Retinal detachment
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Here is a comprehensive overview of retinal detachment drawn from authoritative ophthalmology and medical references.
Retinal Detachment
Definition
A retinal detachment (RD) is a separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE). — Goldman-Cecil Medicine
Types
1. Rhegmatogenous RD (RRD) — Most Common
- Caused by a retinal break (tear or hole) that allows liquefied vitreous to seep under the neurosensory retina
- Nearly always requires concurrent vitreous liquefaction and traction — a break alone rarely causes detachment
- Affects ~1 in 10,000 per year; both eyes eventually affected in ~10% of patients
- Over 40% occur in myopic eyes — higher myopia = greater risk
- Also associated with posterior vitreous detachment (PVD), lattice degeneration, snail-track degeneration, prior cataract surgery, and laser capsulotomy
2. Tractional RD
- Caused by fibrocellular bands in the vitreous contracting and pulling the retina off
- Causes: proliferative diabetic retinopathy (most common), sickle cell retinopathy, retinopathy of prematurity, toxocariasis, trauma, proliferative vitreoretinopathy (PVR)
- Retina appears concave with a smooth surface; detachment rarely reaches the ora serrata; retina is immobile
3. Exudative (Serous) RD
- No break or traction — fluid accumulates under the retina due to breakdown of the blood-retinal barrier
- Causes: malignant hypertension, eclampsia of pregnancy, choroidal tumors, posterior scleritis, uveal effusion syndrome
- Generally resolves when the underlying cause is treated — no direct surgical intervention needed
Symptoms (RRD)
Classic premonitory symptoms (in ~60% of cases):
- Photopsia (flashing lights) — due to vitreoretinal traction from PVD
- Floaters — due to the causative vitreous detachment
- Curtain-like visual field defect — peripheral, progressing centrally; the quadrant of the field defect is in the opposite quadrant to the primary break
- Some patients note the field defect improves on waking (due to overnight SRF reabsorption) and worsens during the day
- Loss of central vision if the macula (fovea) becomes involved
Tractional RD may be asymptomatic or cause gradual visual field loss/visual decline.
Break Localization (Lincoff's Rules)
Distribution of breaks in eyes with RRD:
- 60% superotemporal
- 15% superonasal
- 15% inferotemporal
- 10% inferonasal
Subretinal fluid (SRF) spread can predict break location:
- Superior break → SRF first spreads inferiorly ipsilateral, then rises on opposite side
- 6 o'clock break → equal inferior fluid levels
- Bullous inferior RD → primary break usually above the horizontal meridian
- Superior nasal break → SRF revolves around the optic disc and rises on temporal side
Fundoscopic Appearance
Fresh RRD: Convex configuration, slightly opaque and corrugated (due to retinal edema), loss of underlying choroidal pattern
Wide-field fundus image of a rhegmatogenous retinal detachment — elevated, bullous, pale-green area in the superior quadrant. White dashed lines divide the fundus into quadrants; blue lines measure angular extent (α) from the optic disc for surgical planning.
Workup
- Dilated fundoscopy with indirect ophthalmoscopy + scleral depression of both eyes — identify all breaks
- Slit lamp with 90D or widefield lens — assess vitreous, peripheral retina
- B-scan ultrasound — if media opacity prevents fundus visualization (e.g., dense vitreous hemorrhage)
- OCT — useful in tractional RD to identify membranes and differentiate from other pathology
Differential Diagnosis
| Condition | Key Differentiating Feature |
|---|---|
| Retinoschisis | Bilateral, smooth, bullous, inferotemporal; no pigment cells in vitreous |
| Choroidal detachment | Brown, smooth, extends beyond ora serrata; limited posteriorly by vortex veins; low IOP |
| Uveal effusion syndrome | Idiopathic, bilateral; "leopard spot" RPE mottling after resolution |
Treatment
Urgency
- Macula-on RRD: Surgical emergency — repair as soon as possible; macula must be protected
- Macula-off RRD: Urgent but not emergent — visual outcomes comparable if surgery done within 7–10 days of onset
- Dense vitreous hemorrhage + RD on B-scan: Operate urgently
- Tractional RD: May observe if not threatening the macula; vitrectomy when indicated
- Exudative RD: Treat the underlying cause — usually no direct surgical intervention
Surgical Options
| Procedure | Description | Indications |
|---|---|---|
| Pneumatic retinopexy | Intravitreal gas bubble (SF6 or C3F8) + cryotherapy/laser to seal break; office-based | Uncomplicated RRD, single small break or cluster <2 clock hours, in upper 2/3 of retina |
| Scleral buckling | Silicone explant sutured to sclera creates inward indentation to close break and reduce traction | Preferred for post-traumatic dialysis; peripheral breaks; young patients |
| Pars plana vitrectomy (PPV) | Removal of vitreous, membrane peeling, fluid-gas exchange, laser/cryotherapy, tamponade | Complex RD, PVR, tractional RD, posterior breaks, failed prior repair |
Pre-op: Patient should fast if urgent surgery is planned; bed rest with head positioning so the break is most dependent reduces SRF.
TIP: Even if the macula is already off, surgery within 72 hours gives better visual results. — Kanski's Clinical Ophthalmology
Follow-Up
- Post-RRD repair: 1 day → 1 week → 1 month → 2–3 months → every 6–12 months
- Fellow eye must always be examined given ~10% bilateral risk
Sources: Kanski's Clinical Ophthalmology (10th ed.), The Wills Eye Manual, Goldman-Cecil Medicine, Robbins Pathology
Give retinal detachment for 10 marks
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Here is a structured, 10-mark postgraduate ophthalmology answer on retinal detachment.
Retinal Detachment — 10 Mark Answer
Definition
Retinal detachment (RD) is a separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE), with accumulation of subretinal fluid (SRF) in the potential subretinal space.
Classification
1. Rhegmatogenous RD (RRD) — Most Common
A retinal break (tear or hole) allows liquefied vitreous to pass into the subretinal space. Requires two concurrent conditions: a break and at least partial vitreous liquefaction with traction.
Risk factors:
- High myopia (>40% of all RRDs)
- Posterior vitreous detachment (PVD)
- Predisposing lesions: lattice degeneration, snail-track degeneration, atrophic round holes
- Aphakia/pseudophakia, vitreous loss at cataract surgery, laser capsulotomy
- Trauma (dialysis at ora serrata)
- Family history; fellow eye at ~10% risk
2. Tractional RD
Fibrocellular proliferative membranes contract and physically pull the retina off the RPE. No retinal break is present (unless combined TRD-RRD).
Causes: Proliferative diabetic retinopathy (most common), sickle cell retinopathy, retinopathy of prematurity, penetrating trauma, toxocariasis, proliferative vitreoretinopathy (PVR)
3. Exudative (Serous) RD
Breakdown of the blood-retinal barrier causes fluid accumulation under the retina without a break or traction.
Causes: Malignant hypertension, eclampsia of pregnancy, VKH disease, posterior scleritis, choroidal tumors, uveal effusion syndrome
Symptoms (RRD)
In ~60% of patients, classic premonitory symptoms accompany acute PVD:
- Photopsia — flashing lights from vitreoretinal traction
- Floaters — pigment cells or vitreous debris (including "tobacco dust" = Shafer's sign)
- Curtain-like visual field defect — appears in the opposite quadrant to the primary break
- Decreased central vision — if the macula (fovea) is involved
The quadrant of the field defect corresponds to the opposite quadrant of the primary break. Photopsia location does not predict break location.
Signs
Anterior segment:
- Mild iritis (common); severe iritis suggests Schwartz-Matsuo syndrome
- Reduced IOP (~5 mmHg lower than fellow eye); extremely low IOP suggests associated choroidal detachment
- Relative afferent pupillary defect (RAPD) in extensive RD
- Tobacco dust (Shafer's sign) — pigment cells in anterior vitreous; highly specific for RRD
Fundus — RRD:
- Fresh RD: Convex, corrugated, opaque appearance (retinal edema); elevated with loss of choroidal pattern
- Longstanding RD: Retinal atrophy, intraretinal cysts (after ~1 year), subretinal demarcation lines/pigment "tide marks" (after ~3 months)
- Breaks: Red discontinuities in the retinal surface (colour contrast with choroid); may be less visible in high myopia
Fundus — Tractional RD: Concave, smooth, immobile retina; does not extend to ora serrata; vitreous/epiretinal membranes visible
Break Localization — Modified Lincoff's Rules
| Configuration of SRF | Likely location of primary break |
|---|---|
| Shallow inferior RD, higher on temporal side | Inferior temporal |
| Equal inferior fluid levels | 6 o'clock |
| Bullous inferior RD | Above horizontal meridian |
| SRF crosses vertical midline above | Near 12 o'clock |
| Superior nasal break | SRF revolves around disc, rises temporally |
Break distribution: 60% superotemporal · 15% superonasal · 15% inferotemporal · 10% inferonasal. ~50% of RRDs have more than one break, often within 90° of each other.
Investigations
- Indirect ophthalmoscopy with scleral depression — both eyes; essential to identify all breaks
- Slit lamp + 90D/widefield lens — vitreous assessment, tobacco dust, posterior breaks
- B-scan ultrasound — when fundal view is obscured (dense vitreous haemorrhage, media opacity)
- OCT — useful in tractional membranes, macular status, sub-foveal fluid, and differentiating retinoschisis from RD
Differential Diagnosis
| Condition | Key Feature |
|---|---|
| Retinoschisis | Bilateral, smooth, bullous, inferotemporal; no pigment in vitreous; inner/outer layer holes |
| Choroidal detachment | Brown, extends beyond ora serrata, limited posteriorly by vortex veins; low IOP; no vitreous pigment |
| Uveal effusion syndrome | Idiopathic; "leopard spot" RPE mottling after resolution |
Treatment
Urgency
- Macula-on RRD — surgical emergency; operate as soon as possible
- Macula-off RRD — visual outcome does not significantly change if surgery within 7–10 days of onset
- Dense vitreous haemorrhage + RD on B-scan — urgent surgery
- Exudative RD — treat the underlying cause; direct surgery not usually needed
Surgical Options
1. Pneumatic Retinopexy
- Intravitreal gas bubble (SF₆ or C₃F₈) + cryotherapy or laser
- Office-based, minimally invasive
- Indication: Single small break or cluster <2 clock hours in the upper 2/3 of peripheral retina; uncomplicated RRD
- Limitation: Lower success rate than scleral buckling
2. Scleral Buckling (External Surgery)
- Silicone explant sutured to sclera creates an inward indentation to close the break and reduce vitreoretinal traction
- Configurations: radial, segmental, circumferential, or encircling
- Procedure: Peritomy → break localization → cryotherapy → explant sutured → subretinal fluid drainage if needed
- Indication: Peripheral breaks, post-traumatic dialysis, young phakic patients
- Complications: Diplopia, CME (~25%), epiretinal membrane (~15%), anterior segment ischaemia, buckle extrusion/infection, elevated IOP, choroidal detachment
3. Pars Plana Vitrectomy (PPV) — Internal Surgery
- 3-port approach (infusion + vitreous cutter + light probe via sclerotomies)
- Steps: Core vitrectomy → posterior hyaloid separation → membrane peeling → fluid-air/gas exchange → laser/cryopexy → tamponade
- Tamponade agents: Expanding gas (SF₆, C₃F₈) or silicone oil (for complex cases, PVR, inferior breaks)
- Indications: Posterior/giant breaks, PVR (Grade B or C), tractional RD, haemorrhage obscuring breaks, pseudophakic RD, failed scleral buckle
- For PVR: Membrane peeling ± ILM peeling ± relaxing retinotomy + long-acting tamponade
Proliferative Vitreoretinopathy (PVR) — Major Complication
Epiretinal and subretinal membrane formation causing fixed retinal folds and traction; occurs after surgery or penetrating injury.
| Grade | Features |
|---|---|
| A (minimal) | Diffuse vitreous haze, tobacco dust, pigment clumps inferior retina |
| B (moderate) | Inner surface wrinkling, rolled break edges, retinal stiffness, vascular tortuosity |
| C (marked) | Rigid full-thickness folds (star-shaped), funnel RD in advanced disease |
Management: PPV + membrane peeling ± ILM peeling ± relaxing retinotomy + silicone oil tamponade
Prognosis
- Macula-on RRD repaired promptly: good visual recovery (>6/12 in most)
- Macula-off RRD: Better visual outcomes if surgery within 72 hours; results further decline beyond 7–10 days
- PVR is the leading cause of surgical failure in RRD repair
Sources: Kanski's Clinical Ophthalmology 10th ed., The Wills Eye Manual, Goldman-Cecil Medicine
Rhegmatogenous Rd
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Here is a focused, postgraduate-level answer on Rhegmatogenous Retinal Detachment (RRD).
Rhegmatogenous Retinal Detachment (RRD)
Definition & Etymology
The term "rhegmatogenous" derives from the Greek rhegma = break. RRD is the most common form of retinal detachment, defined as separation of the neurosensory retina from the RPE caused by a full-thickness retinal break, through which liquefied vitreous passes into the subretinal space.
Epidemiology
- Incidence: ~1 in 10,000 per year
- Both eyes eventually affected in ~10%
- Peak age: 50–70 years (PVD-related); younger in high myopes and post-trauma
Pathogenesis
Two conditions must coexist:
- A full-thickness retinal break (tear or hole)
- Vitreous liquefaction (synchysis) + vitreoretinal traction
Without liquefaction and traction, a break alone will almost never cause detachment. Once these coexist, liquid vitreous flows through the break into the subretinal space, progressively separating the neurosensory retina from the RPE.
Types of Retinal Breaks
| Type | Mechanism | Appearance |
|---|---|---|
| Horseshoe (U-) tear | Vitreous traction avulses flap of retina | U-shaped, red, elevated flap — highest risk |
| Operculated hole | Flap completely torn off | Round hole with floating operculum |
| Atrophic round hole | Degeneration (e.g., lattice) | Small, round, no vitreous traction |
| Dialysis | Avulsion at ora serrata — blunt trauma | Circumferential tear; young males |
| Giant tear | ≥90° circumferential break | Large, rolled posterior flap |
| Macular hole | Posterior pole — in high myopia | Central hole with shallow SRF |
Risk Factors / Predisposing Lesions
Ocular:
- High myopia — >40% of all RRDs; elongated globe, vitreous degeneration, chorioretinal atrophy
- Posterior vitreous detachment (PVD) — the most common precipitant of horseshoe tears
- Lattice degeneration — present in ~8% of the population; found in ~40% of eyes with RRD. Areas of spindle-shaped retinal thinning with sclerosed vessels (white arborizing lines), exaggerated vitreous adhesions at margins → tractional tears on PVD
- Snailtrack degeneration — frost-like peripheral white areas; round holes common
- Aphakia/pseudophakia — especially with vitreous loss at surgery
- Trauma — dialysis at ora serrata
- Fellow eye — ~10% bilateral lifetime risk
Systemic:
- Marfan syndrome, Stickler syndrome (hereditary vitreoretinopathy)
- Family history
Symptoms
In ~60% of patients, premonitory symptoms occur with acute PVD:
- Photopsia (flashes) — traction on the retina; does not predict break location
- Floaters — vitreous debris or blood; a sudden "shower" of floaters suggests PVD with possible tear
- Curtain/shadow across visual field — field defect in the opposite quadrant to the primary break
- Lower field defect noticed sooner than upper; upper break → lower field curtain
- Some patients note relief on waking (overnight SRF absorption) that recurs later in day
- Loss of central vision — fovea involved by SRF, or large bullous RD obscuring visual axis
Signs
Anterior Segment
| Sign | Significance |
|---|---|
| Tobacco dust / Shafer's sign — pigment cells in anterior vitreous | Highly specific for RRD; virtually pathognomonic |
| Reduced IOP (~5 mmHg below fellow eye) | Increased RPE fluid pumping |
| Very low IOP | Associated choroidal detachment |
| Raised IOP + mild uveitis | Schwartz-Matsuo syndrome — photoreceptor outer segments clog trabecular meshwork; resolves with RD repair |
| Mild iritis | Common; do not overlook underlying RD |
| RAPD (Marcus Gunn pupil) | Extensive RD |
Fundus — Fresh RRD
- Convex, corrugated, slightly opaque retinal elevation (retinal edema)
- Loss of underlying choroidal pattern
- Retinal blood vessels appear darker and tortuous over detached area
- Retinal break: red discontinuity (colour contrast with choroid); less visible in high myopia
Fundus — Longstanding RRD
- Intraretinal cysts — develop after ~1 year
- Subretinal demarcation lines ("tide marks"/"high-water marks") — RPE cell proliferation at edge of SRF; appear after ~3 months; represent sites of increased adhesion
- Retinal atrophy and thinning
- Fixed folds, subretinal precipitates
Break Localization — Modified Lincoff's Rules
Subretinal fluid (SRF) spread governed by: gravity + anatomical limits (ora serrata, optic nerve) + break location.
| SRF Pattern | Likely Primary Break |
|---|---|
| Shallow inferior RD, higher on temporal side | Inferior temporal |
| Inferior RD with equal fluid levels | 6 o'clock |
| Bullous inferior RD | Above horizontal meridian |
| SRF crosses midline above | Near 12 o'clock; lower edge = side of break |
| Upper nasal break | SRF revolves round disc; rises on temporal side |
| Subtotal RD with superior wedge attached | Break in periphery nearest highest border |
Break distribution: 60% superotemporal · 15% superonasal · 15% inferotemporal · 10% inferonasal
~50% of eyes have more than one break, often within 90° of each other → systematic search of entire periphery mandatory.
Investigations
- Binocular indirect ophthalmoscopy (BIO) with scleral depression — both eyes; identify all breaks; note SRF extent and macula status
- Slit lamp + 90D/widefield lens — vitreous assessment, tobacco dust, posterior breaks
- B-scan ultrasound — when fundal view obscured (vitreous haemorrhage, dense cataract, corneal opacification); RD on B-scan = bright hyperechoic membrane attached at disc and ora
- OCT — macula status (on/off/sub-foveal fluid), epiretinal membrane, intraretinal cysts
- Examination of fellow eye — essential given 10% bilateral risk
Differential Diagnosis
| Condition | Key Differentiator |
|---|---|
| Retinoschisis | Bilateral, smooth, dome-shaped, inferotemporal; absolute VF defect; no pigment cells in vitreous; choroidal pattern visible |
| Tractional RD | Concave, smooth, immobile; fibrous membranes; doesn't reach ora serrata |
| Exudative RD | No break; convex; fluid shifts with gravity; underlying cause (tumour, inflammation) |
| Choroidal detachment | Brown, extends beyond ora serrata; limited posteriorly by vortex veins; low IOP; no vitreous pigment |
Treatment
Pre-operative
- Patient fasts if urgent surgery planned
- Bed rest with head positioning so break is most dependent (reduces SRF)
- Do not apply patch or pad (prevents visual monitoring)
Urgency
| Situation | Urgency |
|---|---|
| Macula-on RRD | Emergency — operate ASAP |
| Macula-off RRD | Surgery within 7–10 days (visual outcome equivalent if done within this window) |
| Dense vitreous haemorrhage + RD on B-scan | Urgent PPV |
| Combined tractional-RRD | Urgent — SRF spreads rapidly |
TIP: Even when the macula is already off, visual results are better if surgery is completed within 72 hours. — Kanski's Clinical Ophthalmology
Surgical Options
1. Pneumatic Retinopexy
- Principle: Intravitreal gas bubble (SF₆ or C₃F₈) expands, tamponades the break from inside; cryotherapy or laser applied to create permanent chorioretinal adhesion
- Head positioning: Patient positions so bubble directly covers the break
- Indication: Single break or cluster of breaks <2 clock hours in the upper 2/3 of peripheral retina; uncomplicated RRD; office-based procedure
- Limitation: Lower success rate than scleral buckling
2. Scleral Buckling (External Surgery)
- Principle: Silicone explant sutured to sclera creates inward indentation (buckle) → opposes RPE to sensory retina, reduces vitreoretinal traction, closes break
- Technique: Peritomy → break localization → cryotherapy to break → explant sutured (radial/segmental/circumferential/encircling) → SRF drainage if needed
- Mandatory: For post-traumatic dialysis
- Explant configuration: Radial (single peripheral tear), segmental (cluster), circumferential or encircling (multiple breaks/high PVR risk)
- Complications: Diplopia, CME (~25%), epiretinal membrane (~15%), buckle extrusion/infection, anterior segment ischaemia (encircling), elevated IOP, choroidal detachment
3. Pars Plana Vitrectomy (PPV — Internal Surgery)
- Principle: Remove vitreous + posterior hyaloid (relieving traction) → drain SRF internally → laser/cryopexy to break → intraocular tamponade to hold retina in place
- 3-port technique: Infusion cannula (4 mm from limbus in phakic; 3.5 mm in pseudophakic) + vitreous cutter + light probe at 10 and 2 o'clock
- Tamponade options: Air, SF₆, C₃F₈ gas (short-to-long acting); silicone oil (for PVR, inferior breaks, giant tears, unable to posture)
- PPV preferred over SB when:
- Breaks not visualizable (haemorrhage, media opacity)
- Giant tears, large posterior breaks
- Proliferative vitreoretinopathy (PVR)
- Pseudophakic RD
- Failed prior scleral buckle
Complications of RRD
1. Proliferative Vitreoretinopathy (PVR) — Leading Cause of Surgical Failure
Epiretinal/subretinal membrane formation → fixed retinal folds and traction
| Grade | Features |
|---|---|
| A (minimal) | Diffuse vitreous haze, tobacco dust, inferior pigment clumps |
| B (moderate) | Inner surface wrinkling, rolled break edges, vascular tortuosity, retinal stiffness |
| C (marked) | Rigid full-thickness star folds; anterior (A) or posterior (P); funnel RD in advanced disease |
Management of PVR: PPV + membrane/ILM peeling ± relaxing retinotomy + silicone oil tamponade
2. Macular complications (macula-off RD)
- Reduced final visual acuity even after successful reattachment
- Epiretinal membrane, CME, persistent subfoveal fluid, photoreceptor loss
Prognosis
- Macula-on, prompt repair: >6/12 visual acuity achievable in most cases
- Macula-off <72 hours: Good recovery likely
- Macula-off >1 week: Significant photoreceptor atrophy; poorer prognosis
- Primary anatomical success rate: ~80–90% with a single procedure; >95% with re-operations
- PVR is the principal cause of failure
Sources: Kanski's Clinical Ophthalmology 10th ed., The Wills Eye Manual, Goldman-Cecil Medicine
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