Retinal detachment: Difference between revisions

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==Background==
==Background==
[[File:A Retinal Detachment.jpg|thumb|Retinal detachement]]
[[File:A Retinal Detachment.jpg|thumb|Retinal detachement]]
[[File:Ocular - Retinal detachment.gif|thumb]]
*Average age of onset ~55
*Average age of onset ~55


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#Exudative
#Exudative
#*Fluid accumulates beneath the retina without a retinal tear
#*Fluid accumulates beneath the retina without a retinal tear
#*Associated w/ neoplasm, inflammatory conditions, hypertension, preeclampsia
#*Associated with neoplasm, inflammatory conditions, hypertension, preeclampsia
#Tractional
#Tractional
#*Acquired fibrocellular bands in the vitrous contract and detach the retina
#*Acquired fibrocellular bands in the vitrous contract and detach the retina
#*Associated w/ DM, sickle cell, trauma
#*Associated with DM, sickle cell, trauma
#Distinguish between mac-off and mac-on
#Distinguish between mac-off and mac-on


==Clinical Features ==
===Other risk factors===
*Abrupt onset of new "floaters" or flashes of light
*Aging
*Previous retinal detachment
*Family history of retinal detachment
*Extreme myopia
*Eye surgery, cataract removals
 
==Clinical Features==
*Abrupt onset of new [[Acute onset flashers and floaters|"floaters" or flashes of light]]
**Vitreous tugs on the retina before separation
**Vitreous tugs on the retina before separation
*Visual acuity loss (filmy, cloudy, or curtain-like) or visual field loss  
*Visual acuity loss (filmy, cloudy, or curtain-like) or visual field loss  
**May be mild or dramatic  
**May be mild or dramatic
 
==Differential Diagnosis==
==Differential Diagnosis==
*[[Acute Vision Loss (Noninflamed)]]
{{Acute vision loss noninflamed DDX}}
*[[Acute Onset Flashers and Floaters]]
 
{{Acute onset flashers and floaters DDX}}


==Diagnosis==
==Evaluation==
[[File:RetinalDetachment.jpeg|thumbnail]]
[[File:RetinalDetachment.jpeg|thumbnail]]
*Examination  
*Examination  
**Visual acuity and visual fields  
**Visual acuity and visual fields  
**Fundoscopic exam with dilation
**Fundoscopic exam with dilation
*[[Ultrasound: Ocular|Ultrasound]]
**On fundoscopy, elevated retina will appear hazy gray and out of focus
*Ocular POCUS (LR+ 12, LR– 0.27)<ref>Kim DJ, Francispragasam M, Docherty G, et al. Test Characteristics of Point-of-care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department. Acad Emerg Med. 2019;26(1):16-22.</ref>
**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<ref>Gariano RF and Kim CH. Evaluation and Management of Suspected Retinal Detachment. Am Fam Physician. 2004 Apr 1;69(7):1691-1699.</ref>:
****Superior detachment may have inferior visual field defect
****Temporal detachment may have nasal visual field defect


==Treatment==
==Disposition==
*Urgent ophtho referral within 24hr
*Most likely admit vs same-day (immediate) referral to retinal surgeon (minutes may matter)
*In macular off retinal detachment, visual acute is significantly decreased if reattachment does not occur within 6 days. <ref>Diederen R et al: Scleral buckling surgery after macula-off retinal detachment: Worse visual outcome after more than 6 days. Ophthalmology 2007; 114:705-709</ref>


==See Also==
==See Also==
*[[Acute Onset Flashers and Floaters]]
*[[Acute Onset Flashers and Floaters]]
*[[Ocular ultrasound]]


==Source==
==References==
<references/>
<references/>


[[Category:Ophtho]]
[[Category:Ophthalmology]]

Revision as of 07:36, 15 June 2019

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

Evaluation

RetinalDetachment.jpeg
  • Examination
    • Visual acuity and visual fields
    • Fundoscopic exam with dilation
    • On fundoscopy, elevated retina will appear hazy gray and out of focus
  • Ocular POCUS (LR+ 12, LR– 0.27)[1]
    • 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[2]:
        • 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. Kim DJ, Francispragasam M, Docherty G, et al. Test Characteristics of Point-of-care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department. Acad Emerg Med. 2019;26(1):16-22.
  2. Gariano RF and Kim CH. Evaluation and Management of Suspected Retinal Detachment. Am Fam Physician. 2004 Apr 1;69(7):1691-1699.