Retinal detachment

Background

Retinal detachement

• 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
• Fundoscopic exam with dilation
  • On fundoscopy, elevated retina will appear hazy gray and out of focus

Differential Diagnosis

Acute Vision Loss (Noninflamed)

• Painful
  • Arteritic anterior ischemic optic neuropathy
  • Optic neuritis
  • Temporal arteritis^†
• Painless
  • Amaurosis fugax
  • Central retinal artery occlusion (CRAO)^†
  • Central retinal vein occlusion (CRVO)^†
  • High altitude retinopathy
  • Open-angle glaucoma
  • Posterior reversible encephalopathy syndrome (PRES)
  • Retinal detachment^†
  • Stroke^†
  • Vitreous hemorrhage
  • Traumatic optic neuropathy (although may have pain from the trauma)

^†Emergent Diagnosis

Acute onset flashers and floaters

• Ocular causes
  • Floaters and/or flashes
    • Posterior vitreous detachment
    • Retinal tear or retinal detachment
    • Posterior uveitis
  • Predominantly floaters
    • Vitreous hemorrhage secondary to proliferative retinopathy
    • Sympathetic ophthalmia
  • Predominantly flashes
    • Oculodigital stimulation
    • Rapid eye movements
    • Neovascular age-related macular degeneration
• Nonocular causes
  • Migraine aura (classic)
  • Migraine aura (acephalgicmigraine)
  • Occipital lobe disorders
  • Postural hypotension

Evaluation

• Ocular ultrasound (LR+ 12, LR– 0.27)
  • Generally remains anchored to the optic disc in most posterior section of the eye
  • Appears as a hyperechoic membrane floating in the vitreous chamber
• There are many studies out there confirming high sensitivity/specificity, recent study showing 94% sensitive/96% specific when performed by radiology and 92% sensitive/91% specific when performed by emergency providers

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:
      • 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

• Acute Onset Flashers and Floaters
• Ocular ultrasound