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Ocular System

Retinal detachment (RD)

Separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE).

Retinal detachment is a separation of the neurosensory retina from the underlying retinal pigment epithelium and choroid | Jorge Muniz, Medcomic

Separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE).

Classification

Rhegmatogenous retinal detachment (RRD) (M/C form):

Retinal “break” allows the ingress of fluid from the vitreous cavity to the subretinal space, resulting in retinal separation
  • Axial myopia
  • Post cataract surgery (aphakia/pseudophakia)
  • Yag laser capsulotomy
  • Lattice degeneration of the retina
  • Symptomatic (flashes/floaters) retinal tears.
  • Ocular trauma
  • Family history

Tractional retinal detachment (TRD):

Due to pre-retinal membrane formation and scarring that pulls the retina from its attachment
  • Proliferative diabetic retinopathy (PDR)
  • Proliferative vitreoretinopathy
  • Retinopathy of prematurity (ROP)
  • Eales’s disease
  • Sickle cell retinopathy
  • Trauma

Exudative/serous retinal detachments:

Subretinal fluid in absence of tear/traction
  • Inflammatory (uveitis, scleritis)
  • Hydrostatic (malignant hypertension, toxaemia of pregnancy)
  • Neoplastic (choroidal melanoma, haemangioma, metastasis)
  • Vascular (Coat’s disease, retinal macroaneurysm)
  • Maculopathy (neovascular macular degeneration, central serous choroidoretinopathy)
  • Congenital disorders (nanophthalmos, optic disc pit)

Presentation

  • Sudden, painless loss of vision
  • Field loss (loss of vision in only one part of the visual field)
  • Photopsia (perception of light not attributable to an incident light)
    • Not seen in exudative RD
  • Floaters (perception of mobile spots, lines, or haze due to vitreous opacities)
  • Mild discomfort and redness (d/t associated uveitis and hypotony)

Complications

  • Proliferative vitreoretinopathy (PVR): Long-standing retinal detachments start to develop scarring that can prevent re-attachment
  • Hypotony
  • Pigmentary glaucoma
  • New iris vessels
  • Cataract
  • Uveitis
Chronic retinal detachment with advanced PVR and large horse-shoe tear
Chronic retinal detachment with advanced PVR and large horse-shoe tear | Photo: Subhadra Jalali

Diagnosis

Binocular indirect ophthalmoscopy with scleral indentation:

  • Loss of red fundus reflex
  • Marked elevation of the retina
Shallow retinal detachment with traumatic dialysis
Shallow retinal detachment with traumatic dialysis misdiagnosed as serous macular detachment due to central serous retinopathy – can be managed by simple scleral buckling | Photo: Subhadra Jalali

Fundus examination:

Funduscopic appearance of rhegmatogenous retinal detachment: The patient noticed blurred vision in her left eye three days earlier. A sector of retina is attached superiorly; shallow retinal detachment over the macula and nasally appears pale and featureless owing to the masking of the choroidal pattern. The fovea appears dark against the pallor of detached macula, and the bullous retinal detachment inferiorly appears pale, opaque, and wrinkled. The detachment was caused by a single superotemporal retinal tear | Kang, H. K., & Luff, A. J. (2008). Management of retinal detachment: a guide for non-ophthalmologists. BMJ (Clinical research ed.), 336(7655), 1235–1240. https://doi.org/10.1136/bmj.39581.525532.47

Management

If the retina is not re-attached promptly (usually less than a week after macular detachment), then visual recovery is progressively affected.

Scleral buckling:

For uncomplicated forms of retinal detachment

Vitrectomy:

For complicated retinal detachments such as those with PVR, giant retinal tears, coloboma choroid, penetrating ocular trauma, etc
Surgery for retinal detachment: A—in scleral buckle surgery, the retinal break is treated with cryotherapy or laser therapy, and an explant (usually a silicone band or strip) is sutured on the outer surface of the sclera to indent the wall of the globe. This interrupts the flow of fluid through the break, allowing it to close. Subretinal fluid is drained through a small sclerotomy or left to be absorbed into the choroid. B—the vitrectomy approach involves removing the vitreous through sclerotomies made in the pars plana. Subretinal fluid is drained internally, and laser therapy or cryotherapy is applied around the flattened retinal break. The vitreous cavity is filled with a tamponade (usually gas but occasionally silicone oil) to hold the retina in place while scarring develops around the break. In some cases, pneumatic retinopexy may be less invasive: a bubble of gas is injected into the vitreous cavity, and the patient’s head is positioned to place the bubble on the retinal break; once the retina is flattened, the break can be treated with laser therapy or cryotherapy | Kang, H. K., & Luff, A. J. (2008). Management of retinal detachment: a guide for non-ophthalmologists. BMJ (Clinical research ed.), 336(7655), 1235–1240. https://doi.org/10.1136/bmj.39581.525532.47

Pneumatic retinopexy:

RD sealed with air insufflation
  • Sulfur hexafluoride

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