Retinal Detachment

Aka: Retinal Detachment, Detached Retina

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II. Definitions

  1. Retinal Detachment
    1. Retina neurosensory layer separates from the underlying pigmented epithelium

III. Epidemiology

  1. Incidence (U.S.): 10 per 100,000 per year (most over age 50 years old)
  2. Lifetime risk: 1 in 300 patients
  3. Age over 50 years old

IV. Pathophysiology

  1. Retina is normally fixed to underlying epithelium by negative fluid pressure
  2. In Retinal Detachment, Retina detaches from underlying epithelium
    1. Affected Neurons are separated from the Choroid, their vascular supply
    2. Vision Loss in affected Neurons is permanent if not corrected within 24 to 72 hours
    3. Retinal Detachments often start localized but may progress to larger area without treatment

V. Types

  1. Rhegmatogenous Retinal Detachment (most common)
    1. Posterior Vitreous Detachment is initiating event
      1. Vitreous seeps via tear in Retina under the Neuronal layer into the subretinal space
      2. Posterior vitreous detachmen confers 10-15% risk of progression to Retinal Detachment
    2. Common age >50-60 years old (with related increased traction at vitreous attachments)
    3. Vitreous pulls on Retina causing brief flashing lights (Photopsias)
    4. Vitreous Detachment will result in shadows forming on the Retina (visual Floaters)
  2. Exudative Retinal Detachment or serous Retinal Detachment ( subretinal inflammation or mass lesion)
    1. Sarcoid Uveitis
    2. Severe Hypertension
    3. Neoplasm
  3. Tractional Retinal Detachment
    1. Fibrosis due to Trauma, infection, inflammation or Retinopathy
    2. Most commonly due to traction from neovascularization (e.g. proliferative Diabetic Retinopathy)

VI. Risk Factors

  1. Most common risks
    1. Myopia (Near-sightedness, due to egg-shaped globe)
      1. Myopia with >3 diopter Refractive Error confers 10x increased risk
    2. Eye Trauma
    3. Coagulopathy
    4. Older age (especially age > 50-60 years)
    5. Prior Cataract surgery (decreases vitreous): 1% risk
    6. History of prior Retinal Detachment in the contralateral eye
  2. Other risk factors
    1. Diabetic Retinopathy
    2. Retinopathy of Prematurity
    3. Congenital Cataracts
    4. Congenital Glaucoma
    5. Retinal Detachment Family History

VII. Symptoms

  1. Classic triad: Flashes, Floaters and Visual Field Defect
  2. Unilateral Photopsia (Light Flashes)
    1. Each light flash lasts <1 second
    2. Occurs with vitreous pulling on the Retina (see above)
    3. Occurs with either Vitreous Detachment or Retinal Detachment
      1. Suggests Retinal Detachment or signficant bleeding if accompanied by Vision Loss
    4. Extraocular Movement may be provocative
  3. Unilateral increase in number of Floaters
    1. Occurs with Vitreous Detachment (see above)
  4. Acute, painless Vision Loss
    1. Develops peripherally and progresses centrally
    2. Develops over a course of hours to days
    3. Ultimately may involve the Macula
      1. Significantly worse prognosis for Vision in the affected eye
  5. Altered Visual Field
    1. Shadow or curtain Sensation falls over affected region of eye (typically from lateral edge)
    2. Vision may be cloudy, or completely lost as in cases associated with severe bleeding
    3. Progresses as Retina peels away from the underlying Choroid
    4. Metamorphopsia (wavy distortion of Vision)

VIII. Signs

  1. Visual Field Exam by Confrontation
    1. Visual Field Deficits may be subtle
  2. Funduscopic Exam with Pupil Dilation (direct and indirect)
    1. Careful exam by a skilled examiner focused on the peripheral Retina
    2. Affected Retina will have the pale billowing appearance of a parachute
    3. Vitreous bleeding may occur if small Retinal vessels are torn
  3. Afferent Pupillary Defect
    1. Typically normal pupil response unless severe Retinal Detachment

IX. Differential Diagnosis

  1. See Floaters (Entopsias)
  2. See Flashing Lights (Photopsias)
  3. See Acute Vision Loss
  4. Vitreous Detachment

X. Imaging

  1. Orbital Ultrasound
    1. Indicated if Ophthalmoscopy is non-diagnostic
    2. in non-dilated Eye Exam, Ocular Ultrasound has better sensitivity
      1. Test Sensitivity: 97-100%
      2. Test Specificity: 83-100%
    3. Bedside Ultrasound in ED has high accuracy with training (Test Sensitivity 91%, Test Specificity 96%)
      1. Jacobsen (2016) West J Emerg Med 17(2): 196-200 +PMID: 26973752 [PubMed]

XI. Management

  1. Emergent, immediate ophthalmology referral
    1. Normal Visual Acuity with suspected new Retinal Detachment confers a higher urgency
    2. Goal is to intervene early to maintain that Visual Acuity
  2. Ophthalmology management
    1. Retina fixed in place (pneumatic retinopexy)
      1. Air or gas injected into the vitreous cavity (holds Retina in place)
      2. Forces out trapped fluid beneath the Retinal tear
    2. Reattachment of Retina
      1. Ophthalmologist locates the Retinal tear
      2. Cryotherapy, diathermy or laser photocoagulation applied to Retinal tear
      3. Reattaches, or tacks down the Retina
    3. Reduce vitreous tension at attachment to Retina (may not be required)
      1. Scleral buckling involves the suturing of constricting band to Sclera
      2. Decreases globe diameter, and hence decreases vitreous traction
    4. Other measures indicated in more complex Retinal Detachments
      1. Posterior vitrectomy

XII. Prognosis

  1. Surgical Repair has a good prognosis
    1. Overall surgery is successful in 95% of cases
    2. Vision 20/40 Vision or better in 75% of cases unless central Macula involvement
  2. Predictors of worse outcome
    1. Delayed repair
    2. Detachment involving Macula

XIII. Complications

  1. Proliferative vitreoretinopathy
    1. Fibrosis forms within weeks of repair
  2. Retinal Detachment in contralateral eye (25% risk)

XIV. Prevention

  1. Sports Eye Protection
  2. Posterior Vitreous Detachment
    1. May require laser "tacking" of Retina
    2. Aggressively follow patients with new onset
    3. Higher risk if increase in Floaters present
  3. Contralateral eye Retinal Detachment
    1. Periodic Eye Exams by ophthalmology in those with Retinal Detachment history

XV. References

  1. Sales, Patel and Patel (2019) Crit Dec Emerg Med 33(12): 3-13
  2. Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
  3. Trobe (2012) Physicians Guide to Eye, p. 151-3
  4. Banker (2001) Ophthalmol Clin North Am 14(4):695-704 [PubMed]
  5. Gariano (2004) Am Fam Physician 69:1691-8 [PubMed]
  6. Gelston (2020) Am Fam Physician 102(9):539-45 [PubMed]
  7. Gelston (2013) Am Fam Physician 88(8):515-9 [PubMed]

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