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Retinal detachment
is separation of the neural retina from the underlying retinal pigment
epithelium. The most common cause is a retinal tear. Symptoms are
decreased peripheral or central vision, often described as a curtain
or dark cloud coming across the field of vision. Associated symptoms
can include painless vision disturbances, including flashing lights and
excessive floaters. Traction and serous retinal detachments cause
either central or peripheral vision loss. Diagnosis is by funduscopy; ultrasonography
may help determine the presence and type of retinal detachment if
it cannot be seen with funduscopy. Immediate treatment is imperative
if rhegmatogenous retinal detachment is acute and threatens central
vision. Treatment of rhegmatogenous detachment may include sealing
retinal holes (by laser, diathermy, or cryotherapy), supporting
the holes with scleral buckling, pneumatic retinopexy, and vitrectomy.
Etiology
There are three types of detachment: rhegmatogenous, which involves a retinal tear, and traction and serous (exudative) detachment, which do not involve a tear (nonrhegmatogenous).
Rhegmatogenous detachment is the most common. Risk factors include the following:
Traction retinal
detachment can be caused by vitreoretinal traction due to preretinal fibrous membranes as may occur in proliferative diabetic or sickle cell retinopathy.
Serous detachment results from transudation of fluid into the subretinal space. Causes include severe uveitis, especially in Vogt-Koyanagi-Harada syndrome, choroidal hemangiomas, and primary or metastatic choroidal tumors (see Retinal Disorders: Cancers Affecting the Retina).
Symptoms and Signs
Retinal detachment is painless. Early symptoms of rhegmatogenous detachment may include dark or irregular vitreous floaters (particularly in large numbers), flashes of light (photopsias), and blurred vision. As detachment progresses, the patient notices a curtain, veil, or grayness in the field of vision. If the macula is involved, central vision becomes poor. Patients may have simultaneous vitreous hemorrhage. Traction and exudative (serous) retinal detachments can cause blurriness of the vision, but they may not cause any symptoms in the early stages.
Diagnosis
Retinal detachment should be suspected in patients, particularly those at risk, who have any of the following:
Funduscopy will show the retinal detachment and can differentiate the subtypes of retinal detachment in nearly all cases. Direct funduscopy using a hand-held ophthalmoscope can miss some retinal detachments, which may be peripheral. Peripheral fundus examination, with either indirect ophthalmoscopy with scleral depression or with a three-mirror lens, should be performed.
If vitreous hemorrhage (which may be from a retinal tear), cataract, corneal opacification, or traumatic injury obscures the retina, retinal detachment should be suspected and B-scan ultrasonography performed.
Treatment
Although often localized, retinal detachments due to retinal tears can expand to involve the entire retina if not treated promptly. Any patient with
a suspected or established retinal detachment should be examined
urgently by an ophthalmologist.
Rhegmatogenous detachment is treated with one or more methods, depending on the cause and location of the lesion. One method involves sealing the retinal holes by laser, diathermy, or cryotherapy. The eye may be treated by scleral buckling (which indents the sclera, pushing the retina inward and thereby relieving vitreous traction on the retina), during which fluid may be drained from the subretinal space. Pneumatic retinopexy (intravitreal injection of gas) and vitrectomy are other treatments. Retinal tears without detachment can be sealed by laser photocoagulation or transconjunctival cryopexy. Nearly all rhegmatogenous detachments can be reattached surgically.
Nonrhegmatogenous
detachments due to vitreoretinal traction may be treated by surgical vitrectomy; transudative detachments due to uveitis may respond to systemic corticosteroids, systemic steroid-sparing drugs (eg, methotrexate , azathioprine , anti-tumor necrosis factor drugs), or a slow-release corticosteroid implant, which is surgically implanted into the eye. Primary and metastatic choroidal cancers also require treatment. Choroidal hemangiomas may respond to localized photocoagulation.
Last full review/revision December 2008 by Sunir J. Garg, MD
Content last modified December 2008
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