• Clinical science

Retinal detachment

Abstract

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.

Etiology

Type of retinal detachment Rhegmatogenous retinal detachment Non-rhegmatogenous retinal detachment
Tractional retinal detachment Exudative retinal detachment
Mechanism
  • Most common type
  • Retinal tears → retinal fluid, which is formed by vitreous degeneration, seeps into the subretinal space → retinal detachment
  • Formation of vitreoretinal bands → traction on the vitreoretinal band during eye movements or as a result of sudden decrease in intraocular pressure → retinal detachment
  • Subretinal fluid accumulation without retinal tears
Risk factors

References:[1][2][3][4][5][6]

Pathophysiology

  • Detachment of the neurosensory retina from the retinal pigment epithelium.
  • Loss of retinal function due to disturbed metabolic processes
  • Separation of the retina from the choroid for more than 12 hours leads to retinal ischemia and retinal degeneration.

References:[1]

Clinical features

  • Prodromal symptoms
    • Floaters
    • 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

References:[1][2][3]

Diagnostics

  • Opthalmoscopic findings: A freshly detached retina has a grey color instead of the normal pink color.
    • 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.
      • 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
      • Exudative retinal detachment
        • The detachment appears round/convex with a 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]

Differential diagnoses

References:[8][9]

The differential diagnoses listed here are not exhaustive.

Treatment

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

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]

Complications

  • 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.

Prognosis

  • 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]