Retinal Detachment

Definition

Retinal detachment (RD) is the separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE). This separation deprives the photoreceptors of their metabolic support, making it a surgical emergency — time to treatment directly determines visual outcome.

Types

Type	Mechanism	Common Causes
Rhegmatogenous	Retinal break (hole/tear/flap) allows liquefied vitreous into the subretinal space	Myopia, trauma, cataract surgery, lattice degeneration
Tractional	Fibrovascular membranes pull the retina away without a break	Proliferative diabetic retinopathy, sickle cell, ROP
Exudative (serous)	Fluid accumulates beneath the retina without a break or traction	Malignant hypertension, choroidal tumors, uveitis, Vogt-Koyanagi-Harada

Rhegmatogenous RD is the most common type.

Pathophysiology (Rhegmatogenous)

As described in Harrison's Principles of Internal Medicine (p. 966):

A hole, flap, or tear develops — often in areas of lattice degeneration (peripheral retinal thinning)
Liquefied vitreous enters the subretinal space through the break
Vitreous traction on the retinal surface + hydrostatic pressure behind the retina drive progressive detachment
If the fovea becomes involved, central vision is acutely threatened

Risk Factors

High myopia (elongated axial length, predisposes to lattice degeneration)
Prior cataract extraction (posterior capsule rupture, vitreous loss)
Ocular trauma
Family history of RD
Posterior vitreous detachment (PVD) — especially if symptomatic with floaters/flashes
Age > 50

Clinical Presentation

Symptom	Significance
Floaters (new or sudden increase)	Vitreous syneresis or hemorrhage from a retinal tear
Photopsia (flashing lights)	Vitreoretinal traction stimulating photoreceptors
Curtain/shadow in peripheral vision	Detached retina casting a scotoma
Sudden painless vision loss	Foveal detachment — urgent
Afferent pupillary defect (APD)	Extensive detachment involving the macula

Pain is notably absent — this distinguishes RD from acute angle-closure glaucoma.

Imaging

B-scan ultrasound (left) showing a V-shaped echogenic membrane tethered to the optic nerve head, and fundus photography (right) showing pale, elevated, corrugated retina with distorted vessels

B-scan ocular ultrasound (left) demonstrating the classic V-shaped membrane anchored at the optic disc — characteristic of total/subtotal RD. Fundus photography (right) showing pale, elevated, corrugated retina with distorted vessels, contrasting with the normal flat orange-red appearance.

Diagnostic modalities

Dilated fundoscopy — gold standard for confirming the diagnosis (Harrison's, p. 966); reveals the elevated, corrugated retina and visible break(s)
B-scan ultrasonography — essential when media opacity (e.g., vitreous hemorrhage, dense cataract) prevents fundoscopic visualization; shows the classic V-shaped echogenic membrane tethered to the optic nerve
OCT (optical coherence tomography) — useful for macular-off vs. macular-on determination and post-op monitoring
Indirect ophthalmoscopy with scleral depression — identifies peripheral breaks

Management

RD is a surgical emergency. Management depends on type and extent.

Rhegmatogenous RD

Procedure	Indication
Pneumatic retinopexy	Single superior break, phakic/pseudophakic, no significant PVR
Scleral buckle	Young phakic patients, inferior breaks, multiple breaks
Pars plana vitrectomy (PPV)	Complex cases, posterior breaks, vitreous hemorrhage, PVR, pseudophakic
Laser photocoagulation / cryotherapy	Treat retinal breaks before RD develops; adjunct to surgery

Macular-on RD = urgent surgery within hours to days (preserve central vision)
Macular-off RD = emergent surgery; even 1-week delay worsens prognosis

Tractional RD

Treat underlying disease (e.g., anti-VEGF + vitrectomy for proliferative diabetic retinopathy)

Exudative RD

Treat the underlying cause (BP control, steroids for uveitis, radiation/resection for tumors)

Complications

Proliferative vitreoretinopathy (PVR) — most common cause of surgical failure; fibrous membranes cause re-detachment
Macular pucker / epiretinal membrane
Persistent subretinal fluid
Permanent vision loss if untreated

Prognosis

Macular-on RD: >90% achieve good visual acuity with timely surgery
Macular-off RD: ~40–75% recover reading vision; recovery can continue for up to 2 years
Re-detachment rate: ~5–10% after primary repair

Key Differentials

Condition	Distinguishing Feature
Posterior vitreous detachment (PVD)	Floaters/flashes without curtain; Weiss ring visible; retina attached
Vitreous hemorrhage	Dense floaters, red haze; no scotoma; retina may be attached
Retinoschisis	Smooth, convex elevation; no breaks (usually); stable
Choroidal detachment	Post-op or hypotony context; extends further anteriorly

Harrison's Principles of Internal Medicine, 21st Ed., p. 966

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