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Retinal Detachment

Retinal detachment (RD) is the separation of the neurosensory retina from the retinal pigment epithelium (RPE). It is an ophthalmological emergency — delayed treatment risks permanent visual loss.

Anatomy of Separation

The neurosensory retina and RPE are joined only loosely; a potential subretinal space exists between them. When fluid accumulates here (from any cause), the retina lifts away from its metabolic support and photoreceptors begin to die.

Types

1. Rhegmatogenous Retinal Detachment (RRD) — Most Common

"Rhegma" = break (Greek). A full-thickness defect (tear or hole) forms in the retina, allowing liquefied vitreous to seep through and lift the retina.

Pathogenesis:

Posterior vitreous detachment (PVD) exerts traction at adhesion points on the retinal internal limiting membrane
A retinal tear forms at the traction site
Liquefied vitreous passes through the tear → accumulates in the subretinal space
Incidence ~1/10,000/year; bilateral in ~10%
40% occur in myopic eyes (vitreous degeneration + predisposing lesions like lattice degeneration are more common)
Also associated with cataract surgery, laser capsulotomy, prior trauma

Diagram — Rhegmatogenous vs. Nonrhegmatogenous:

Rhegmatogenous vs nonrhegmatogenous retinal detachment diagram showing retinal tear, liquefied vitreous, and protein-rich subretinal fluid

Robbins & Kumar Basic Pathology — (A) Rhegmatogenous: vitreous traction tears retina; liquefied vitreous enters subretinal space. (B) Nonrhegmatogenous: protein-rich exudate lifts retina without a break.

2. Tractional Retinal Detachment

Caused by fibrovascular membranes (e.g., in proliferative diabetic retinopathy) pulling the retina off the RPE without a retinal break. No vitreous enters the subretinal space. Vitrectomy with membrane delamination or segmentation is the treatment.

3. Exudative (Nonrhegmatogenous) Retinal Detachment

Caused by fluid leaking from damaged choroidal or retinal vessels into the subretinal space — no retinal break. Causes include malignant hypertension, choroidal tumours, posterior uveitis (e.g., Vogt-Koyanagi-Harada syndrome), and severe inflammatory states.

Fundus Photographs

Fresh Rhegmatogenous Detachment — Temporal, Macula On

Fresh rhegmatogenous retinal detachment — temporal detachment with macula on, showing elevated pale retina on the temporal side with normal posterior pole

Kanski's Clinical Ophthalmology — Fig. 16.22A: Temporal detachment, macula on. The elevated, slightly opaque, pale retinal area is visible temporally. Fovea (macula) remains attached = vision preserved.

Fresh Detachment — Corrugated Retina, Macula Off

Fresh retinal detachment showing typical corrugated appearance of detached retina with the macula off — superior bullous elevation with white folds

Kanski's Clinical Ophthalmology — Fig. 16.22C: Typical corrugated, opaque appearance of detached retina. Macula off = central vision lost.

Macular Hole with Shallow Subretinal Fluid

Kanski's Clinical Ophthalmology — Fig. 16.22D: Macular hole (arrowheads) surrounded by shallow subretinal fluid confined to the posterior pole.

Classic Fundus View from Harrison's

Retinal detachment fundus photograph from Harrison's — inferior elevated folded white retinal sheet with spared fovea and superior scotoma

Harrison's Principles of Internal Medicine — FIGURE 32-14: Retinal detachment as an elevated, folded sheet of retinal tissue in the inferior fundus. The fovea was spared (normal acuity), but the inferior detachment produced a superior visual field scotoma.

Rhegmatogenous Detachment with Subretinal Fluid Demarcation

Fundus photograph of rhegmatogenous retinal detachment with arrows marking the demarcation line of subretinal fluid in the inferior temporal region

Inferior temporal rhegmatogenous detachment. Black arrows mark the demarcation line (boundary of subretinal fluid). The dashed white line indicates the OCT scan path across the macula ("macula-on" scenario).

Exudative Detachment — Serous Elevation (VKH Syndrome)

Fundus photograph showing serous retinal detachment superior to optic disc — pale elevated patch with green arrow, associated with Vogt-Koyanagi-Harada syndrome

Exudative (serous) detachment in VKH syndrome. Green arrow points to pale, elevated serous detachment superior to the disc — no retinal break, no traction.

Symptoms

Symptom	Detail
Photopsia (flashing lights)	~60% of patients; from vitreoretinal traction at PVD
Floaters	Pigment cells ("tobacco dust"), blood, or condensed vitreous
Curtain / shadow	Peripheral field defect progressing toward centre
Central visual loss	Fovea involved by subretinal fluid or large bullous RD

A key clinical point: field defect may be absent on waking (SRF resorbs overnight in the supine position) but returns during the day. The field defect appears in the opposite quadrant to the primary break.

Signs on Examination

Sign	Significance
Relative afferent pupillary defect (Marcus Gunn)	Extensive RD
Low IOP (~5 mmHg asymmetry)	Typical of RRD
Very low IOP	Suspect associated choroidal detachment
High IOP	Schwartz-Matsuo syndrome (RRD with pseudouveitis from photoreceptor outer segments)
"Tobacco dust" in vitreous	Pigment cells from RPE — highly specific
Red retinal break	Full-thickness defect; red = choroidal colour contrast
Convex, opaque, corrugated retina	Fresh RD with retinal oedema

Location of Breaks — Lincoff's Rules

Distribution of breaks in RRD: ~60% superotemporal, 15% superonasal, 15% inferotemporal, 10% inferonasal. ~50% of eyes have more than one break.

Subretinal fluid (SRF) spread predicts break location:

Shallow inferior RD higher on one side → break on that side inferiorly
Equal inferior fluid levels → break at 6 o'clock
Bullous inferior RD → break above the horizontal meridian
Subtotal RD with superior wedge of attached retina → break nearest the highest border

Stages of Retinal Detachment

Stage	Features
Fresh	Convex, opaque, corrugated retina; retinal oedema
Longstanding (>3 months)	Retinal thinning/atrophy; intraretinal cysts (if >1 year); subretinal demarcation lines ("tide marks") from RPE proliferation
Proliferative vitreoretinopathy (PVR)	Epiretinal/subretinal membranes; fixed retinal folds; star folds; funnel-shaped total detachment in advanced PVR

PVR Grading (Complication of RD)

Grade	Features
A (minimal)	Diffuse vitreous haze, tobacco dust, pigmented inferior clumps
B (moderate)	Inner retinal surface wrinkling, rolled break edges, retinal rigidity
C (severe)	Fixed retinal folds; full-thickness folds; star-shaped folds; anterior or posterior; funnel detachment

Management

Procedure	Indication
Laser photocoagulation / cryotherapy	Prophylaxis for at-risk breaks without detachment
Pneumatic retinopexy	Selected superior breaks; gas bubble tamponade with cryotherapy/laser
Scleral buckling	Peripheral RD, young patients, lattice-related tears; silicone band/sponge indents sclera to close break
Pars plana vitrectomy (PPV)	Complex RD, PVR, posterior breaks, giant tears, tractional RD; vitreous removal + gas/oil tamponade
PPV with membrane delamination/segmentation	Diabetic tractional RD; careful removal of fibrovascular membranes from friable retina

Key Risk Factors

High myopia (>6 D)
Prior cataract surgery / Nd:YAG capsulotomy
Blunt ocular trauma
Fellow eye RD (~10% bilateral)
Lattice degeneration / snailtrack degeneration
Family history

Sources: Kanski's Clinical Ophthalmology 10th ed., Robbins & Kumar Basic Pathology, Harrison's Principles of Internal Medicine 21st ed.

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