Retinal Detachment

Last Updated: April 11, 2006

INTRODUCTION
Background:
Next to central retinal artery occlusion and chemical burns to the eye, retinal
detachment is one of the most time-critical eye emergencies encountered in the
ED. Retinal detachment (RD) was first recognized in the early !""s by de #aint-
$%es, but clinical diagnosis remained elusi%e until &elmholtz in%ented the
o'hthalmosco'e in ().
*ragically, RDs were uniformly blinding until the +,"s when -ules .onin,
/D, 'ioneered the first re'air of RDs in 0ausanne, #witzerland. *oday, with the
ad%ent of scleral buc1ling, intra%itreal gas, microsco'ic, laser, and cryothera'y
techni2ues, ra'id ED diagnosis and treatment of an RD truly can be a %ision-
sa%ing o''ortunity.
Pathophysiology:
Retinal detachment refers to se'aration of the inner layers of the retina from
the underlying retinal 'igment e'ithelium (R3E, choroid). *he choroid is a
%ascular membrane containing large branched 'igment cells sandwiched
between the retina and sclera. #e'aration of the sensory retina from the
underlying R3E occurs by the following 4 basic mechanisms5
6 hole, tear, or brea1 in the neuronal layer allowing fluid from the %itreous
ca%ity to see' in between and se'arate sensory and R3E layers (ie,
rhegmatogenous RD)
*raction from inflammatory or %ascular fibrous membranes on the surface
of the retina, which tether to the %itreous
Exudation of material into the subretinal s'ace from retinal %essels such
as in hy'ertension, central retinal %enous occlusion, %asculitis, or
'a'illedema
RDs may be associated with congenital malformations, metabolic disorders,
trauma (including 're%ious ocular surgery), %ascular disease, choroidal tumors,
high myo'ia or %itreous disease, or degeneration.
7f the 4 ty'es of retinal detachment, rhegmatogenous RD is the most
common, deri%ing its name from rhegma, meaning rent or brea1. 8itreous fluid
enters the brea1 and se'arates the sensory retina from the underlying R3E,
resulting in detachment.
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Exudati%e or serous detachments occur when subretinal fluid accumulates
and causes detachment without any corres'onding brea1 in the retina. *he
etiologic factors are often tumor growth or inflammation.
*ractional retinal detachment occurs as a result of adhesions between the
%itreous gel and the retina. :entri'etal mechanical forces cause the se'aration of
the retina from the R3E without a retinal brea1. 6d%anced adhesion may result in
the de%elo'ment of a tear or brea1. *he most common causes of tractional RD
are 'roliferati%e diabetic retino'athy, sic1le cell disease, ad%anced retino'athy of
'rematurity, and 'enetrating trauma. 8itreoretinal traction increases with age, as
the %itreous gel shrin1s and colla'ses o%er time, fre2uently causing 'osterior
%itreous detachments in a''roximately two thirds of 'ersons older than !" years.
Frequency:
In the U: 6lthough 9; of the general 'o'ulation ha%e retinal brea1s,
most of these are benign atro'hic holes, which are without accom'anying
'athology and do not lead to retinal detachment. <ncidence of retinal
detachment is in ),""" 'o'ulation, with a 're%alence of ".4; in the
=#. *he annual incidence is a''roximately one in ",""" or about in
4"" o%er a lifetime (&aimann, +(,). 7ther sources suggest that the age-
ad>usted incidence of idio'athic retinal detachments is a''roximately ,.)
cases 'er "",""" 'er year, or about ,(,""" cases 'er year in the =#.
(#ubramanian and *o''ing, ,""?).
:ertain grou's ha%e higher 're%alence than others. 3atients with
high myo'ia (@9 dio'ters), a condition that is more common in males than
in females ha%e a ); ris1A indi%iduals with a'ha1ia (ie, cataract remo%al
without lens im'lant) ha%e a ,; ris1. :ataract extraction com'licated by
%itreous loss during surgery has an increased detachment rate to ";.
Internationally:
*he most common worldwide etiologic factors associated with RD are
myo'ia (ie, nearsightedness), a'ha1ia, 'seudo'ha1ia (ie, cataract
remo%al with lens im'lant), and trauma. 6''roximately ?"-)"; of all
'atients with detachments ha%e myo'ia, 4"-?"; ha%e undergone cataract
remo%al, and "-,"; ha%e encountered direct ocular trauma. *raumatic
detachments are more common in young 'ersons, and myo'ic
detachment occurs most commonly in 'ersons aged ,)-?) years.
6lthough no studies are a%ailable to estimate incidence of RD related to
contact s'orts, s'ecific s'orts (eg, boxing and bungee >um'ing) ha%e an
increased ris1 of RD.
!ortality"!or#idity:
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Estimates re%eal that ); of 'eo'le with retinal detachments in one eye
de%elo' detachment in the other eye. Ris1 of bilateral detachment is increased
(,)-4";) in 'atients who ha%e had bilateral cataract extraction.
Race:
<ncidence of retinal detachment is relati%ely fre2uent in 'eo'le of -ewish
ethnicity and relati%ely low in blac1 'ersons.
e$:
No 'redilection existsA o%erall, incidence is unchanged e%en when
corrections for the higher rate of ocular trauma in men is considered.
7f those younger than ?) years who ha%e RD, 9"; are male and ?"; are
female.
%ge:
6s the 'o'ulation ages, RDs are becoming more common. Retinal detachment
usually occurs in 'ersons aged ?"-!" years. &owe%er, 'aintball in>uries in young
children and teens are becoming increasingly common causes of eye in>uries,
including traumatic retinal detachments.
C&INIC%&
'istory:
<nitial sym'toms commonly include the sensation of a flashing light
('hoto'sia) related to retinal traction and often accom'anied by a shower
of floaters (R3E) and %ision loss.
7%er time, the 'atient may re'ort a shadow in the 'eri'heral %isual field,
which, if ignored, may s'read ra'idly to in%ol%e the entire %isual field in a
matter of days. 8ision loss may be filmy, cloudy, irregular, or curtainli1e.
Retinal tissue is stimulated by light but also res'onds to mechanical
disturbances. Blashing lights usually are caused by se'aration of the
'osterior %itreous. 6s the %itreous gel se'arates from the retina, it
stimulates the retinal tissue mechanically, resulting in the release of
'hos'henes and the sensation of light.
3athologic stimulation of the retina and 'roduction of 'hos'henes cause
'hoto'sia.
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3atients often may note decreased %isual acuity and a wa%y distortion of
ob>ects (metamor'ho'sia). <f a RD in%ol%es the macula, acuity is se%erely
reduced.
3osterior %itreous detachment is usually a benign 'rocessA howe%er, ,;
of sym'tomatic detachments re%eal a 'eri'heral tear in the retina. *he
location of the light sensation in the 'atientCs %isual field has no correlation
to the location of a retinal tear.
Bloaters are a %ery common %isual sym'tom in the 'o'ulationA thus,
distinguishing their etiology re2uires eliciting a detailed history.
o *he sudden onset of one large floater in the center of the %isual axis
indicates 'osterior %itreous detachment (38D). *he 'atient obser%es a
circular floater when the %itreous detaches from its annular ring
surrounding the o'tic ner%e.
o Numerous cur%ilinear o'acities indicate %itreous degeneration, which is
considered a normal as'ect of a mature eye. /ore ominous and
concerning is the descri'tion of hundreds of tiny blac1 s'ec1s
a''earing before the eye. *his is 'athognomonic for %itreous
hemorrhage, resulting from disru'tion of a retinal %essel caused by a
retinal tear or mechanical traction of a %itreoretinal adhesion.
o 6 few hours after the initial shower of blac1 s'ots, the 'atient can note
cobwebs that result from blood forming irregular clots.
o .enerally, the new onset of floaters associated with flashing lights
indicates a retinal tear until 'ro%en otherwise.
8isual field defects are a late sym'tom of retinal detachment.
Dhile sym'toms of 'hoto'sia and floaters are not hel'ful in locating the
'osition of the retinal tear or detachment, the %isual field defect is %ery
s'ecific for locating the detachment.
Detachments anterior to the e2uator of the eye cannot be detected with
%isual field testing.
Detachment 'osterior to the e2uator can be isolated with %isual field
testing, but the 'atient usually is unaware of a defect until it in%ol%es the
'osterior 'ole and macula.
3atients are less aware of a su'erior field defect (indicating an inferior
detachment) than an inferior field defect (indicating a su'erior retinal
detachment).
<nferior retinal detachment can be a long-standing condition that
'rogresses without sym'toms until the detachment reaches the fo%ea.
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Eullous (ie, large ballooning) detachments 'roduce dense %isual field
defects (ie, blac1ness), and flat detachments 'roduce relati%e field defects
(ie, grayness).
Dhen a 'atient has an extensi%e detachment, in2uiring about the initial
sym'toms of the %isual field loss is hel'ful to assist in localization of the
tear.
7nset of decreased %isual acuity dates the duration of fo%ea in%ol%ement
of the detachment, which correlates with the 'rognosis for reco%ery of the
central %ision.
/etamor'ho'sia is a macular fluid-based distortion of a %isual image and
is commonly described by 'atients as wa%iness.
<n2uire about history of trauma, including whether it occurred se%eral
months before the sym'toms or coincided with the onset of sym'toms.
Documentation of head or ocular trauma may be sub>ect to legal
in%estigation, es'ecially in children.
Note 're%ious surgery, including cataract extraction, intraocular foreign
body remo%al, and retinal 'rocedures.
Fuestion the 'atient about 're%ious conditions, such as u%eitis, %itreous
hemorrhage, amblyo'ia, glaucoma, and diabetic retino'athy. Fuery about
family history of eye disease because, although RDs usually are s'oradic
e%ents, certain 'edigrees may be 'rone to detachment. #ystemic
diseases associated with retinal detachment include the following5
o Diabetes
o *umors (eg, breast cancer, melanoma)
o 6ngiomatosis of the :N#
o #ic1le cell disease
o 0eu1emia
o Eclam'sia
o 3rematurity
Physical:
:hec1 %isual acuity, correcting for refracti%e error.
:onduct an external examination for signs of trauma, chec1ing the %isual
field (usually a confrontation field examination is ade2uate). 8isual fields
can hel' isolate the location of the RD.
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:hec1 'u'il reaction (a fixed dilated 'u'il may indicate 're%ious traumaA a
'ositi%e /arcus-.unn 'u'il can occur with any disturbance of the afferent
'u'illomotor 'athway, including RD).
6dminister slit-lam' biomicrosco'y (the anterior segment is usually
normal).
Examine the %itreous for signs of 'igment or tobacco dust (ie, #hafer
sign), which is 'athognomonic for a retinal tear in !"; of cases with no
're%ious eye disease or surgery.
:hec1 intraocular 'ressure measurement in both eyes (hy'otony of @?-)
mm &g less than the fellow eye is common).
:onduct a fundus examination with o'hthalmosco'y ('u'ils must be
dilated or a 'ano'tic may be used).
o <ndirect o'hthalmosco'y is the definiti%e means of diagnosing RD with
the use of scleral de'ression in order to see the anterior retina and
definiti%ely identify the location of the tear or hole.
o Direct fundusco'y may detect %itreous hemorrhage and large
detachment of the 'osterior 'ole, but it is inade2uate for com'lete
examination because of the lower magnification and illumination, lac1
of stereo'sis, and limited %iew of the 'eri'heral retina.
o 6 4-mirror contact lens examination with a slit-lam' may accom'lish
ade2uate examination without scleral de'ression.
o 7b%ious detachment is obser%ed as mar1ed ele%ation of the retina,
which a''ears gray with dar1 blood %essels that may lie in folds.
o *he detached retina may undulate and a''ear out of focus. #hallow
detachments are much more difficult to detectA thus, com'aring the
sus'ected area with an ad>acent normal 2uadrant is hel'ful to detect
any change in retinal trans'arency. Einocular %ision is needed to do
this well.
o 6 'igmented or non'igmented line may demarcate the limit of a
detachment, and the retinal surface may ha%e an orange-'eel
a''earance.
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