Traction Retinal Detachment (TRD)

Definition & Pathophysiology

Etiology

Clinical Features

Symptoms

• Visual loss or visual field defect
• May be asymptomatic, especially when extramacular

Signs (Key Features)

Fundus photograph: Tractional retinal detachment — note the fibrovascular membranes (yellow-green) pulling the retina, with the optic disc displaced

• The detached retina has a concave, tent-like configuration with a smooth surface (cf. rhegmatogenous RD which is convex/bullous)
• Cellular and vitreous fibrovascular membranes are visible exerting traction on the retina
• Retinal striae (folds) radiate from areas of traction
• The retina is immobile (does not shift with eye movement)
• Detachment rarely extends to the ora serrata
• A mild relative afferent pupillary defect (RAPD) may be present in large detachments
• If a retinal tear develops within the TRD, it converts to a combined TRD/rhegmatogenous RD — now convex and more bullous (urgent)

Comparison with Other Types of Retinal Detachment

Workup

1. Slit lamp examination — assess lens status, neovascularization of the iris (rubeosis), and posterior vitreous detachment (PVD)
2. Indirect ophthalmoscopy with scleral depression of both eyes; slit lamp + 90D or widefield lens for peripheral breaks
3. B-scan ultrasound — essential when media opacities (vitreous hemorrhage, cataract) are present
4. OCT — identifies tractional membranes, differentiates membranes from detached retina, essential for evaluating macular involvement

Management

Observation

• Extramacular TRDs (not involving the fovea) can often be observed — they tend to remain stationary for prolonged periods
• Decision depends on: etiology, fellow eye status, extent/location of traction

Surgical Indications

1. TRD threatening or involving the macula — treat without delay
2. Combined TRD + rhegmatogenous RD — treat urgently
3. Dense, non-clearing vitreous hemorrhage preventing adequate visualization or laser
4. Macular epiretinal membranes or vitreomacular traction causing significant symptoms
5. Severe fibrovascular proliferation unresponsive to laser/anti-VEGF

Surgical Approach: Pars Plana Vitrectomy (PPV)

• The mainstay of treatment for TRD
• Goals: remove vitreous, segment and delaminate fibrovascular membranes, relieve traction
• Combined with endolaser photocoagulation (PRP) in diabetic cases
• Intravitreal anti-VEGF agents (e.g., aflibercept, bevacizumab) may be given preoperatively (1–7 days before surgery) to reduce intraoperative bleeding from fibrovascular membranes
• DRCR.net Protocol AB: initial vitrectomy + PRP leads to faster visual recovery vs. aflibercept, with similar 2-year outcomes

TRD secondary to branch retinal vein occlusion: preoperative fibrovascular band with foveal-involving detachment confirmed on OCT (a,c); post-vitrectomy with traction released (b,d); 5-year stable OCT follow-up (e,f)

Follow-Up

• After surgery, patients are typically seen at 1 day → 1 week → 1 month → 2–3 months → every 6–12 months
• TRD follow-up schedule depends on underlying etiology and patient factors
• Retinal specialist referral is required for all cases

Key Points to Remember

• TRD is always secondary to another process — treat the underlying cause (e.g., control DM, treat PDR with PRP)
• The characteristic concave, immobile, smooth surface distinguishes TRD from RRD
• A TRD that develops a retinal break becomes a combined TRD/RRD, which behaves differently (more bullous, requires urgent repair)
• Macular involvement is the surgical tipping point — extramacular TRDs are often observed; macular TRDs require prompt vitrectomy
• Young type 1 diabetics have more aggressive PDR and benefit from earlier intervention