ocular causes that result in subretinal fluid accumulation. Small detachments typically present with photopsia, floaters, and/or visual field defects. Loss of vision may be severe if the retinal detachment is extensive and/or the macula is affected. The diagnosis is confirmed by ophthalmoscopy. To prevent retinal detachment, laser photocoagulation in the direct vicinity of the retinal defect should be performed after diagnosis of retinal tears or holes. Extensive retinal detachment is an ophthalmic emergency and usually requires prompt surgery to prevent further detachment and restore sensory function. Visual prognosis depends particularly on the extent of retinal detachment (poor with macular involvement) and how much time passes before the retina is reattached.
|Type of retinal detachment||Rhegmatogenous retinal detachment||Non-rhegmatogenous retinal detachment|
|Tractional retinal detachment||Exudative retinal detachment|
|Mechanism|| || || |
|Risk factors|| |
- Flash of light (photopsia)
Localized retinal detachment: scotoma (visual field defect)
- Depending on the location of the detachment, a rising wall/dark shadow may appear from the top to the bottom (descending curtain) or from the bottom to top.
- The visual field defects may begin in either the nasal or temporal visual field.
- Extensive retinal detachment and/or macular involvement
Opthalmoscopic findings: A freshly detached retina has a grey color instead of the normal pink color.
- Rhegmatogenous retinal detachment
Non-rhegmatogenous retinal detachment: No retinal tear is observed.
- Tractional retinal detachment
- Exudative retinal detachment
- Ocular ultrasound: if the retina cannot be viewed during fundoscopy (e.g., in the case of vitreous hemorrhage or an advanced cataract)
- Perimetry: to assess visual field defects
- Electroretinography: decreased or absent impulse in the region of the retinal detachment
The unaffected eye should always be examined, as in ∼ 15% of cases of rhegmatogenous retinal detachment, there is a bilateral tear. Preliminary stages of retinal detachment should be diagnosed early and, if necessary, promptly treated (e.g., via laser)!
- Choroidal detachment
The differential diagnoses listed here are not exhaustive.
Rhegmatogenous retinal detachment
- For retinal holes/retinal tears with little or no retinal detachment (prophylaxis against retinal detachment): laser photocoagulation or cryoretinopexy in the direct vicinity of the retinal defect
In the case of extensive retinal detachment: prompt surgical treatment
First-line: 2 approaches
- Scleral buckling (external tamponade)
- Pneumatic retinopexy (internal tamponade)
- Second-line: vitrectomy followed by subretinal fluid drainage, internal tamponade, and laser photocoagulation/cryoretinopexy
- First-line: 2 approaches
Non-rhegmatogenous retinal detachment
- Tractional retinal detachment: Vitrectomy followed by internal tamponade and laser photocoagulation/cryoretinopexy.
Exudative (serous) retinal detachment:
- Due to sub-retinal fluid accumulation: spontaneous reabsorption of fluid; no treatment is required
- Due to tumors: enucleation (see “Therapy” in )
- Without treatment, progressive retinal detachment causes blindness, especially if the macula is involved.
- Proliferative vitreoretinopathy
- Toxic uveitis (due to endocular toxins) in the case of long-standing retinal detachment
- Retinal detachment in the other eye
We list the most important complications. The selection is not exhaustive.
Rhegmatogenous retinal detachment
- The smaller the area of detachment, the better the prognosis.
- The prognosis is good if surgery is performed at an early stage and if there is no macular involvement.
- Non-rhegmatogenous retinal detachment: significantly poorer prognosis