Achieve Mastery of Medical Concepts

Study for medical school and boards with Lecturio

Retinal Detachment

Retinal detachment is the separation of the neurosensory retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy from the retinal pigmented epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology and choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy. Rhegmatogenous retinal detachment, the most common type, stems from a break in the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy, allowing fluid to accumulate in the subretinal space. In the setting of an intact retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy, detachment occurs when the vitreous pulls on the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy (traction) or when an underlying condition leads to increased leakage of fluid (exudative). Symptoms of photopsia Photopsia Chorioretinitis, floaters Floaters Chorioretinitis, and visual defects can present over hours or gradually over weeks. Retinal detachment with visual loss is an emergency. Once macular detachment occurs, visual prognosis Prognosis A prediction of the probable outcome of a disease based on a individual's condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is poor. Symptomatic rhegmatogenous retinal detachment with intact central acuity warrants urgent surgery. For non-rhegmatogenous retinal detachments, treatment is directed toward the primary process.

Last updated: 15 Sep, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Retinal detachment is the separation of the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy from the underlying retinal pigment epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology and choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy.

Anatomy

Retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy:

  • Innermost layer, containing photoreceptors that convert light stimuli Light Stimuli Pupil: Physiology and Abnormalities into nervous impulses
  • Optic retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy
    • Neural or neurosensory layer 
      • Contains the photoreceptor cells 
      • Ends anteriorly along the ora serrata
    • Outer pigmented cell layer or retinal pigment epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology (RPE) 
      • Attached to the choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy
      • Single layer of melanin Melanin Insoluble polymers of tyrosine derivatives found in and causing darkness in skin (skin pigmentation), hair, and feathers providing protection against sunburn induced by sunlight. Carotenes contribute yellow and red coloration. Seborrheic Keratosis-containing cells that absorb light and reduce the light scatter within the eye
  • Non-visual retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy: anterior continuation of pigment cell layer over the ciliary body Ciliary body A ring of tissue extending from the scleral spur to the ora serrata of the retina. It consists of the uveal portion and the epithelial portion. The ciliary muscle is in the uveal portion and the ciliary processes are in the epithelial portion. Eye: Anatomy and posterior surface of the iris Iris The most anterior portion of the uveal layer, separating the anterior chamber from the posterior. It consists of two layers – the stroma and the pigmented epithelium. Color of the iris depends on the amount of melanin in the stroma on reflection from the pigmented epithelium. Eye: Anatomy 
  • Macula Macula An oval area in the retina, 3 to 5 mm in diameter, usually located temporal to the posterior pole of the eye and slightly below the level of the optic disk. It is characterized by the presence of a yellow pigment diffusely permeating the inner layers, contains the fovea centralis in its center, and provides the best phototropic visual acuity. It is devoid of retinal blood vessels, except in its periphery, and receives nourishment from the choriocapillaris of the choroid. Eye: Anatomy 
    • Center of the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy 
    • Contains the fovea Fovea An area approximately 1. 5 millimeters in diameter within the macula lutea where the retina thins out greatly because of the oblique shifting of all layers except the pigment epithelium layer. It includes the sloping walls of the fovea (clivus) and contains a few rods in its periphery. In its center (foveola) are the cones most adapted to yield high visual acuity, each cone being connected to only one ganglion cell. Eye: Anatomy, which holds the highest density of cone cells
Eye anatomy

Anatomy of the human eye

Image by Lecturio.
Components uvea and general structure of the eye

Left: the components of the innermost, neural, and sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology layers of the eye
Right: general structure of the eye

Image by Lecturio.

Epidemiology

  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: 1 in 10,000
  • Men > women
  • Increased risk in Southeast Asians (related to higher risk of myopia Myopia Refractive Errors)

Categories and Risk Factors

Rhegmatogenous retinal detachment

  • Most common
  • A tear, break, or hole occurs in the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy.
  • Risk factors:
    • Posterior vitreous detachment 
    • Lattice degeneration or abnormal thinning of the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy
    • Pathologic myopia Myopia Refractive Errors
    • Enclosed ora bays
    • Meridional folds
    • Cataract Cataract Partial or complete opacity on or in the lens or capsule of one or both eyes, impairing vision or causing blindness. The many kinds of cataract are classified by their morphology (size, shape, location) or etiology (cause and time of occurrence). Neurofibromatosis Type 2 surgery
    • Trauma
    • Previous retinal detachment of the other eye
    • Marfan’s syndrome
    • Cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus (CMV) retinitis
    • Retinoschisis
    • Family history Family History Adult Health Maintenance of retinal detachment

Non-rhegmatogenous retinal detachment

  • Does not include a break in the neurosensory retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy
  • Types:
    • Traction retinal detachment: involves proliferative membranes on the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy or vitreous
    • Exudative (serous) retinal detachment: related to fluid entering the subretinal space
  • Risk factors for traction retinal detachment:
  • Risk factors for exudative retinal detachment:
    • Tumors:
      • Primary ocular tumors
      • Ocular metastases
    • Ocular diseases:
      • Sympathetic ophthalmia Sympathetic Ophthalmia Diseases of the Uvea
      • Central serous chorioretinopathy
      • Polypoidal choroidal vasculopathy
      • Optic nerve Optic nerve The 2nd cranial nerve which conveys visual information from the retina to the brain. The nerve carries the axons of the retinal ganglion cells which sort at the optic chiasm and continue via the optic tracts to the brain. The largest projection is to the lateral geniculate nuclei; other targets include the superior colliculi and the suprachiasmatic nuclei. Though known as the second cranial nerve, it is considered part of the central nervous system. The 12 Cranial Nerves: Overview and Functions pit
      • Acute retinal necrosis Acute Retinal Necrosis Herpes Zoster (Shingles)
      • Coats’ disease
    • Systemic diseases or conditions:
      • Sarcoidosis Sarcoidosis Sarcoidosis is a multisystem inflammatory disease that causes noncaseating granulomas. The exact etiology is unknown. Sarcoidosis usually affects the lungs and thoracic lymph nodes, but it can also affect almost every system in the body, including the skin, heart, and eyes, most commonly. Sarcoidosis
      • Syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis
      • Toxoplasmosis Toxoplasmosis Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host’s immune status. Toxoplasma/Toxoplasmosis
      • Tuberculosis Tuberculosis Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis
      • Corticosteroid therapy
      • Vogt-Koyanagi-Harada syndrome
      • Pre- eclampsia Eclampsia Onset of hyperreflexia; seizures; or coma in a previously diagnosed pre-eclamptic patient (pre-eclampsia). Hypertensive Pregnancy Disorders, eclampsia Eclampsia Onset of hyperreflexia; seizures; or coma in a previously diagnosed pre-eclamptic patient (pre-eclampsia). Hypertensive Pregnancy Disorders, uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or “uncontrolled” hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension
      • Organ transplantation Organ Transplantation Transplantation is a procedure that involves the removal of an organ or living tissue and placing it into a different part of the body or into a different person. Organ transplantations have become the therapeutic option of choice for many individuals with end-stage organ failure. Organ Transplantation

Pathophysiology

Precursors of retinal detachment

  • Posterior vitreous detachment
    • The vitreous slowly shrinks (vitreous degeneration) and pulls on fibrils connecting the vitreous to the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy.
    • More common in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship > 70 years
    • Also occurs in myopia Myopia Refractive Errors, ocular trauma Ocular Trauma Cataracts in Children, and ocular inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
    • Leads to:
      • Rhegmatogenous detachment by causing a retinal tear or hole
      • Traction detachment when vitreous is strongly attached to the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy
  • Retinal breaks
    • Discontinuity in the neurosensory retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy
    • Presents as a retinal hole (round) or tear (horseshoe-shaped)
    • Allows liquid vitreous fluid to pass through and accumulate in the subretinal space
    • Associated with rhegmatogenous retinal detachment
Retinal detachment

The image shows a retinal break (tear) where fluid can enter the subretinal space.

Image by Lecturio.

Rhegmatogenous retinal detachment

  • Retinal holes or tears allow fluid to enter the subretinal space and separate the neural retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy from the RPE.
  • Detachment can occur over hours to months.

Non-rhegmatogenous retinal detachment

  • Tractional retinal detachment:
    • Proliferative membranes pull on the neurosensory retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy, separating it from the retinal pigment epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology.
    • Associated with diseases leading to neovascularization (e.g., diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, retinopathy Retinopathy Degenerative changes to the retina due to hypertension. Alport Syndrome of prematurity Prematurity Neonatal Respiratory Distress Syndrome)
  • Exudative retinal detachment:
    • Impaired outflow of fluid from the vitreous to the choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy or change in the vascular permeability in the affected region → serous or hemorrhagic fluid accumulation
    • Caused by: 
      • Hydrostatic factors (e.g., severe acute hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension)
      • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation (e.g., sarcoid uveitis Uveitis Uveitis is the inflammation of the uvea, the pigmented middle layer of the eye, which comprises the iris, ciliary body, and choroid. The condition is categorized based on the site of disease; anterior uveitis is the most common. Diseases of the Uvea)
      • Large lesion or neoplasm causing effusions

Sequela of retinal detachment

  • Separation of the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy from the choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy → loss of blood supply → ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage → rapid and progressive photoreceptor degeneration 
  • When central retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy is involved → loss of vision Vision Ophthalmic Exam

Clinical Presentation

Initial symptoms

  • Photopsia Photopsia Chorioretinitis:
    • Flashes of light, sometimes associated with eye movement
    • Effect of mechanical depolarization Depolarization Membrane Potential of the axons Axons Nerve fibers that are capable of rapidly conducting impulses away from the neuron cell body. Nervous System: Histology in the nerve fiber layer of the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy, brought about by vitreoretinal traction
    • Not commonly seen in exudative retinal detachment
  • Floaters Floaters Chorioretinitis:
    • When the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy tears, RPE cells and blood go to the vitreous cavity → “ floaters Floaters Chorioretinitis
    • When vitreous detaches from the annular Annular Dermatologic Examination ring around the optic nerve Optic nerve The 2nd cranial nerve which conveys visual information from the retina to the brain. The nerve carries the axons of the retinal ganglion cells which sort at the optic chiasm and continue via the optic tracts to the brain. The largest projection is to the lateral geniculate nuclei; other targets include the superior colliculi and the suprachiasmatic nuclei. Though known as the second cranial nerve, it is considered part of the central nervous system. The 12 Cranial Nerves: Overview and Functions → large circular floater or Weiss ring 
    • Retinal separation disrupts a blood vessel and leads to vitreous hemorrhage Vitreous Hemorrhage Hemorrhage into the vitreous body. Diseases of the Vitreous Body → “shower of black spots”
    • After the black spots appear, irregular clots form → “cobwebs”

Progression to retinal detachment

  • Onset:
    • Small retinal tears: progress slowly (weeks to months)
    • Large tears: progress over days
    • Non-rhegmatogenous detachment: takes weeks to months
  • Localized or peripheral detachment:
  • Extensive detachment or macular detachment:
    • Sudden painless loss of vision Vision Ophthalmic Exam (“descending curtain”): an emergency!
    • Detachment involving the macula Macula An oval area in the retina, 3 to 5 mm in diameter, usually located temporal to the posterior pole of the eye and slightly below the level of the optic disk. It is characterized by the presence of a yellow pigment diffusely permeating the inner layers, contains the fovea centralis in its center, and provides the best phototropic visual acuity. It is devoid of retinal blood vessels, except in its periphery, and receives nourishment from the choriocapillaris of the choroid. Eye: Anatomy: ↑ risk of permanent visual loss 
    • Relative afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology pupillary defect (RAPD); indicative of death of the photoreceptors
Table: Overview of symptoms and their causes
Symptom Cause
Photopsia Photopsia Chorioretinitis Vitreoretinal traction
Floaters Floaters Chorioretinitis Vitreous cells, blood
Visual field Visual Field The Visual Pathway and Related Disorders loss or defect Peripheral detachment
Blurred vision Vision Ophthalmic Exam or loss of central vision Vision Ophthalmic Exam Macular detachment

Diagnosis

Initial assessment

  • History
  • Visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam test
  • Confrontational visual field Visual Field The Visual Pathway and Related Disorders test, which helps localize the lesion
  • Pupillary reaction (check for RAPD)

Ophthalmologic examination

  • Assess both eyes Both Eyes Refractive Errors: retinal detachment increases risk in the other eye
  • Dilated funduscopic examination and slit-lamp biomicroscopy 
    • Fundoscopy Fundoscopy Cranial Nerve Palsies: retinal tears and/or obvious detachment seen as gray, elevated retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy that undulate
    • Anterior segment examination: may show pigmented vitreous cells or “tobacco dust” (free-floating retinal pigment epithelial cells)
  • Ophthalmic B-scan ultrasound: 
    • Use in cases of non-diagnostic ophthalmologic exam
    • Detects detachment in dense vitreous hemorrhage Vitreous Hemorrhage Hemorrhage into the vitreous body. Diseases of the Vitreous Body (as this prevents a good fundoscopic view of the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy)

Management

Procedures

  • Laser (photocoagulation) retinopexy: use of laser to induce greater chorioretinal adhesion Adhesion The process whereby platelets adhere to something other than platelets, e.g., collagen; basement membrane; microfibrils; or other ‘foreign’ surfaces. Coagulation Studies
  • Cryoretinopexy: cryotherapy Cryotherapy A form of therapy consisting in the local or general use of cold. The selective destruction of tissue by extreme cold or freezing is cryosurgery. Chondrosarcoma applied to produce scarring Scarring Inflammation and retinal adhesion Adhesion The process whereby platelets adhere to something other than platelets, e.g., collagen; basement membrane; microfibrils; or other ‘foreign’ surfaces. Coagulation Studies 
  • Pneumatic retinopexy: in-office procedure utilizing cryoretinopexy and injection of intravitreal gas bubble to tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis the affected area
  • Scleral buckle:
    • Pliable silicone element sutured to the sclera Sclera The white, opaque, fibrous, outer tunic of the eyeball, covering it entirely excepting the segment covered anteriorly by the cornea. It is essentially avascular but contains apertures for vessels, lymphatics, and nerves. Eye: Anatomy to produce buckling (inward scleral indentation)
    • Brings the detached retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy in closer apposition to the eye wall, reduces internal vitreo-retinal traction, and closes the retinal breaks.
  • Vitrectomy: removal of vitreous and use of silicone oil or air bubble to replace the vitreous

Management considerations

  • Prevention:
    • Protective eyewear, especially in contact sports
    • Early diagnosis of posterior vitreous detachment and, when indicated, performance of vitrectomy
    • Treatment of retinal tears or holes to prevent retinal detachment: laser retinopexy or cryoretinopexy
  • Macular detachment: indicates poor visual prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas 
  • Complications of retinal detachment repair:
    • Proliferative retinopathy Retinopathy Degenerative changes to the retina due to hypertension. Alport Syndrome: most common cause of repair failure
    • Cataract Cataract Partial or complete opacity on or in the lens or capsule of one or both eyes, impairing vision or causing blindness. The many kinds of cataract are classified by their morphology (size, shape, location) or etiology (cause and time of occurrence). Neurofibromatosis Type 2 formation in vitrectomy

Treatment of rhegmatogenous retinal detachment

  • Symptomatic: 
    • For those with preserved central vision Vision Ophthalmic Exam acuity: Perform treatment within 24 hours (to prevent progression to macular detachment).
    • Small detachment: laser retinopexy or cryoretinopexy
    • Options for large detachment:
      • Pneumatic retinopexy
      • Scleral buckle placement
      • Vitrectomy
  • Asymptomatic:
    • Small lesions: consider laser or cryoretinopexy
    • Options for large lesions:
      • Laser retinopexy or cryoretinopexy
      • Scleral buckling
      • Vitrectomy
Scleral buckle

The image illustrates scleral buckling, the placement of a pliable silicone sutured to the sclera Sclera The white, opaque, fibrous, outer tunic of the eyeball, covering it entirely excepting the segment covered anteriorly by the cornea. It is essentially avascular but contains apertures for vessels, lymphatics, and nerves. Eye: Anatomy. Scleral buckling pushes the sclera Sclera The white, opaque, fibrous, outer tunic of the eyeball, covering it entirely excepting the segment covered anteriorly by the cornea. It is essentially avascular but contains apertures for vessels, lymphatics, and nerves. Eye: Anatomy inward, thereby keeping the separated structures closer and allowing the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy to reattach.

Image by Lecturio.

Treatment of non-rhegmatogenous retinal detachment

  • Tractional:
    • Treat underlying disease (e.g., diabetic retinopathy Diabetic retinopathy Disease of the retina as a complication of diabetes mellitus. It is characterized by the progressive microvascular complications, such as aneurysm, intraretinal edema, and intraocular pathologic neovascularization. Chronic Diabetic Complications)
    • Removal of tractional forces by vitrectomy (may be combined with scleral buckling)
  • Exudative:
    • Treat underlying disease process.
    • Malignancies may require enucleation.

Differential Diagnosis

  • Central retinal artery occlusion: occlusion of the central retinal artery, the main blood supply of the optic nerve, by an embolus or an atheroma. Patients usually present with sudden, painless, monocular visual loss. Funduscopic findings include retinal whitening with a “cherry-red” spot. Central retinal artery occlusion Retinal Artery Occlusion Retinal Vessel Occlusion is a medical emergency and visual recovery is dependent on immediate evaluation and treatment.
  • Retinoschisis: splitting Splitting Defense Mechanisms of the retina Retina The ten-layered nervous tissue membrane of the eye. It is continuous with the optic nerve and receives images of external objects and transmits visual impulses to the brain. Its outer surface is in contact with the choroid and the inner surface with the vitreous body. The outermost layer is pigmented, whereas the inner nine layers are transparent. Eye: Anatomy (usually in the outer plexiform layer) with development of 2 major layers. The congenital Congenital Chorioretinitis form (juvenile X-linked X-linked Genetic diseases that are linked to gene mutations on the X chromosome in humans or the X chromosome in other species. Included here are animal models of human X-linked diseases. Common Variable Immunodeficiency (CVID) recessive type) affects men more than women, while in acquired or senile retinoschisis, both men and women aged > 50 years are affected. Reduced visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam is the usual presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor of congenital Congenital Chorioretinitis retinoschisis. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with the acquired condition are usually asymptomatic. Can lead to retinal detachment, which is surgically treated.
  • Choroidal effusion: abnormal fluid accumulation in the suprachoroidal space (between the choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy and sclera Sclera The white, opaque, fibrous, outer tunic of the eyeball, covering it entirely excepting the segment covered anteriorly by the cornea. It is essentially avascular but contains apertures for vessels, lymphatics, and nerves. Eye: Anatomy). Choroidal effusion can result from glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma surgery or from trauma, infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease, and neoplasms Neoplasms New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. Benign Bone Tumors. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship can be asymptomatic when effusion is small; however, refractive changes, decreased vision Vision Ophthalmic Exam, and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways occur in larger effusions. Ophthalmic ultrasonography helps differentiate retinal detachment from choroidal effusion. Depending on the underlying pathology, management ranges from observation to surgical drainage.
  • Choroidal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast: can result from a benign Benign Fibroadenoma nevus Nevus Nevi (singular nevus), also known as “moles,” are benign neoplasms of the skin. Nevus is a non-specific medical term because it encompasses both congenital and acquired lesions, hyper- and hypopigmented lesions, and raised or flat lesions. Nevus/Nevi to malignant lesions such as melanomas. The choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy has abundant vascular supply, making it a common site of metastasis Metastasis The transfer of a neoplasm from one organ or part of the body to another remote from the primary site. Grading, Staging, and Metastasis of neoplasms Neoplasms New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. Benign Bone Tumors. Presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor can range from asymptomatic cases to blurry vision Vision Ophthalmic Exam. Ultrasonography helps in differentiating the various eye lesions. Treatment is directed toward the etiology of the mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast.
  • Suprachoroidal hemorrhage: bleeding between the choroid Choroid The thin, highly vascular membrane covering most of the posterior of the eye between the retina and sclera. Eye: Anatomy and sclera Sclera The white, opaque, fibrous, outer tunic of the eyeball, covering it entirely excepting the segment covered anteriorly by the cornea. It is essentially avascular but contains apertures for vessels, lymphatics, and nerves. Eye: Anatomy. The condition is rare, but can result from intraocular surgery. Risk factors include diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or “uncontrolled” hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension, and anticoagulation Anticoagulation Pulmonary Hypertension Drugs or antiplatelet medications. Suprachoroidal hemorrhage can occur intraoperatively or postoperatively. Symptoms include headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess, nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics, eye pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, and decreased visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam. Ultrasonography detects the extent and location of the bleeding. Management is aimed at reducing intraocular pressure Intraocular Pressure The pressure of the fluids in the eye. Ophthalmic Exam with control of the pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and bleeding.

References

  1. Arroyo, J., Gardiner, M. Givens, J. (2020) Retinal detachment. UpToDate. Retrieved 5 Oct 2020, from https://www.uptodate.com/contents/retinal-detachment?search=retinal%20detachment&source=search_result&selectedTitle=1~144&usage_type=default&display_rank=1#H11
  2. Blair, K., Czyz, C. (2020) Retinal detachment. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK551502/#_article-28444_s8_
  3. Gariano, R., Kim, C. (2004) Evaluation and Management. Medscape. Retrieved 7 Oct 2020, from https://emedicine.medscape.com/article/798501-overview

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details