Retinal detachment

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.

References:^{[1][2][3][4][5][6]}

• Detachment of the neurosensory retina, which contains the photoreceptor layer, from the retinal pigment epithelium.
• Disturbed metabolism of the photoreceptor layer leads to loss of retinal function (i.e., vision impairment)
• Separation of the retina from the choroid for more than 12 hours leads to retinal ischemia and retinal degeneration.

References:^[1]

• Prodromal symptoms: result from posterior vitreous detachment
  • Floaters
  • Flashes of light (photopsia)
    • Caused by traction on the retina (e.g., in posterior vitreous detachment via adhesion between the retina and vitreous body)
    • Irritation of the retina and perception of optic sensations, such as flashes of light, may occur.
    • Photopsia is usually absent in the case of exudative retinal detachments.
• Localized retinal detachment: scotoma (visual field defect)
  • Possible curtain or shadow either descending or ascending on the field of vision depending on the location of detachment
  • The visual field defects may begin in either the nasal or temporal visual field.
  • Typically unilateral
• Extensive retinal detachment and/or macular involvement
  • Sudden, painless loss of vision in the affected eye (often described by patients as a curtain descending over their field of vision)
  • Relative afferent pupillary defect

References:^[1][2][3]

Both direct and indirect ophthalmoscopy should be performed after dilating the pupil. Indirect retinoscopy is useful to visualize the peripheral retina.

• Opthalmoscopic findings: A freshly detached retina has a grey color instead of the normal pink color and may appear crinkled.
  • Rhegmatogenous retinal detachment
    • A retinal tear may potentially be visible (e.g., horseshoe, linear, or round retinal tears).
    • The detached retina floats freely in the vitreous body, and moves with eye movements.
    • Blood-vessel orientation in the detached portion of the retina differs from that in the normal retina.
    • Old retinal detachments: retinal thinning, subretinal demarcation line (high-water mark), secondary intraretinal cysts
  • Non-rhegmatogenous retinal detachment: No retinal tear is observed.
    • Tractional retinal detachment
      • The detached retina appears tented and is relatively immobile.
      • Retinal connective tissue membranes and/or connective tissue proliferation in the papilla region
      • Retinal hemorrhage
    • Exudative retinal detachment
      • The detachment appears round/convex with hyperpigmentation and/or retinal vessels at the summit of the retinal detachment
      • Subretinal fluid
      • Subretinal lipid accumulation (exudate) and hemorrhage
      • Tumor-related retinal detachment
        • Visible tumor
        • The detachment appears opaque upon transillumination
• 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)!
References:^[1][7]

• Retinoschisis
• Choroidal detachment

References:^[8][9]

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

Retinal detachment is an emergency condition that warrants prompt surgical intervention!

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 retinoblastoma)

References:^[1][10]

• 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

References:^[7][11]

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

References:^[8][12]

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4. Wong JX, Wong EP, Teoh SC. Outcomes of cytomegalovirus retinitis-related retinal detachment surgery in acquired immunodeficiency syndrome patients in an Asian population. BMC Ophthalmol. 2014; 14 : p.150. doi: 10.1186/1471-2415-14-150 . | Open in Read by QxMD
5. Feltgen N, Walter P. Rhegmatogenous retinal detachment - an ophthalmologic emergency. Dtsch Arztebl Int. 2014; 111 (1-2): p.12-22. doi: 10.3238/arztebl.2014.0012 . | Open in Read by QxMD
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7. Pandya HK. Retinal Detachment. Retinal Detachment. New York, NY: WebMD. http://emedicine.medscape.com/article/798501. Updated: November 22, 2016. Accessed: February 17, 2017.
8. Medina CA, Townsend JH, Singh AD. Manual of Retinal Diseases. Springer ; 2016
9. Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. Elsevier Health Sciences ; 2011
10. García-arumí J, Martínez-castillo V, Boixadera A, et al. Rhegmatogenous retinal detachment treatment guidelines. Arch Soc Esp Oftalmol. 2013; 88 (1): p.11-35. doi: 10.1016/j.oftale.2013.02.002 . | Open in Read by QxMD
11. Ivanišević M. The natural history of untreated rhegmatogenous retinal detachment. Ophthalmologica. 1997; 211 (2): p.90-92. doi: 10.1159/000310766 . | Open in Read by QxMD
12. Facts About Retinal Detachment. https://nei.nih.gov/health/retinaldetach/retinaldetach. Updated: October 1, 2009. Accessed: March 1, 2018.