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.

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	Tumor growth
Risk factors	Previous intraocular surgery (e.g., cataract surgery) Posterior vitreous detachment Retinal detachment of the other eye Peripheral retinal breaks, commonly due to: Pathological myopia Trauma Family history of retinal detachment CMV retinitis Lattice degeneration Retinoschisis	Proliferative diabetic retinopathy Retinopathy of prematurity Sickle cell retinopathy Inflammatory effusions	Systemic diseases Pre-eclampsia Hypertension Bleeding disorders Polyarteritis nodosa Ocular diseases Sudden decrease in intra-ocular pressure due to perforating injuries or intraocular surgery	Retinoblastoma Malignant melanoma of the choroid

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

• 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)
  • Patients may describe the impression of a 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]

• 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.
  • Non-rhegmatogenous retinal detachment: No retinal tear is observed.

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]

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]