Retinal detachment

Specialties > Ophthalmology

Background knowledge 🧠

Definition

Retinal detachment is the separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE).
This condition disrupts the retinal layer’s blood supply, leading to photoreceptor damage.
It is a medical emergency requiring prompt intervention to prevent vision loss.

Epidemiology

Annual incidence is approximately 1 in 10,000 people in the UK.
More common in individuals aged 50-75 years.
Higher risk in males and those with a history of myopia or cataract surgery.
Associated with trauma and a family history of retinal detachment.

Aetiology and Pathophysiology

Most commonly due to a retinal tear, which allows vitreous fluid to seep under the retina (rhegmatogenous).
Tractional detachment occurs due to fibrovascular tissue pulling on the retina, often seen in diabetic retinopathy.
Exudative detachment is caused by fluid accumulation without a retinal break, associated with inflammatory conditions or tumors.
Risk factors include myopia, trauma, and posterior vitreous detachment.

Types

Rhegmatogenous: Most common type, caused by a retinal tear.
Tractional: Caused by mechanical forces from fibrous tissue.
Exudative: Caused by fluid leakage from blood vessels.
Combined (tractional-rhegmatogenous): Occurs when both traction and a break are present.

Clinical Features 🌡️

Symptoms

Sudden onset of floaters, often described as spots, cobwebs, or flies.
Photopsia (flashes of light), particularly in peripheral vision.
A shadow or curtain over the visual field, usually starts peripherally and progresses centrally.
Visual field loss may be partial or complete depending on the extent of detachment.
Painless vision loss, which can be rapid and severe if the macula is involved.

Signs

Decreased visual acuity depending on macular involvement.
Relative afferent pupillary defect (RAPD) in severe cases.
Visualisation of the detached retina during ophthalmoscopy, often appears as a grey, wrinkled surface.
Retinal tears or holes may be visible.
Shafer’s sign (tobacco dust) may be present, indicating pigment cells in the vitreous.

Investigations 🧪

Tests

Slit-lamp examination with dilated fundoscopy is the primary diagnostic tool.
Indirect ophthalmoscopy may be required to visualise peripheral retina.
Optical coherence tomography (OCT) can be used to assess macular involvement.
B-scan ultrasonography is useful in cases with media opacities where the fundus is not clearly visible.

Management 🥼

Management

Urgent referral to ophthalmology for surgical intervention.
Surgical options include pneumatic retinopexy, scleral buckle, and vitrectomy depending on the case.
Laser photocoagulation or cryotherapy may be used to seal retinal tears.
Postoperative care includes positioning, avoiding strenuous activities, and regular follow-up.
Patients should be advised on the symptoms of recurrent detachment.

Complications

Proliferative vitreoretinopathy (PVR) leading to recurrent detachment.
Endophthalmitis, although rare, can occur postoperatively.
Cataract formation, especially after vitrectomy.
Persistent subretinal fluid, which may delay visual recovery.
Macular pucker formation, leading to distorted vision.

Prognosis

Prognosis is generally good if treated promptly, especially if the macula is not detached.
Visual outcomes depend on the duration of detachment and whether the macula was involved.
Recurrent detachment may occur in some cases, requiring further surgical intervention.
Long-term follow-up is essential to monitor for complications and recurrence.
Visual rehabilitation may be necessary for those with significant vision loss.

Key Points

Retinal detachment is an ophthalmic emergency requiring prompt diagnosis and treatment.
Early symptoms such as floaters and photopsia should be thoroughly investigated.
Surgical intervention is the mainstay of treatment, with options tailored to the type and extent of detachment.
Postoperative care and monitoring are crucial for preventing recurrence and managing complications.

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