1. Classification: rhegmatogenous, tractional, and exudative/serous detachment
2. Risk factors and pathophysiology: retinal breaks, posterior vitreous detachment, myopia, trauma, diabetic retinopathy, inflammation, tumors
3. Clinical features: flashes, floaters, visual-field curtain/shadow, reduced vision
4. Examination and diagnosis: dilated fundus examination, ocular ultrasound when the fundus cannot be visualized
5. Urgency and initial actions: macula-on versus macula-off detachment, referral and activity advice
6. Treatment: laser retinopexy, cryotherapy, pneumatic retinopexy, scleral buckling, pars plana vitrectomy
7. Complications and prognosis: proliferative vitreoretinopathy, redetachment, macular involvement, visual outcomes
8. Differentials: vitreous hemorrhage, posterior vitreous detachment, migraine aura, retinal tear without detachment

1. Classification: rhegmatogenous, tractional, and exudative/serous detachment
2. Risk factors and pathophysiology: retinal breaks, posterior vitreous detachment, myopia, trauma, diabetic retinopathy, inflammation, tumors
3. Clinical features: flashes, floaters, visual-field curtain/shadow, reduced vision
4. Examination and diagnosis: dilated fundus examination, ocular ultrasound when the fundus cannot be visualized
5. Urgency and initial actions: macula-on versus macula-off detachment, referral and activity advice
6. Treatment: laser retinopexy, cryotherapy, pneumatic retinopexy, scleral buckling, pars plana vitrectomy
7. Complications and prognosis: proliferative vitreoretinopathy, redetachment, macular involvement, visual outcomes
8. Differentials: vitreous hemorrhage, posterior vitreous detachment, migraine aura, retinal tear without detachment

Retinal Detachment (RD) - BSc Nursing Notes

1. Introduction / Definition

• Retina: eye ki inner light-sensitive layer
• RPE: retina ko support, nutrition aur attachment provide karne wali layer
• Macula: central sharp vision ka area
• Fovea: macula ka central part, finest vision ke liye responsible

2. Why is it important?

3. Types of Retinal Detachment

A. Rhegmatogenous Retinal Detachment - Most common surgical type

Meaning

Pathogenesis

Risk factors

• Increasing age and vitreous degeneration
• High myopia
• Previous retinal detachment in other eye
• Family history of RD
• Lattice degeneration
• Previous cataract surgery, especially complicated surgery
• YAG laser capsulotomy in susceptible patients
• Blunt or penetrating trauma
• Retinal tear or retinal hole
• Previous intraocular surgery

Features

• Sudden flashes of light: photopsia
• Sudden onset/increase in floaters
• “Cobwebs” or black dots in vision
• Peripheral visual-field defect
• “Curtain/veil/shadow coming over the eye”
• Central visual acuity may remain normal initially if macula is still attached
• If macula detaches: decreased central vision, distortion, and poor reading vision

Fundus findings

• Elevated, mobile, convex, wrinkled or corrugated retina
• Retinal tear may appear red
• Retinal vessels may look dark and tortuous
• Pigment cells in anterior vitreous called tobacco dust or Shafer sign may indicate a retinal break
• Vitreous hemorrhage may occur

B. Tractional Retinal Detachment (TRD)

Meaning

Common causes

• Proliferative diabetic retinopathy: most important cause
• Retinopathy of prematurity (ROP)
• Sickle-cell retinopathy
• Retinal vein occlusion with neovascularization
• Ocular trauma
• Previous retinal surgery or inflammation

Clinical features

• Vision loss is usually gradual
• Flashes and floaters may be absent because traction slowly develops
• Progressive visual-field defect
• May remain stable for months or years
• If a retinal break develops, it becomes a combined tractional-rhegmatogenous RD, which may progress rapidly.

Fundus features

• Detached retina has a concave configuration
• Retina is relatively immobile
• Retinal breaks are absent in pure TRD
• Shifting fluid absent
• Fibrovascular membranes may be seen

C. Exudative / Serous Retinal Detachment

Meaning

Causes

• Inflammatory eye disease: posterior uveitis, VKH disease
• Severe hypertension, including pre-eclampsia/eclampsia
• Choroidal tumors: melanoma, hemangioma, metastasis
• Coats disease
• Central serous chorioretinopathy
• Scleritis
• Renal disease or systemic inflammatory conditions

Features

• Blurred vision and visual-field defect
• Usually no flashes and floaters unless another retinal problem is present
• Retina smooth, elevated and often mobile
• Shifting subretinal fluid may occur with change in posture
• No retinal break seen

Treatment principle

• Inflammation: corticosteroids/immunosuppression as prescribed
• Hypertension/pre-eclampsia: urgent medical and obstetric management
• Tumor: oncology/ophthalmology-directed treatment

4. Macula-On vs Macula-Off RD

5. Clinical Manifestations

Subjective symptoms

1. Floaters: black dots, spots, cobwebs
2. Photopsia: flashes of light, commonly peripheral visual field mein
3. Curtain/veil effect: peripheral side se shadow spreading over vision
4. Painless loss of vision
5. Blurring of vision
6. Peripheral visual-field loss
7. Distorted vision if macula is involved

6. Assessment and Diagnosis

History taking

• Symptoms kab start hue?
• Flashes of light hain?
• New floaters hain?
• Curtain, shadow, or field loss hai?
• Vision suddenly reduced hui?
• Eye trauma hua?
• High myopia hai?
• Diabetes mellitus hai?
• Previous cataract or eye surgery?
• Retinal detachment in family or other eye?
• Any previous retinal tear or laser treatment?

Eye examination

• Visual acuity in both eyes
• Pupil examination, including relative afferent pupillary defect in significant macular/optic involvement
• Visual-field assessment by confrontation
• Slit-lamp examination
• Dilated fundus examination with indirect ophthalmoscopy
• Scleral depression to locate peripheral tear
• Intraocular pressure may be low in RD

Investigations

1. Dilated fundus examination: most important test
2. B-scan ultrasonography: useful when media are opaque due to dense cataract, vitreous hemorrhage, or severe inflammation
3. Optical coherence tomography (OCT): useful for macular involvement and shallow RD
4. Fundus photography, fluorescein angiography, or OCT angiography when indicated for underlying disease

7. Differential Diagnosis

8. Treatment

A. Treatment of retinal tear before detachment

• Laser photocoagulation
• Cryotherapy (cryopexy)

B. Surgical repair of established RD

1. Pneumatic retinopexy

• Gas bubble injected into vitreous cavity
• Bubble presses against retinal tear
• Laser or cryopexy seals tear
• Suitable for selected uncomplicated RRD, especially superior breaks
• Patient must maintain prescribed head position

2. Scleral buckle

• Silicone band/sponge is placed around outer wall of eye
• Indents sclera inward to support retinal break
• Usually combined with cryotherapy or laser
• Commonly used in selected young or phakic patients and some uncomplicated RRDs

3. Pars plana vitrectomy (PPV)

• Vitreous gel removed
• Traction relieved
• Retinal break treated with laser/cryopexy
• Gas or silicone oil may be injected as internal tamponade
• Often used for complex RD, vitreous hemorrhage, PVR, giant tear, pseudophakia, or tractional RD

4. Drainage of subretinal fluid

5. Treatment of underlying cause

• Diabetic retinopathy: glycemic control, panretinal photocoagulation, anti-VEGF treatment, vitrectomy when indicated
• Uveitis: anti-inflammatory therapy
• Hypertension/preeclampsia: urgent medical treatment
• Tumor: specialist treatment

9. Complications

• Permanent visual impairment or blindness
• Macular involvement
• Recurrent retinal detachment
• Proliferative vitreoretinopathy (PVR)
• Cataract, especially after vitrectomy
• Raised intraocular pressure or glaucoma
• Infection, though uncommon after surgery
• Endophthalmitis, rare but serious
• Subretinal fibrosis/scarring
• Diplopia or refractive change after scleral buckle

Proliferative Vitreoretinopathy (PVR)

10. Nursing Management

A. Immediate nursing priorities

1. Treat as urgent
   • Sudden flashes, floaters, curtain/shadow, or painless field loss needs immediate ophthalmology evaluation.
   • Do not delay for routine appointment.
2. Assess vision
   • Record visual acuity in both eyes.
   • Ask about onset and progression of vision loss.
   • Note peripheral field loss and central vision status.
3. Protect the affected eye
   • Avoid eye rubbing or pressure.
   • Use protective shield if instructed.
   • Do not apply pressure dressing unless prescribed.
4. Positioning
   • Follow ophthalmologist’s instructions.
   • In some patients, position may help keep fluid away from macula before surgery.
   • After gas tamponade, strict posturing is often prescribed.
5. Prevent falls/injury
   • Reduced vision causes fall risk.
   • Assist with ambulation, toileting, and unfamiliar environments.
   • Keep call bell within reach.
   • Ensure adequate lighting and remove hazards.
6. Emotional support
   • Sudden visual loss causes fear and anxiety.
   • Explain that urgent treatment is intended to preserve vision.
   • Encourage patient and family questions.

B. Preoperative Nursing Care

• Confirm consent and identity according to policy.
• Record baseline vital signs, visual status, allergies, comorbidities, medicines, and anticoagulant use.
• Ensure fasting status if surgery under anesthesia is planned.
• Administer prescribed preoperative eye drops or systemic medicines.
• Teach not to rub or press the eye.
• Explain procedure, possible positioning, eye shield, follow-up, and activity restrictions.
• For diabetic patients: monitor blood glucose as ordered.
• For hypertensive patients: monitor BP and report severe elevation.
• Maintain infection-control measures.

C. Postoperative Nursing Care

Eye care

• Keep eye pad/shield clean and intact as prescribed.
• Do not allow patient to rub or press eye.
• Administer antibiotic, steroid, cycloplegic, and pressure-lowering eye drops exactly as ordered.
• Teach correct eye-drop technique:
  • Hand hygiene
  • Avoid touching bottle tip to eye/eyelashes
  • Leave 5 minutes between different drops
  • Apply gentle pressure over inner canthus only if advised

Monitor for warning signs

• Sudden decrease in vision
• Increasing severe eye pain
• Marked redness/swelling
• Purulent discharge
• Severe headache, nausea, vomiting
• New curtain, flash, or many floaters
• Fever
• Injury to operated eye

Activity restriction

• Heavy lifting
• Straining
• Vigorous exercise
• Bending with head down
• Rubbing the eye
• Swimming until surgeon permits

Follow-up

• Raised intraocular pressure
• Cataract
• Re-detachment
• Infection
• PVR

11. Special Instruction After Intraocular Gas Injection

1. Maintain prescribed head position exactly.
2. No air travel until gas completely absorbs.
3. Avoid high-altitude travel.
4. Inform every doctor, dentist, and anesthetist that an intraocular gas bubble is present.
5. Nitrous oxide anesthesia must not be used while gas remains in the eye because gas expansion can dangerously raise intraocular pressure.
6. Vision may remain blurred while bubble is present.

12. Health Education and Prevention

• Seek urgent eye review for sudden flashes, floaters, or a curtain over vision.
• Use protective eyewear during sports, industrial work, and trauma-risk activities.
• Diabetic patients should maintain glycemic control and attend retinal screening.
• High-myopia patients need regular dilated retinal examination.
• Attend follow-up after cataract surgery or retinal laser treatment.
• Patients with RD in one eye should report symptoms in the other eye immediately.
• Avoid self-medication and delaying specialist consultation.

13. Short Exam Answer

14. One-Line Memory Trick

References

• Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed., pp. 682, 695-696, 705.
• The AAO retinal detachment triage guide emphasizes urgent referral, particularly for macula-on detachments.
• The AAO retinal-break guideline discusses retinal tears, lattice degeneration, and early prevention of rhegmatogenous RD.