Retinal detachment

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Background

Retinal detachement
Ocular - Retinal detachment.gif
  • Average age of onset ~55

Types

  1. Rhegmatogenous (rhegma means "tear")
    • As vitreous separates from retina the traction creates a hole in retina
      • Fluid goes through the hole and peels the retina off like wallpaper
  2. Exudative
    • Fluid accumulates beneath the retina without a retinal tear
    • Associated with neoplasm, inflammatory conditions, hypertension, preeclampsia
  3. Tractional
    • Acquired fibrocellular bands in the vitrous contract and detach the retina
    • Associated with DM, sickle cell, trauma
  4. Distinguish between mac-off and mac-on

Other risk factors

  • Aging
  • Previous retinal detachment
  • Family history of retinal detachment
  • Extreme myopia
  • Eye surgery, cataract removals

Clinical Features

  • Abrupt onset of new "floaters" or flashes of light
    • Vitreous tugs on the retina before separation
  • Visual acuity loss (filmy, cloudy, or curtain-like) or visual field loss
    • May be mild or dramatic

Differential Diagnosis

Acute Vision Loss (Noninflamed)

Emergent Diagnosis

Acute onset flashers and floaters

  • Ocular causes
  • Nonocular causes
    • Migraine aura (classic)
    • Migraine aura (acephalgicmigraine)
    • Occipital lobe disorders
    • Postural hypotension

Evaluation

RetinalDetachment.jpeg
  • Examination
    • Visual acuity and visual fields
    • Fundoscopic exam with dilation
  • Ocular ultrasound
    • Generally remains anchored to the optic disc in most posterior section of the eye
    • Appears as a hyperechoic membrane floating in the vitreous chamber

Management

  • Position patient relative to area of retinal detachment so retina lies flat:
    • Superior detachment = lay patient's head in supine position
    • Inferior detachment = elevate head up
    • Different from face-down recovery position after pneumatic retinopexy (so that bubble covers retinal break)
    • May know where retinal detachment is by a couple of clues:
      • Good fundoscopy
      • US beam orientation
      • Visual Field Defects examples[1]:
        • Superior detachment may have inferior visual field defect
        • Temporal detachment may have nasal visual field defect

Disposition

  • Most likely admit vs same-day (immediate) referral to retinal surgeon (minutes may matter)

See Also

References

  1. Gariano RF and Kim CH. Evaluation and Management of Suspected Retinal Detachment. Am Fam Physician. 2004 Apr 1;69(7):1691-1699.