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Retinal Detachment
Richard W. Allinson, MD
image BASICS
DESCRIPTION
  • Separation of the sensory retina from the underlying retinal pigment epithelium
  • Rhegmatogenous retinal detachment (RRD): most common type; occurs when the fluid vitreous gains access to the subretinal space through a break in the retina (Greek rhegma, “rent”)
  • Exudative or serous detachment: occurs in the absence of a retinal break, usually in association with inflammation or a tumor
  • Traction detachment: Vitreoretinal adhesions mechanically pull the retina from the retinal pigment epithelium. The most common cause is proliferative diabetic retinopathy.
  • System(s) affected: nervous
EPIDEMIOLOGY
Incidence
  • Predominant age: Incidence increases with age.
  • Predominant sex: male > female (3:2)
  • Per year: 1/10,000 in patients who have not had cataract surgery
Prevalence
After cataract surgery, 1-3% of patients will develop a retinal detachment.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Traction from a posterior vitreous detachment (PVD) causes most retinal tears. With aging, vitreous gel liquefies, leading to separation of the vitreous from the retina. The vitreous gel remains attached at the vitreous base, in the retinal periphery, resulting in vitreous traction that produces tears in the retinal periphery. There is an ˜15% chance of developing a retinal tear from a PVD.
  • PVD associated with vitreous hemorrhage has a high incidence of retinal tears.
  • Exudative detachment
    • Tumors
    • Inflammatory diseases (Vogt-Koyanagi-Harada disease, posterior scleritis)
    • Miscellaneous (central serous retinopathy, uveal effusion syndrome, malignant hypertension)
  • Traction detachment
    • Proliferative diabetic retinopathy
    • Cicatricial retinopathy of prematurity
    • Proliferative sickle-cell retinopathy
  • Penetrating trauma
Genetics
  • Most cases are sporadic.
  • There is an increased risk of RRD if a sibling has been affected by this condition. The risk increases with higher levels of myopia in the family history.
RISK FACTORS
  • Myopia (>5 diopters)
  • Aphakia or pseudophakia
    • In patients undergoing small-incision coaxial phacoemulsification with high myopia (axial length ≥26 mm), the incidence of retinal detachment is 2.7%.
  • PVD and associated conditions (e.g., aphakia, inflammatory disease, and trauma)
  • Trauma
  • Retinal detachment in fellow eye
  • Lattice degeneration: a vitreoretinal abnormality found in 6-10% of the general population
  • Glaucoma: 4-7% of patients with retinal detachment have chronic open-angle glaucoma.
  • Vitreoretinal tufts: Peripheral retinal tufts are caused by focal areas of vitreous traction.
  • Meridional folds: Redundant retina usually is found in the supranasal quadrant.
GENERAL PREVENTION
Patients at risk for retinal detachment should have regular ophthalmologic exams.
Geriatric Considerations
  • PVD
  • Cataract surgery
Pediatric Considerations
Usually associated with underlying vitreoretinal disorders and/or retinopathy of prematurity
COMMONLY ASSOCIATED CONDITIONS
  • Lattice degeneration
  • High myopia
  • Cataract surgery
  • Glaucoma
  • History of retinal detachment in the fellow eye
  • Trauma
Pregnancy Considerations
Preeclampsia/eclampsia may be associated with exudative retinal detachment. No intervention is indicated, provided hypertension is controlled. Prognosis is usually good.
image DIAGNOSIS
PHYSICAL EXAM
  • Slit-lamp exam
  • Dilated fundus exam with binocular indirect ophthalmoscopy
DIFFERENTIAL DIAGNOSIS
Retinoschisis (splitting of the retina)
  • Vitreous cells and vitreous hemorrhage are found rarely in the vitreous with retinoschisis, whereas they are seen commonly in RRD.
  • Retinoschisis usually has a smooth surface and is dome-shaped, whereas RRD often has a corrugated, irregular surface.
DIAGNOSTIC TESTS & INTERPRETATION
Visual field testing: differentiates RRD from retinoschisis. An absolute scotoma is seen in retinoschisis, whereas RRD causes a relative scotoma.
Initial Tests (lab, imaging)
  • US can demonstrate a detached retina and may be helpful when the retina cannot be visualized directly (e.g., with cataracts).
  • Fluorescein dye leakage can be seen in exudative retinal detachment; caused by central serous retinopathy and other inflammatory conditions
Test Interpretation
  • Elevation of the neurosensory retina from the underlying retinal pigment epithelium
  • Elevation of retina associated with ≥1 retinal tears in RRD or elevation of the retina without tears in exudative detachment
  • In 3-10% of patients with presumed RRD, no definite retinal break is found.
  • Tenting of the retina without retinal tears in traction detachment
  • Pigmented cells within the vitreous (“tobacco dust”)
image TREATMENT
GENERAL MEASURES
  • Not all retinal tears or breaks need to be treated:
    • Flap or horseshoe tears in symptomatic patients (e.g., patients with flashes or floaters) are treated frequently.
    • Operculated holes in symptomatic patients are treated sometimes.
    • Atrophic holes in symptomatic patients are treated rarely.
  • Lattice degeneration with or without holes within the lattice in an asymptomatic patient with prior retinal detachment in the fellow eye may be treated prophylactically.
  • Flap retinal tears in asymptomatic patients frequently are treated prophylactically.
  • Exudative detachments usually are managed by treating underlying disorder.
  • Traction detachments usually are managed by observation. If the fovea is involved, a vitrectomy is needed.
MEDICATION
First Line
  • Intraocular gases
    • Air
    • Perfluoropropane (C3F8)
    • Sulfur hexafluoride (SF6)
  • Perfluorocarbon liquids
  • Silicone oil
  • Contraindications to intraocular gas: patients with poorly controlled glaucoma
  • Precautions with intraocular gas: Expanding intraocular gas bubble increases intraocular pressure; therefore, avoid higher altitudes.
  • Significant possible interactions with intraocular gas: Nitrous oxide used in general anesthesia can expand an intraocular gas bubble.
Second Line
Steroids may cause worsening of central serous retinopathy.
SURGERY/OTHER PROCEDURES
  • Timing of repairs
    • Macula attached: within 24 hours. If the detachment is peripheral and does not have features suggestive of rapid progression (e.g., large and/or superior tears), repair can be performed within a few days.
  • Macula recently detached: within 10 days of development of a macula-off retinal detachment (1)[B]
    • Old macular detachment: elective repair within 2 weeks
  • P.913

  • If a retinal break has led to the development of a retinal detachment, surgery is needed. Surgical options (and combinations) include the following:
    • Demarcation laser treatment
    • Pneumatic retinopexy: Head positioning is required postoperatively.
    • Scleral buckle
    • Vitrectomy
    • Perfluorocarbon liquids for giant tears (circumferential tears ≥90 degrees)
    • Silicone oil for complex repairs
  • Anesthesia: local or general
  • RRD may have >1 break. If any retinal break is not closed at the time of surgery, the surgery will fail.
  • Additional surgery may be required if the retina redetaches secondary to a new retinal break or because of proliferative vitreoretinopathy (PVR).
  • Adjuvant combination therapy using 5-fluorouracil (5-FU) and low-molecular-weight heparin (LMWH) may reduce the incidence of PVR in patients undergoing vitrectomy for RRD who are at a greater risk of developing PVR, such as patients with uveitis, but does not seem to be of benefit in cases of established PVR.
  • If a vitreous hemorrhage is present, presumably from a retinal tear and the fundus cannot be well visualized, consideration can be given for early vitrectomy (2)[C].
  • There is a trend toward primary vitrectomy in the management of RRD. Eyes undergoing pars plana vitrectomy (PPV) for primary RRD repair may not need the addition of a scleral buckle (3)[B].
  • There is no statistical difference in the primary reattachment rate between eyes treated with PPV and scleral buckle for RRD in both phakic and pseudophakic/aphakic eyes (4)[A].
  • Patients with RRD who are at high risk for PVR (retinal detachment in two or more quadrants, retinal tears >1 clock hour, preoperative PVR, or vitreous hemorrhage). PPV-scleral buckle was associated with higher rates of anatomical success compared to PPV alone (5)[B].
  • There is a reduced incidence of intraoperative retinal tear formation using a transconjunctival cannulated PPV system compared to the standard 20-gauge system requiring suture closure.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Recognition of condition is key (see “Diagnosis”).
  • Refer to an ophthalmologist for exam and treatment, if indicated.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Bed rest prior to surgery.
  • Postoperatively, if intraocular gas has been used, the patient may need specific head positioning and should not travel to high altitudes.
Patient Monitoring
  • Alert ophthalmologist if there is new onset of floaters or flashes, increase in floaters or flashes, sudden shower of floaters, curtain or shadow in the peripheral visual field, or reduced vision.
  • Patients with acute symptomatic PVD should be reexamined by the ophthalmologist in 3 to 4 weeks. The development of a retinal detachment is unlikely if no retinal tears are present on reexamination in 3 to 4 weeks.
  • If acute symptomatic PVD is associated with gross vitreous hemorrhage that interferes with complete visualization of the retinal periphery by indirect ophthalmoscopy, the patient should be reexamined at short intervals with indirect ophthalmoscopy until the entire retinal periphery can be observed.
  • If the examiner is not certain whether the retina is detached in the presence of opaque medium, US should be performed.
DIET
NPO if surgery is imminent.
PATIENT EDUCATION
American Academy of Ophthalmology, 655 E. Beach Street, San Francisco, CA 94109-1336
PROGNOSIS
  • RRD
    • 90% of retinal detachments can be reattached successfully after ≥1 surgical procedures. Postoperative visual acuity depends primarily on the status of the macula preoperatively. Also important is the length of time between the detachment and the repair (75% of eyes with macular detachments of <1 week will obtain a final visual acuity of 20/70 or better).
    • 87% of eyes with a retinal detachment not involving the macula attain a visual acuity of 20/50 or better postoperatively. 37% of eyes with a detached macula preoperatively attain 20/50 or better vision postoperatively.
    • In 10-15% of successfully repaired retinal detachments not involving the macula preoperatively, visual acuity does not return to the preoperative level. This decrease is secondary to complications such as macular edema and macular pucker.
  • Risk factors associated with primary RRD repair failure include choroidal detachment, significant hypotony, grade C-1 PVR, four detached quadrants, and large or giant retinal breaks (6)[B]. Additional risk factors associated with primary RRD repair failure include increased number of breaks and inferior location of retinal breaks (7)[B]. Tractional retinal detachment: When not involving the fovea, the patient usually can be observed because it is uncommon for these to extend into the fovea.
  • Exudative retinal detachment
    • Management is usually nonsurgical.
    • The presence of shifting fluid is highly suggestive of an exudative retinal detachment. Fixed retinal folds, which are indicative of PVR, are seen rarely in exudative retinal detachment. If the underlying condition is treated, the prognosis generally is good.
REFERENCES
1. Hassan TS, Sarrafizadeh R, Ruby AJ, et al. The effect of duration of macular detachment on results after the scleral buckle repair of primary, macula-off retinal detachments. Ophthalmology. 2002;109(1):146-152.
2. Tan HS, Mura M, Bijl HM. Early vitrectomy for vitreous hemorrhage associated with retinal tears. Am J Ophthalmol. 2010;150(4):529-533.
3. Kinori M, Moisseiev E, Shoshany N, et al. Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment. Am J Ophthalmol. 2011;152(2):291.e2-297.e2.
4. Soni C, Hainsworth DP, Almony A. Surgical management of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials. Ophthalmology. 2013;120(7):1440-1447.
5. Storey P, Alshareef R, Khuthaila M, et al. Pars plana vitrectomy and scleral buckle versus pars plana vitrectomy alone for patients with rhegmatogenous retinal detachment at high risk for proliferative vitreoretinopathy. Retina. 2014;34(10):1945-1951.
6. Adelman RA, Parnes AJ, Michalewska Z, et al. Clinical variables associated with failure of retinal detachment repair: the European vitreo-retinal society retinal detachment study report number 4. Ophthalmology. 2014;121(9):1715-1719.
7. Williamson TH, Lee EJ, Shunmugam M. Characteristics of rhegmatogenous retinal detachment and their relationship to success rates of surgery. Retina. 2014;34(7):1421-1427.
8. Tan HS, Mura M, Oberstein SY, et al. Primary retinectomy in proliferative vitreoretinopathy. Am J Ophthalmol. 2010;149(3):447-452.
See Also
&NA;
Retinopathy, Diabetic
Codes
&NA;
ICD10
  • H33.001 Unspecified retinal detachment with retinal break, right eye
  • H33.019 Retinal detachment with single break, unspecified eye
  • H33.20 Serous retinal detachment, unspecified eye
Clinical Pearls
&NA;
  • If a patient complains of the new onset of floaters or flashes of light, the patient should undergo a dilated eye exam to rule out a retinal tear or retinal detachment.
  • There is an increased risk of retinal detachment after cataract surgery.
  • PVR can result in redetachment of the retina after an initially successful repair.