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 | #*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 | #*Associated with [[DM]], [[sickle cell]], [[facial trauma|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 | *[[vision loss|Visual acuity loss]] (filmy, cloudy, or curtain-like) or [[visual field defects|visual field]] loss | ||
**May be mild or dramatic | **May be mild or dramatic | ||
*[[Fundoscopic exam]] with dilation | |||
**On fundoscopy, elevated retina will appear hazy gray and out of focus | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Acute vision loss noninflamed DDX}} | |||
{{Acute onset flashers and floaters DDX}} | {{Acute onset flashers and floaters DDX}} | ||
== | ==Evaluation== | ||
[[File:RetinalDetachment.jpeg|thumbnail]] | [[File:RetinalDetachment.jpeg|thumbnail]] | ||
* | *[[Ocular ultrasound]] (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 | ||
*[[ | *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<ref>Point-of-care ocular ultrasound for the diagnosis of retinal detachment: a systematic review and meta-analysis Gottlieb M, Holladay D, Peksa GD. Acad Emerg Med. 2019;26(8):931-939.</ref> | ||
==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 | |||
== | ==Disposition== | ||
* | *Most likely admit vs same-day (immediate) referral to retinal surgeon (minutes may matter) | ||
==See Also== | ==See Also== | ||
*[[Acute Onset Flashers and Floaters]] | *[[Acute Onset Flashers and Floaters]] | ||
*[[Ocular ultrasound]] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Ophthalmology]] | ||
Latest revision as of 19:48, 20 February 2020
Background
- Average age of onset ~55
Types
- 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
- As vitreous separates from retina the traction creates a hole in retina
- Exudative
- Fluid accumulates beneath the retina without a retinal tear
- Associated with neoplasm, inflammatory conditions, hypertension, preeclampsia
- Tractional
- Acquired fibrocellular bands in the vitrous contract and detach the retina
- Associated with DM, sickle cell, trauma
- 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
- Floaters and/or flashes
- Non-ocular causes
- Intraocular foreign body
- Migraine aura (classic)
- Migraine aura (acephalgicmigraine)
- Occipital lobe disorders
- Postural hypotension
Evaluation
- Ocular ultrasound (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
- 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[2]
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[3]:
- 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
- ↑ 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.
- ↑ Point-of-care ocular ultrasound for the diagnosis of retinal detachment: a systematic review and meta-analysis Gottlieb M, Holladay D, Peksa GD. Acad Emerg Med. 2019;26(8):931-939.
- ↑ Gariano RF and Kim CH. Evaluation and Management of Suspected Retinal Detachment. Am Fam Physician. 2004 Apr 1;69(7):1691-1699.