Overview
Retinal Detachment
Topic Overview
Summary
Retinal detachment (RD) is separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE). It is an ophthalmic emergency. There are three main types: rhegmatogenous (most common — retinal break), tractional (vitreoretinal traction), and exudative (fluid accumulation). Classic presentation is sudden floaters, flashes (photopsia), and a "curtain" over vision. Untreated rhegmatogenous RD leads to permanent vision loss. Treatment is urgent surgery (vitrectomy, scleral buckle, pneumatic retinopexy).
Key Facts
- Types: Rhegmatogenous (break), tractional, exudative
- Symptoms: Floaters → flashes → curtain/shadow → vision loss
- Risk factors: Myopia, previous cataract surgery, trauma
- Macula status: Macula-on vs macula-off (urgent vs very urgent)
- Treatment: Surgical repair (vitrectomy, scleral buckle, pneumatic retinopexy)
- Prognosis: Better if macula-on at time of surgery
Clinical Pearls
Floaters + flashes = retinal tear until proven otherwise — urgent ophthalmology review
"Curtain" or "shadow" in vision = RD has already occurred
Macula-on RD = same-day surgery; Macula-off = within 24-72 hours
Why This Matters Clinically
RD is painless and can be mistaken for migraine aura or vitreous floaters. Delay in recognition leads to permanent vision loss. Any patient with new floaters and flashes needs urgent dilated fundoscopy.
Visual Summary
Visual assets to be added:
- Retinal detachment anatomy diagram
- Fundus photo showing RD
- Types of RD comparison
- Surgical repair options diagram
Epidemiology
Incidence
- 10-15 per 100,000/year
- Lifetime risk: ~1 in 300
Demographics
- Peak age: 60-70 years (PVD) and younger myopes
- Male = Female
- More common in Caucasians
Risk Factors
| Factor | Relative Risk |
|---|---|
| High myopia (over -6D) | 10x |
| Previous cataract surgery | 2-4x |
| Previous RD in other eye | 10-15% risk |
| Trauma | |
| Family history | 2x |
| Lattice degeneration | |
| Posterior vitreous detachment (PVD) |
Pathophysiology
Types of Retinal Detachment
1. Rhegmatogenous (Most Common — 90%):
- Retinal break (tear or hole) allows vitreous fluid under retina
- Often preceded by posterior vitreous detachment (PVD)
- Vitreous traction causes tear
2. Tractional:
- Vitreoretinal membranes pull retina off
- Common in diabetic retinopathy
- No retinal break
3. Exudative (Serous):
- Fluid accumulates under retina without break
- Causes: Tumour, inflammation, choroidal neovascularisation
Posterior Vitreous Detachment (PVD)
- Vitreous separates from retina (age-related)
- Causes flashes and floaters
- May cause retinal tear if vitreous adherent
Why Macula Status Matters
- Macula-on: Central vision intact; urgent surgery to prevent macula involvement
- Macula-off: Central vision lost; visual prognosis worse
Clinical Presentation
Symptoms — Classic Sequence
- Floaters — new onset, sudden increase
- Flashes (photopsia) — especially in peripheral vision
- Shadow or curtain — progressive, from periphery
- Visual loss — if macula detaches
Key Features
| Symptom | Significance |
|---|---|
| Floaters | Vitreous haemorrhage or debris |
| Flashes | Vitreoretinal traction |
| Curtain | Detached retina |
| Painless | Not inflammatory |
Red Flags
| Finding | Significance |
|---|---|
| Curtain/shadow in vision | RD already occurred |
| Sudden vision loss | Macula-off — urgent |
| Floaters + flashes | Retinal tear — needs same-day exam |
Clinical Examination
Visual Acuity
- May be normal (macula-on) or reduced (macula-off)
Visual Field
- May have relative defect corresponding to RD location
Pupil
- RAPD may be present if extensive RD
Dilated Fundoscopy
- Retinal detachment: Pale, elevated, undulating retina
- Retinal tear: May be visible with associated haemorrhage
- Vitreous: May show pigment cells ("tobacco dust" = Shafer's sign)
Slit Lamp
- Anterior segment usually normal
- May see vitreous cells
Investigations
Clinical Diagnosis
- Dilated fundoscopy is diagnostic
Imaging
| Modality | Indication |
|---|---|
| B-scan ultrasound | If media opaque (vitreous haemorrhage, cataract) |
| OCT | To assess macula status |
Not Routine
- Bloods not needed unless systemic cause suspected
Classification & Staging
By Mechanism
| Type | Cause |
|---|---|
| Rhegmatogenous | Retinal break |
| Tractional | Vitreoretinal membrane traction |
| Exudative | Subretinal fluid without break |
By Macula Involvement
| Status | Definition | Urgency |
|---|---|---|
| Macula-on | Macula attached | Same-day surgery |
| Macula-off | Macula detached | Surgery within 24-72 hours |
Management
Immediate
- Urgent ophthalmology referral (same day)
- Keep patient flat if inferior RD (slows progression)
- Dilate pupil for examination
Surgical Treatment
1. Pneumatic Retinopexy:
- Gas bubble injected into vitreous
- Positions to tamponade break
- Laser/cryotherapy to seal break
- Outpatient procedure; requires positioning
2. Scleral Buckle:
- Silicone band around eye
- Indents sclera to close break
- External surgery
3. Pars Plana Vitrectomy (PPV):
- Remove vitreous
- Drain subretinal fluid
- Laser to break
- Gas or silicone oil tamponade
- Most common for complex RD
Post-Operative Care
- Posturing (if gas used)
- Avoid flying (gas expands at altitude)
- Monitor for recurrence
Non-Rhegmatogenous RD
- Tractional: May observe or vitrectomy if threatening macula
- Exudative: Treat underlying cause
Complications
Of Retinal Detachment
- Permanent vision loss
- Proliferative vitreoretinopathy (PVR)
- Phthisis bulbi (end-stage)
Of Surgery
- Cataract
- Raised IOP
- Recurrent detachment
- Diplopia (scleral buckle)
- Silicone oil complications
Prognosis & Outcomes
Anatomical Success
- Over 90% with single surgery
- May need further surgery for PVR
Visual Outcome
| Macula Status | Visual Prognosis |
|---|---|
| Macula-on | Good (maintain vision) |
| Macula-off (under 7 days) | Variable (some recovery) |
| Macula-off (over 7 days) | Poorer |
Recurrence
- 5-10% recurrence risk
Evidence & Guidelines
Key Guidelines
- Royal College of Ophthalmologists Guidelines
- AAO Preferred Practice Pattern: Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration
Key Evidence
- Early surgery for macula-on RD prevents central vision loss
- Vitrectomy is most versatile technique for complex RD
Patient & Family Information
What is Retinal Detachment?
Retinal detachment is when the light-sensitive layer at the back of the eye (retina) pulls away. Without treatment, it can cause permanent blindness.
Warning Signs
- Sudden increase in floaters
- Flashing lights
- A shadow or curtain across your vision
What Should I Do?
- If you have these symptoms, see an eye doctor TODAY
- Go to A&E if you can't see an eye doctor quickly
Treatment
- Surgery to reattach the retina
- Most people have a good outcome if treated quickly
Resources
References
Primary Guidelines
- Williamson TH, et al. Retinal detachment: guidelines. Royal College of Ophthalmologists. 2019.
Key Reviews
- Feltgen N, Walter P. Rhegmatogenous retinal detachment—an ophthalmologic emergency. Dtsch Arztebl Int. 2014;111(1-2):12-22. PMID: 24565273
- Ghazi NG, Green WR. Pathology and pathogenesis of retinal detachment. Eye. 2002;16(4):411-421. PMID: 12101448