Retinal detachment is an ophthalmic condition in which the retina is detached from the deeper retinal pigment epithelial layer (RPE) of the eye, requiring prompt treatment.
Retinal detachment (10-15 per 100,000 population in the UK) principally presents with flashers and floaters, which shares a similar presentation to the more prevalent condition of posterior vitreous detachment (PVD). PVD occurs in 53% of the population aged 50 years and over, and 66% between 66-86 years (1,2).
Types of Retinal Detachment
There are a number of types of retinal detachment which may occur s described below; the commonest type being a rhegmatogenous retinal detachment.
- Rhegmatogenous retinal detachment (RRD): (**Most common type) [Fig. 1]
– *This type of retinal detachment is caused by a tear within the retina. Vitreous humour then accumulates between the retina and underlying retinal pigment epithelium layer (RPE), causing peripheral-to-central visual loss (3).
Clinical tip:
It is important to note that the majority of posterior vitreous detachments do not occur with retinal tears; however, they may present with similar symptoms.
Fig. 1: Rhegmatogenous retinal detachment
https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/rhegmatogenous-ret-detach.htm
2. Tractional retinal detachment: [Fig. 2]
– Tractional retinal detachment occurs as a result of scar tissue on the retina, causing it to pull away from the back of the eye. These types are mainly seen in patients with diabetic retinopathy, where new blood vessels grow into the vitreous and fibrose (4).
Fig. 2: Tractional retinal detachment
https://www.nature.com/articles/6702195
3. Exudative retinal detachment: [Fig. 3]
– Fluid accumulates beneath the retina in the absence of retinal holes or tears. These types of retinal detachments may occur as a result of tumours, ocular trauma, infection or inflammatory disorders (5).
Fig. 3: Exudative retinal detachment.
https://eyewiki.aao.org/Exudative_Retinal_Detachment
Risk Factors:
Certain factors can increase the risk of developing a retinal tear or detachment (2):
- Age (**Most common risk factor)
- Severe myopia (-6 diopter or greater)
- Family history or previous history of retinal tear of detachment
- Previous eye trauma
- Diabetic retinopathy
- Malignancy
- Previous ocular surgery
- Other eye disorders (eg.inflammation, peripheral degenerative retinal disorders, lattice degeneration
Clinical Findings:
The symptoms of retinal detachment can be recalled by the 4 ‘F’s (2,6):
- Flashes and floaters (increase in specks appearing to float in front of your vision).
In retinal detachment, these are usually sudden-onset and occur due to retinal traction.
- Falling (reduced) visual acuity.
- Visual acuity is usually normal in macula-sparing retinal detachment. If the macula is affected, this will lead to a fall in visual acuity and loss of central vision.
- Field loss (shadows in peripheral vision).
This is usually progressive and sudden-onset, described as a “curtain-like shadow”, beginning in the periphery and progressing centrally. This may occur over hours to days.
However, flashes and floaters are not pathognomic of retinal detachment, therefore it is vital to consider other differential diagnoses.
Differential diagnosis:
Posterior vitreous detachment (PVD): PVD occurs due to a separation in the posterior hyaloid through which liquefied vitreous humour passes to the subretinal space, separating the posterior hyaloid from the retina. This may present with vitreous haemorrhage in 50-70% of cases, particularly if over retinal vessels. It is treated surgically by a pars plana vitrectomy if sight-threatening (2,6).
| Retinal detachment | Posterior vitreous detachment | |
| Defining features | Presence of retinal break, allowing liquefied vitreous to accumulate between thr retina and RPE | Separation of vitreous humour from neurosensory retina |
| Risk factors | AgeMyopiaFamily historyPrevious eye surgeryDiabetic retinopathyMalignancy | AgeMyopia |
| Clinical history | Sudden-onset floaters.Gradually reduced visual fields.Flashes.Curtain-like shadow | Often asymptomatic***No changes in visual fields.May have decreased visual acuity. Flashes > floaters. |
Treatment:
NB: Surgical procedures for treatment of retinal tears and detachment are performed during the day. Although this is an ophthalmic emergency this is not operated on during night hours, but will be seen on the next day in the Eye Casualty.
- Pars plana vitrectomy, cryotherapy/laser with intraocular tamponade (gas or oil):
The mainstay of treatment is to find the retinal tears, drain the subretinal fluid and apply cryotherapy (cold therapy) to cause scarring between the detached retina and RPE/deeper layers. This will weld the areas of torn retina to prevent fluid from re-entering and causing a re-detachment, then place a tamponading agent (gas or oil) to prop up the retina whilst the scar tissue forms (7,8).
- Other treatments
- Scleral buckling:
Reserved for more complicated detachments which don’t involve PVDs and involve indenting the ocular globe with a silicone buckle to bring the detachment retina and deeper layers closer together. This then allows the RPE to do its job to pump and recycle excess sub-retinal fluid (8).
Pneumatic retinopexy:
In this procedure, a bubble of gas or air is injected into the vitreous cavity under local anaesthesia. This pushes the area with the retinal defect against the surrounding tissues, effectively stopping the flow of fluid. However, this procedure has a success rate of approximately 66% and is preferred in treating shallow superior detachments (8).
References
- Nguyen KH, Patel BC, Tadi P. Anatomy, Head and Neck: Eye Retina. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542332/
- Retinal Detachment: Summary [Internet] https://cks.nice.org.uk/topics/retinal-detachment/
- File:Rhegmatogenous retinal detachment.jpg – WebEye [Internet] https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/rhegmatogenous-ret-detach.htm
- File:Left eye fundoscopy showing localized retinal detachment with horseshoe retinal tear at 2 O’clock and an avulsed neovascular frond with ghosting of superotemporal blood vessels – https://www.nature.com/articles/6702195
- File:Exudative retinal detachment – EyeWiki [Internet] https://eyewiki.aao.org/Exudative_Retinal_Detachment
- Retinal Detachment – Stanford Medicine [Internet] https://stanfordhealthcare.org/medical-conditions/eyes-and-vision/retinal-detachment/diagnosis.html
- File:Oct_830.png – EyeWiki [Internet] https://www.aao.org/young-ophthalmologists/yo-info/article/3-steps-to-interpret-octs
- Understanding retinal detachment – https://www.rcophth.ac.uk/wp-content/uploads/2020/05/Understanding-Retinal-Detachment_2017_v4.pdf
Written by Dr Osman Elmahi (SHO) & reviewed by Mr Zeyad Al-Moasseb (Ophthalmology Registrar)
