Retinal Detachment

Author: Hemang K Pandya, MD; Chief Editor: Robert E O'Connor, MD, MPH
Updated: Oct 20, 2015

Practice Essentials
Retinal detachment (see the image below) refers to separation of the inner layers of the
retina from the underlying retinal pigment epithelium (RPE, choroid). Next to central retinal
artery occlusion, chemical burns to the eye, and endophthalmitis, it is one of the most timecritical eye emergencies encountered in the emergency setting.

Retinal detachment. Courtesy of Kresge Eye Institute, Detroit, Michigan.

Signs and symptoms

Symptoms of retinal detachment may include the following:

Photopsia (common initially)

Visual field defect (developing over time; may help localize detachment)
Floaters
The history should include inquiries into the following:

History of trauma
Previous ophthalmologic surgery
Previous eye conditions (eg, uveitis and vitreous hemorrhage)
Duration of visual symptoms and visual loss
Physical examination should include the following:

Checking of visual acuity

External examination for signs of trauma and checking of the visual field
Assessment of pupil reaction
Measurement of intraocular pressure in both eyes
Slit-lamp biomicroscopy
Examination of the vitreous for signs of pigment or tobacco dust

Examination of the dilated fundus with ophthalmoscopy (preferably indirect)

Diagnosis
Retinal detachment occurs by 3 basic mechanisms and thus is classified into the following 3
main types:

Rhegmatogenous retinal detachment (the most common type) This results when a
hole, tear, or break in the neuronal layer allows fluid from the vitreous to seep between and
separate sensory and RPE layers
Traction retinal detachment This results from adhesions between the vitreous
gel/fibrovascular proliferation and the retina
Exudative (serous) retinal detachment This results from exudation of material into
the subretinal space from retinal vessels (as in hypertension, central retinal venous
occlusion, vasculitis, or papilledema)
Laboratory tests are not helpful in detecting retinal detachment, but basic blood work may be
useful if the patient requires surgical intervention.
Unless globe rupture, orbital/facial bone fractures, or intraocular foreign bodies are
suspected, diagnostic imaging is not warranted.

Management
General treatment measures include the following:

Nil per os (NPO) status in anticipation of retinal surgery

In trauma cases, protection of the globe with a metallic eye shield
Avoidance of any pressure on the globe
Limitation of activity to a minimum until further evaluation
Treatment of any unstable vital signs in preparation for possible emergency surgery
Consideration of referral to a retina specialist (eg, whenever a macula-on retinal
detachment is suspected)
Specific techniques for treating retinal detachments include the following:

Scleral buckling
Pars plana vitrectomy
Pneumatic retinopexy
Retinal detachment repair is usually done on an outpatient basis.

Background
Next to central retinal artery occlusion, chemical burns to the eye, and endophthalmitis, a
retinal detachment is one of the most time-critical eye emergencies encountered in the ED.
Retinal detachment (RD) was first recognized in the early 1700s by de Saint-Yves, but
clinical diagnosis remained elusive until Helmholtz invented the ophthalmoscope in 1851.

Tragically, retinal detachments were uniformly blinding until the 1920s when Jules Gonin,
MD, pioneered the first repair of retinal detachments in Lausanne, Switzerland. Today, with
the advent of scleral buckling and small-gauge pars plana vitrectomy, in addition to laser and
cryotherapy techniques, rapid ED diagnosis and treatment of a retinal detachment truly can
be a vision-saving opportunity.

Pathophysiology
Eye anatomy is shown in the image below.

Anatomy of the eye.

Retinal detachment refers to separation of the inner layers of the retina from the underlying
retinal pigment epithelium (RPE, choroid). The choroid is a vascular membrane containing
large branched pigment cells sandwiched between the retina and sclera. Separation of the
sensory retina from the underlying RPE occurs by the following 3 basic mechanisms:

A hole, tear, or break in the neuronal layer allowing fluid from the vitreous cavity to
seep in between and separate sensory and RPE layers (ie, rhegmatogenous RD)
Traction from inflammatory or vascular fibrous membranes on the surface of the
retina, which tether to the vitreous
Exudation of material into the subretinal space from retinal vessels such as in
hypertension, central retinal venous occlusion, vasculitis, or papilledema
Retinal detachments may be associated with congenital malformations, metabolic disorders,
trauma (including previous ocular surgery), [1] vascular disease, choroidal tumors, high myopia
or vitreous disease, or degeneration.

Of the 3 types of retinal detachment, rhegmatogenous RD is the most common, deriving its
name from rhegma, meaning rent or break. Vitreous fluid enters the break and separates the
sensory retina from the underlying RPE, resulting in detachment.[2]
Exudative or serous detachments occur when subretinal fluid accumulates and causes
detachment without any corresponding break in the retina. The etiologic factors are often
tumor growth or inflammation. These types of retinal detachment do not usually require
surgical intervention. Correction of the underlying disorder typically leads to resolution of
these detachments.
Tractional retinal detachment occurs as a result of adhesions between the vitreous
gel/fibrovascular proliferation and the retina. Mechanical forces cause the separation of the
retina from the RPE without a retinal break. Advanced adhesion may result in the eventual
development of a tear or break. The most common causes of tractional retinal detachment
are proliferative diabetic retinopathy, sickle cell disease, advanced retinopathy of
prematurity, and penetrating trauma.
Retinal detachments are shown in the images below.

Retinal detachment. Courtesy of Kresge Eye Institute, Detroit, Michigan.

Epidemiology
Frequency
United States
Although 6% of the general population are thought to have retinal breaks, most of these are
asymptomatic benign atrophic holes, which are without accompanying pathology and do not
lead to retinal detachment. The annual incidence is approximately one in 10,000 or about 1
in 300 over a lifetime.[2] Other sources suggest that the age-adjusted incidence of idiopathic
retinal detachments is approximately 12.5 cases per 100,000 per year, or about 28,000
cases per year in the US.[3]
Certain groups have higher prevalence than others. Patients with high myopia (>6 diopters)
and individuals with aphakia (ie, cataract removal without lens implant) have a higher risk.
Cataract extraction complicated by vitreous loss during surgery can have an increased
detachment rate of up to 10%.
International
The most common worldwide etiologic factors associated with retinal detachment are
myopia (ie, nearsightedness), aphakia, pseudophakia (ie, cataract removal with lens
implant), and trauma. Approximately 40-50% of all patients with detachments have myopia,
30-40% have undergone cataract removal, and 10-20% have encountered direct ocular
trauma. Traumatic detachments are more common in young persons, and myopic
detachment occurs most commonly in persons aged 25-45 years. Although no studies are
available to estimate incidence of retinal detachment related to contact sports, specific
sports (eg, boxing) have an increased risk of retinal detachment.

Mortality/Morbidity
Estimates reveal that 15% of people with retinal detachments in one eye develop
detachment in the other eye. Risk of bilateral detachment is increased (25-30%) in patients
who have had bilateral cataract extraction.

Race
There exists no racial predilection for retinal detachment incidence.

Sex
There exists no gender predilection for retinal detachment incidence.

Age
As the population ages, retinal detachments (RDs) are becoming more common. Retinal
detachment usually occurs in persons aged 40-70 years. However, paintball injuries in young
children and teens are becoming increasingly common causes of eye injuries, including
traumatic retinal detachments.