Retinal Detachment

Retinal detachment is separation of the neural retinal layer from the underlying retinal pigment epithelium layer. Symptoms are decreased peripheral or central vision, often described in the acute phase as a curtain coming down. Patients may have painless vision disturbances, including flashes of light and numerous floaters. Diagnosis is by indirect funduscopy. Prognosis is good if patients are treated before the macula detaches. Treatment involves correction of the cause and surgery to reattach the retina; if central vision is threatened, surgery must be done immediately.

The most common type of retinal detachment in the elderly is rhegmatogenous retinal detachment, which is caused by liquefied vitreous passing through a retinal break into the potential space between the sensory retina and retinal pigment epithelium. Risk factors include myopia and a history of cataract surgery or ocular trauma.

Nonrhegmatogenous detachment (detachment without a retinal tear) can be caused by vitreoretinal traction (which may be due to proliferative diabetic retinopathy or sickle cell disease) or by transudation of fluid into the subretinal space (which may be due to severe uveitis, especially in Vogt-Koyanagi-Harada syndrome, or to primary or metastatic choroidal tumors).

Symptoms and Signs

Retinal detachment is painless. Early symptoms may include dark or irregular vitreous floaters, flashes of light, and blurred vision. As detachment progresses, patients notice a curtain or veil in the field of vision. If the macula detaches, central visual acuity decreases drastically.

Diagnosis

Diagnosis is by indirect funduscopy with scleral depression. This technique is used to check the peripheral retina for tears and detachment; the sclera is pushed in to bring the peripheral retina into view. Findings may include a bullous retinal elevation with darkened blood vessels, usually a retinal break in the peripheral retina, and occasionally vitreous hemorrhage. Slit-lamp examination may show pigmented cells in the anterior segment or vitreous cavity.

If vitreous hemorrhage from a retinal tear obscures the retina, retinal detachment should be suspected, and B-scan ultrasonography should be done.

Prognosis

Prognosis is good if treatment is done before the macula detaches.

Treatment

Treatment varies by detachment type; any patients with suspected or confirmed retinal detachment should be seen immediately by an ophthalmologist. If central vision is threatened, surgery must be done immediately to reattach the retina.

For rhegmatogenous detachment, a laser, diathermy, or cryotherapy is used to seal the retinal holes. Scleral buckling may be used; during this procedure, fluid may be drained from the subretinal space. Anterior retinal tears without detachment can be sealed by transconjunctival cryopexy; posterior tears can be sealed by photocoagulation. Most (> 90%) rhegmatogenous detachments can be reattached surgically. For simple detachments with tears in the superior 2/3 of the eye, treatment is pneumatic retinopexy, an in-office procedure.

For nonrhegmatogenous detachments caused by vitreoretinal traction, surgical vitrectomy may be done. Transudative detachments caused by uveitis may respond to systemic corticosteroids. Primary choroidal tumors (malignant melanomas) are treated with proton beam radiation therapy but may require enucleation. Choroidal hemangiomas may respond to localized photocoagulation. Metastatic choroidal tumors, most often from the breast, lung, or GI tract, may respond well to radiation therapy.

This topic was last updated May 2006.