INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

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 1700s by de Saint-Yves, but clinical diagnosis remained elusive until Helmholtz invented the ophthalmoscope in 1851.

Tragically, RDs were uniformly blinding until the 1920s when Jules Gonin, MD, pioneered the first repair of RDs in Lausanne, Switzerland. Today, with the advent of scleral buckling, intravitreal gas, microscopic, laser, and cryotherapy techniques, rapid ED diagnosis and treatment of an RD truly can be a vision-saving opportunity.

For more information, see Medscape's AMD and Retinal Disease Resource Center.

Pathophysiology

Retinal detachment refers to separation of the inner layers of the retina from the underlying retinal pigment epithelium (RPE, choroid). The choroid is a vascular membrane containing large branched pigment cells sandwiched between the retina and sclera. Separation of the sensory retina from the underlying RPE occurs by the following 3 basic mechanisms:

• A hole, tear, or break in the neuronal layer allowing fluid from the vitreous cavity to seep in between and separate sensory and RPE layers (ie, rhegmatogenous RD)
• Traction from inflammatory or vascular fibrous membranes on the surface of the retina, which tether to the vitreous
• Exudation of material into the subretinal space from retinal vessels such as in hypertension, central retinal venous occlusion, vasculitis, or papilledema

RDs may be associated with congenital malformations, metabolic disorders, trauma (including previous ocular surgery), vascular disease, choroidal tumors, high myopia or vitreous disease, or degeneration.

Of the 3 types of retinal detachment, rhegmatogenous RD is the most common, deriving its name from rhegma, meaning rent or break. Vitreous fluid enters the break and separates the sensory retina from the underlying RPE, resulting in detachment.

Exudative or serous detachments occur when subretinal fluid accumulates and causes detachment without any corresponding break in the retina. The etiologic factors are often tumor growth or inflammation.

Tractional retinal detachment occurs as a result of adhesions between the vitreous gel and the retina. Centripetal mechanical forces cause the separation of the retina from the RPE without a retinal break. Advanced adhesion may result in the development of a tear or break. The most common causes of tractional RD are proliferative diabetic retinopathy, sickle cell disease, advanced retinopathy of prematurity, and penetrating trauma. Vitreoretinal traction increases with age, as the vitreous gel shrinks and collapses over time, frequently causing posterior vitreous detachments in approximately two thirds of persons older than 70 years.

Frequency

United States

Although 6% of the general population have retinal breaks, most of these are benign atrophic holes, which are without accompanying pathology and do not lead to retinal detachment. Incidence of retinal detachment is 1 in 15,000 population, with a prevalence of 0.3% in the US. The annual incidence is approximately one in 10,000 or about 1 in 300 over a lifetime.¹ Other sources suggest that the age-adjusted incidence of idiopathic retinal detachments is approximately 12.5 cases per 100,000 per year, or about 28,000 cases per year in the US.²

Certain groups have higher prevalence than others. Patients with high myopia (>6 diopters), a condition that is more common in males than in females have a 5% risk; individuals with aphakia (ie, cataract removal without lens implant) have a 2% risk. Cataract extraction complicated by vitreous loss during surgery has an increased detachment rate to 10%.

International

The most common worldwide etiologic factors associated with RD are myopia (ie, nearsightedness), aphakia, pseudophakia (ie, cataract removal with lens implant), and trauma. Approximately 40-50% of all patients with detachments have myopia, 30-40% have undergone cataract removal, and 10-20% have encountered direct ocular trauma. Traumatic detachments are more common in young persons, and myopic detachment occurs most commonly in persons aged 25-45 years. Although no studies are available to estimate incidence of RD related to contact sports, specific sports (eg, boxing and bungee jumping) have an increased risk of RD.

Mortality/Morbidity

Estimates reveal that 15% of people with retinal detachments in one eye develop detachment in the other eye. Risk of bilateral detachment is increased (25-30%) in patients who have had bilateral cataract extraction.

Race

Incidence of retinal detachment is relatively frequent in people of Jewish ethnicity and relatively low in black persons.

Sex

• No predilection exists; overall, incidence is unchanged even when corrections for the higher rate of ocular trauma in men is considered.
• Of those younger than 45 years who have RD, 60% are male and 40% are female.

Age

As the population ages, RDs are becoming more common. Retinal detachment usually occurs in persons aged 40-70 years. However, paintball injuries in young children and teens are becoming increasingly common causes of eye injuries, including traumatic retinal detachments.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

History

• Initial symptoms commonly include the sensation of a flashing light (photopsia) related to retinal traction and often accompanied by a shower of floaters (RPE) and vision loss.
• Over time, the patient may report a shadow in the peripheral visual field, which, if ignored, may spread rapidly to involve the entire visual field in a matter of days. Vision loss may be filmy, cloudy, irregular, or curtainlike.
• Retinal tissue is stimulated by light but also responds to mechanical disturbances. Flashing lights usually are caused by separation of the posterior vitreous. As the vitreous gel separates from the retina, it stimulates the retinal tissue mechanically, resulting in the release of phosphenes and the sensation of light.
• Pathologic stimulation of the retina and production of phosphenes cause photopsia.
• Patients often may note decreased visual acuity and a wavy distortion of objects (metamorphopsia). If a RD involves the macula, acuity is severely reduced.
• Posterior vitreous detachment is usually a benign process; however, 12% of symptomatic detachments reveal a peripheral tear in the retina. The location of the light sensation in the patient's visual field has no correlation to the location of a retinal tear.
• Floaters are a very common visual symptom in the population; thus, distinguishing their etiology requires eliciting a detailed history.
• • The sudden onset of one large floater in the center of the visual axis indicates posterior vitreous detachment (PVD). The patient observes a circular floater when the vitreous detaches from its annular ring surrounding the optic nerve.
  • Numerous curvilinear opacities indicate vitreous degeneration, which is considered a normal aspect of a mature eye. More ominous and concerning is the description of hundreds of tiny black specks appearing before the eye. This is pathognomonic for vitreous hemorrhage, resulting from disruption of a retinal vessel caused by a retinal tear or mechanical traction of a vitreoretinal adhesion.
  • A few hours after the initial shower of black spots, the patient can note cobwebs that result from blood forming irregular clots.
  • Generally, the new onset of floaters associated with flashing lights indicates a retinal tear until proven otherwise.
• Visual field defects are a late symptom of retinal detachment.
• While symptoms of photopsia and floaters are not helpful in locating the position of the retinal tear or detachment, the visual field defect is very specific for locating the detachment.
• Detachments anterior to the equator of the eye cannot be detected with visual field testing.
• Detachment posterior to the equator can be isolated with visual field testing, but the patient usually is unaware of a defect until it involves the posterior pole and macula.
• Patients are less aware of a superior field defect (indicating an inferior detachment) than an inferior field defect (indicating a superior retinal detachment).
• Inferior retinal detachment can be a long-standing condition that progresses without symptoms until the detachment reaches the fovea.
• Bullous (ie, large ballooning) detachments produce dense visual field defects (ie, blackness), and flat detachments produce relative field defects (ie, grayness).
• When a patient has an extensive detachment, inquiring about the initial symptoms of the visual field loss is helpful to assist in localization of the tear.
• Onset of decreased visual acuity dates the duration of fovea involvement of the detachment, which correlates with the prognosis for recovery of the central vision.
• Metamorphopsia is a macular fluid-based distortion of a visual image and is commonly described by patients as waviness.
• Inquire about history of trauma, including whether it occurred several months before the symptoms or coincided with the onset of symptoms. Documentation of head or ocular trauma may be subject to legal investigation, especially in children.
• Note previous surgery, including cataract extraction, intraocular foreign body removal, and retinal procedures.
• Question the patient about previous conditions, such as uveitis, vitreous hemorrhage, amblyopia, glaucoma, and diabetic retinopathy. Query about family history of eye disease because, although RDs usually are sporadic events, certain pedigrees may be prone to detachment. Systemic diseases associated with retinal detachment include the following:
• • Diabetes
  • Tumors (eg, breast cancer, melanoma)
  • Angiomatosis of the CNS
  • Sickle cell disease
  • Leukemia
  • Eclampsia
  • Prematurity

Physical

• Check visual acuity, correcting for refractive error.
• Conduct an external examination for signs of trauma, checking the visual field (usually a confrontation field examination is adequate). Visual fields can help isolate the location of the RD.
• Check pupil reaction (a fixed dilated pupil may indicate previous trauma; a positive Marcus-Gunn pupil can occur with any disturbance of the afferent pupillomotor pathway, including RD).
• Administer slit-lamp biomicroscopy (the anterior segment is usually normal).
• Examine the vitreous for signs of pigment or tobacco dust (ie, Shafer sign), which is pathognomonic for a retinal tear in 70% of cases with no previous eye disease or surgery.
• Check intraocular pressure measurement in both eyes (hypotony of >4-5 mm Hg less than the fellow eye is common).
• Conduct a fundus examination with ophthalmoscopy (pupils must be dilated or a panoptic may be used).
• • Indirect ophthalmoscopy is the definitive means of diagnosing RD with the use of scleral depression in order to see the anterior retina and definitively identify the location of the tear or hole.
  • Direct funduscopy may detect vitreous hemorrhage and large detachment of the posterior pole, but it is inadequate for complete examination because of the lower magnification and illumination, lack of stereopsis, and limited view of the peripheral retina.
  • A 3-mirror contact lens examination with a slit-lamp may accomplish adequate examination without scleral depression.
  • Obvious detachment is observed as marked elevation of the retina, which appears gray with dark blood vessels that may lie in folds.
  • The detached retina may undulate and appear out of focus. Shallow detachments are much more difficult to detect; thus, comparing the suspected area with an adjacent normal quadrant is helpful to detect any change in retinal transparency. Binocular vision is needed to do this well.
  • A pigmented or nonpigmented line may demarcate the limit of a detachment, and the retinal surface may have an orange-peel appearance.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

Other Problems to be Considered

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/infection

• Acute retinal necrosis syndrome
• Cytomegalovirus retinitis
• Ocular toxocariasis
• Ocular toxoplasmosis
• Pars planitis

Tractional retinal detachment

Proliferative diabetic retinopathy
Sickle cell (SC) disease (hemoglobin SC, hemoglobin S-thalassemia)
Familial exudative vitreoretinopathy
Retinopathy of prematurity
Penetrating trauma with vitreous bands
Cataract surgery with vitreous loss

Exudative retinal detachment

Primary tumors (eg, malignant melanoma of the choroid, hemangioma of the choroid, retinoblastoma)
Metastatic carcinoma to the choroid (eg, breast cancer, lung cancer)
Inflammation (eg, choroiditis [Harada disease], retinitis [toxoplasmosis, CMV])
Vascular disease

• Angiomatosis of the retina (ie, Von Hippel disease)
• Telangiectasia retina
• Juvenile Coat disease
• Adult Coat disease
• Eales disease
• Retinal vein occlusion

• Pit of the optic disc with serous detachment of the macula
• Nerve head drusen with serosanguineous detachment of adjacent retina
• Leber Stellate maculopathy

• Central serous chorioretinopathy
• Age-related macular degeneration
• Other causes of disciform detachment
• Ocular histoplasmosis
• Angioid streaks, high myopia (>6 diopters)

Lesions that may simulate retinal detachment

Cerebrovascular accident or transient ischemic attack
Optic neuritis
Atypical migraine
Vitreous (eg, membranes, hemorrhages, inflammation)
Posterior vitreous detachment
Retinal

• Primary retinoschisis
• Juvenile
• Degenerative
• Secondary retinoschisis
• Retinopathy of prematurity
• Diabetic retinopathy
• Retinal artery occlusion (mainly branch retinal artery occlusion)

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

Lab Studies

• Laboratory tests are generally unhelpful, but they may be useful for patients who have underlying medical problems that need to be managed. Subsequent testing may be necessary to detect underlying causes or related illnesses.

Imaging Studies

• Imaging techniques, such as orbital films, CT scans, or MRIs, are not necessary or indicated to assist the diagnoses retinal detachment, but they may be necessary to detect intraocular foreign bodies and tumors.
• If the retina cannot be visualized because of corneal changes, cataracts, or hemorrhage, ultrasonography is necessary.
• • A scan ultrasound and B scan ultrasound both can assist the diagnoses of RD and differentiate it from posterior vitreous detachment. They also can differentiate rhegmatogenous from nonrhegmatogenous detachment.
  • In exudative detachments, the presence of underlying subretinal tumors, choroidal hemorrhage, or detachment can be detected by ultrasound.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

Prehospital Care

Protecting the globe in cases of traumatic retinal detachment may be important to prevent extrusion of intraocular contents (ie, uveal tissue), and can be achieved with goggles or a metallic eye shield, if available. It is imperative to avoid pressure on the globe.

Emergency Department Care

ED treatment of retinal detachment consists of evaluating the patient and treating any unstable vital signs, preparing the patient for possible emergency surgery.

• The repair technique is dependent on the type, location, and size of the detachment.
• • Laser therapy and cryotherapy are ambulatory outpatient procedures.
  • Use of intraocular gas (ie, pneumatic retinopexy) to tamponade the detachment can be an outpatient procedure with close follow-up of the intraocular pressure.
  • Scleral buckling, in which a silicone band indents the eye to approximate the retina and RPE, is possible as an outpatient procedure. The tear is closed with supplemental cryotherapy or laser.
  • Intraocular repair with pars plana vitrectomy may be necessary in complicated tractional and exudative detachments. This procedure once required hospitalization but is now being performed on an outpatient or short-stay basis because of insurance restrictions.
  • Inflammatory RDs usually are treated medically.
  • An important study in 25 European centers comparing scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment (SPR Study) may answer questions as to the better therapy.

Consultations

• When diagnosed or highly suspected, RD requires an emergent ophthalmologic consultation for confirmation and treatment. This is particularly true for RDs that threaten the fovea or central vision.
• Ideally, patients with RD should be referred to a retinal-vitreous specialist as soon as they are suspected. However, immediate retinal-vitreous specialist consultation is not necessary in all cases because many general ophthalmologists are capable of performing indirect ophthalmoscopy and determining the need for further intervention.
• Frequently, time is critical; however, the time frame is hours and not minutes, and many cases do not require emergency surgery. Inflammatory retinal detachments, for example, usually are treated medically. Acute retinal breaks should be surgically repaired within 24 hours if at all possible.

FOLLOW-UP

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

Further Inpatient Care

• Immediate ophthalmologic referral is mandatory.

Transfer

• In some cases, transfer to a facility with an available ophthalmologist or retinal specialist is in the patient's best interest after initial ophthalmologic evaluation. Make these decisions in accordance with the patient's wishes and the direction of the ophthalmologic consultant.

Complications

• Loss of acuity and blindness is the most common complication of a retinal detachment.
• Loss of vision to hand motion or light perception is a frequent complication of RDs that involve the macula.

Prognosis

• Ultimate outcome depends upon the time the retina is detached, the underlying mechanism of the RD, and whether the macula is involved.
• Prognosis is related inversely to the degree of macular involvement and the length of time the retina has been off.

MULTIMEDIA

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

Media file 1:  Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Media file 2:  Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Media file 3:  Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Media file 4:  Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Media file 5:  Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Media file 6:  Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Media file 7:  Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Media file 8:  Anatomy of the eye.
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REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Multimedia
• References

1. Haimann MH, Burton TC, Brown CK. Epidemiology of retinal detachment. Arch Ophthalmol. Feb 1982;100(2):289-92. [Medline].
2. Subramanian ML, Topping TM. Controversies in the management of primary retinal detachments. Int Ophthalmol Clin. 2004;44(4):103-14. [Medline].
3. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. Aug 2002;9(8):791-9. [Medline].
4. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 3^rd ed. WB Saunders; 1998.
5. Rosen P, Baker FJ, Barkin RM. Emergency Medicine: Concepts and Clinical Practice. Vol 1. Mosby-Year Book; 1988:1033-49.
6. Rosen P, Barkin RM, Sternbach GL. Essentials of Emergency Medicine. Mosby-Year Book; 1991:553-66.
7. Tintinalli JE, Krome RL, Ruiz E. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill; 1992:833-40.
8. Wilkes SR, Beard CM, Kurland LT, et al. The incidence of retinal detachment in Rochester, Minnesota, 1970-1978. Am J Ophthalmol. Nov 1982;94(5):670-3. [Medline].

Article Last Updated: Apr 7, 2008