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Retinal Detachment

Retina Detachment

Retinal detachment is defined as the separation of the retina from the underlying tissue.


Presentation

Retinal detachment is often preceded by a posterior vitreous detachment and the following are symptoms of posterior vitreous detachment [7]:

  • Photopsia (flashes of light often very brief in the extreme peripheral part of vision)
  • A sharp upsurge in the number of floaters
  • Slight feeling of heaviness in the eye

Most cases of posterior vitreous detachments don’t progress to retinal detachments but when progression occurs, the following symptoms are often seen:

  • Dense shadow beginning from the peripheral vision and slowly progressing towards central vision. 
  • The impression of a curtain or veil being drawn over the field of vision.
  • Positive Amsler grid test (straight lines suddenly appearing curved).
  • Central visual loss.

As soon as an appearance of sudden flashes of light or floaters is seen or any kind of vision loss is recorded adequate consultations must be made as this is an emergency.

Gaucher Disease
  • This is the first report of vitreous surgery for traction retinal detachment in a patient with type III Gaucher disease with multiple vitreous opacities.[ncbi.nlm.nih.gov]
Down Syndrome
  • RATIONALE: The aim of this study was to report a case of Down syndrome (DS) complicated with bilateral retinal detachment (RD) due to unusual retinal degeneration.[ncbi.nlm.nih.gov]
HELLP Syndrome
  • At 32 weeks of gestation, the 34-year-old Japanese woman underwent cesarean section due to HELLP syndrome.[ncbi.nlm.nih.gov]
Acne Vulgaris
  • A patient who used isotretinoin orally for nodular-cystic acne vulgaris developed concurrent unilaterally excessive subretinal fluid and serous retinal detachment.[ncbi.nlm.nih.gov]
Blurred Vision
  • Abstract A 24-year-old healthy male presented with a chief complaint of blurred vision in the right eye for 1-week. Fundus examination indicated right exudative retinal detachment and choroidal ischemia.[ncbi.nlm.nih.gov]
Vitreous Floaters
  • The prompt and conscientious vitreoretinal examination of each patient older than 45 years of age who experiences vitreous floaters, even though limited to one or two, should be undertaken without delay.[ncbi.nlm.nih.gov]
  • In some cases, there may be significant vitreous floaters , inflammatory cells, or blood in front of the retina, obscuring the doctor's view. In such cases, ultrasound may be used to determine if the retina detached.[emedicinehealth.com]
  • Symptoms are blurred vision, flashes of light, vitreous floaters, and loss of visual acuity.[medical-dictionary.thefreedictionary.com]
  • People with RRD often have a history of flashing lights, vitreous floaters, or both, caused by an acute posterior vitreous detachment.[doi.org]
Scotoma
  • RESULTS: A 41-year-old woman was referred with a 2-week history of decreased vision and scotoma in the left eye. She was in her sixth month of pregnancy.[ncbi.nlm.nih.gov]
  • […] response to local tumors–eg, melanoma, local inflammation, or malignant HTN, idiopathic, trauma, aging, tumors, inflammation; in premature infants, RD is caused by retinopathy of prematurity Clinical Progressive loss of visual field, often accompanied by scotomas[medical-dictionary.thefreedictionary.com]
  • Macular degeneration is the leading cause of painless sudden vision loss in older patients, but the scotoma is central and the peripheral field is intact.[aafp.org]
Retinal Lesion
  • Rhegmatogenous retinal detachment Posterior vitreous detachment Peripheral retinal lesions (eg, enclosed oral bays, meridional folds, cystic retinal tufts, lattice degeneration) Myopia Senile retinoschisis Cataract extraction Trauma Intraocular inflammation[web.archive.org]
  • Family history of retinal break or detachment: there may be a tendency towards inherited myopia or degenerative retinal lesions.[patient.info]
Chemosis
  • Cryotherapy There is often an associated transient lid chemosis. Other complications include transient diplopia, vitritis (inflammation of the vitreous) and, rarely, maculopathy.[patient.info]
Neglect
  • This practice, combined with expeditious treatment of any secondary retinal tears, provides the most effective known means of preventing rhegmatogenous retinal detachment, and currently it appears to be neglected.[ncbi.nlm.nih.gov]

Workup

Examination for retinal detachment can be completed by ophthalmoscopy or fundus photography [8]. Fundus photography generally needs to be completed with instruments larger than the ophthalmoscope but is has the distinct advantage of make the image available to be viewed by a specialist elsewhere. It also delivers photo documentation for future reference. Modern fundus photographs often reproduce much larger areas of the fundus than what can be seen at any point in time with the aid of handheld ophthalmoscopes.

Treatment

There are different treatment procedures for a detached retina but each of them is dependent on finding the breaks that have formed in the retina and closing them [9]. All three of the procedures generally follow the same principles.

  • Discovering all retinal breaks
  • Sealing all retinal breaks
  • Relieving present and future vitreoretinal traction 

The major types of treatment include the following: 

  • Cryopexy and laser photocoagulation
  • Scleral buckle surgery
  • Pneumatic retinopexy
  • Vitrectomy

Prognosis

The visual prognosis is difficult to predict in retinal detachment because the retina is a neuro-sensitive tissue [6]. On average however, retinal detachment devoid of macular involvement generally has better final prognosis.

Etiology

Retinal detachment has various etiologic and risk factors some of which are [2]:

Epidemiology

In the United States, around 6% of the general population are believed to have retinal breaks [3]. Most of these however, are asymptomatic benign atrophic holes which are often without any accompanying pathology. This means a greater percentage of retinal leaks do not lead to retinal detachment. The annual incidence is approximately 1 in 10,000 or about 1 in 300 over a lifetime.

Worldwide, the most common etiologic factors associated with retinal detachment are aphakia, pseudophakia, myopia and trauma [4]. Around 40%-50% of all patients with detachments have myopia, 30%-40% have had cataract correction surgeries while 10%-20% have had direct ocular trauma.

There is no gender or racial predilection for retinal detachment incidence and the condition is mostly seen in people aged 40-70 years.

Sex distribution
Age distribution

Pathophysiology

The retina refers to a thin layer of light sensitive tissue often found on the back wall of the eye. The optical system of the eye focuses light on the retina just as it is seen in the camera where light is focused on the film [5]. The retina then translates the focused image into neural impulses, before sending them to the brain through the optic nerve. Retinal detachment disintegrates the retinal pigment epithelium (RPE).

Separation of the sensory retinal from the underlying RPE happens in three different ways:

  • Rhegmatous RD: Here there is a hole, tear or break in the neuronal layer which allows fluid from the vitreous cavity to seep in between the sensory and RPE layers separating them in the process. 
  • Traction from inflammatory or vascular fibrous over the surface of the retina, which is connected normally to the vitreous body.
  • Exudation of material into the subretinal space from retinal vessels as seen in hypertension, central retinal venous occlusion, vasculitis, or papilledema

Any of the above three mechanisms can be triggered by metabolic disorders, trauma (also including previous ocular surgery), degeneration, vascular disease, choroidal tumors, high myopia, disease affecting the vitreous.

Prevention

There is no clear prevention path for retinal detachment [10]. However, permanent loss of vision can be prevented by taking note of the main signs of a detached retina which include bright flashes of light, sudden increase in floaters, a shadow or curtain that appears across the field of vision.

People older than 40 years of age who notice any of these signs, those who have a family member with a case of retinal detachment and those with extreme myopia should seek instant medical attention with any or all of these symptoms present.

Summary

Retinal detachment (RD) refers to a medical emergency of the eye where the retina is affected, peeling away from the supporting tissue beneath it [1]. Initially, detachment may be localised or partially broad but without quick treatment, the entire retina may detach and this often leads to blindness. Permanent damage kicks in following 72 hours of inaction.

Patient Information

Retinal detachment is an emergency disorder where an important layer of tissue in the back of the eye known as retina pulls away from the layer of blood vessels that supply it with nourishment and oxygen.

When the detachment is complete, the retinal cells are left in need of oxygen. Leaving the retinal detachment untreated for long greatly increases your chances of permanently losing your eyesight.

Retinal detachment however has symptoms which are clear warning signs. Early diagnosis by an ophthalmologist and treatment of retinal detachment will save your vision 85% of the time. The condition is seen mostly in people aged 40 and above.

References

Article

  1. Mattioli S, Curti S, De Fazio R, Mt Cooke R, Zanardi F, Bonfiglioli R, et al. Occupational lifting tasks and retinal detachment in non-myopics and myopics: extended analysis of a case-control study. Saf Health Work. Mar 2012;3(1):52-7.
  2. Haimann MH, Burton TC, Brown CK. Epidemiology of retinal detachment. Arch Ophthalmol. Feb 1982;100(2):289-92.
  3. Subramanian ML, Topping TM. Controversies in the management of primary retinal detachments. Int Ophthalmol Clin. Fall 2004;44(4):103-14.
  4. Bjerrum SS, Mikkelsen KL, La Cour M. Risk of Pseudophakic Retinal Detachment in 202?226 Patients Using the Fellow Nonoperated Eye as Reference. Ophthalmology. Sep 8 2013.
  5. Yang L, Bula D, Arroyo JG, Chen DF. Preventing retinal detachment-associated photoreceptor cell loss in Bax-deficient mice. Invest Ophthalmol Vis Sci 2004; 45:648.
  6. Wilson CA, Khawly JA, Hatchell DL, Machemer R. Experimental traction retinal detachment in the cat. Graefes Arch Clin Exp Ophthalmol 1991; 229:568.
  7. Matthews GP, Das A, Brown S. Visual outcome and ocular survival in patients with retinal detachments secondary to open- or closed-globe injuries. Ophthalmic Surg Lasers 1998; 29:48.
  8. Sarrafizadeh R, Hassan TS, Ruby AJ, et al. Incidence of retinal detachment and visual outcome in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage. Ophthalmology 2001; 108:2273.
  9. Rumpf J. Jules Gonin. Inventor of the surgical treatment for retinal detachment. Surv Ophthalmol 1976; 21:276.
  10. Hikichi T, Trempe CL, Schepens CL. Posterior vitreous detachment as a risk factor for retinal detachment. Ophthalmology 1995; 102:527.

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Last updated: 2019-07-11 21:22