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 w/ neoplasm, inflammatory conditions, hypertension, preeclampsia
3. Tractional
   • Acquired fibrocellular bands in the vitrous contract and detach the retina
   • Associated w/ DM, sickle cell, trauma
4. Distinguish between mac-off and mac-on

• Other risk factors:
  • Aging
  • Previous retinal detachment
  • Family hx 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)

• 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
• Non-ocular causes
  • Intraocular foreign body
  • Migraine aura (classic)
  • Migraine aura (acephalgicmigraine)
  • Occipital lobe disorders
  • Postural hypotension

Diagnosis

• Examination
  • Visual acuity and visual fields
  • Fundoscopic exam with dilation
• Ultrasound

Treatment

• Urgent ophtho referral within 24hr
• Position pt relative to area of retinal detachment so retina lies flat:
  • Inferior detachment = elevate head up
  • Superior detachment = lay pt's head in supine position
• In macular off retinal detachment, visual acute is significantly decreased if reattachment does not occur within 6 days.

See Also

• Acute Onset Flashers and Floaters