CASE REPORT

Retinal Detachment

Arranged By :
Suharyadi Sasmanto
I11106012

Oponents :
Juniar Anugrah
Rendika Bani Triono
Yessi Putri
Mui Mui
Salman A
Yeni Purnama Sari
Elegi Dewa Perdana

EYE DEPARTEMENT RSUD Dr. SOEDARSO

FACULTY OF MEDICINE
TANJUNGPURA UNIVERSITY
PONTIANAK
2011

1
 CHAPTER I
INTRODUCTION

The retina is an extremely thin tissue that lines the inside of the back of the
eye. The retina is about the size of a postage stamp. It consists of a central area
called the macula and a much larger peripheral area of the retina. A retinal
detachment is a separation of the retina from its attachments to the underlying
tissue within the eye. Most retinal detachments are a result of a retinal break, hole,
or tear. These retinal breaks may occur when the vitreous gel pulls loose or
separates from its attachment to the retina, usually in the peripheral parts of the
retina.

Each year approximately one out of 10,000 people develops a retinal

detachment. Certain people have a greater chance of getting a retinal detachment
than others: those with a high degree of nearsightedness, a family history of
retinal detachment, or those who once had a retinal detachment in the other eye.
Patients who have thinning of the retina (termed “lattice degeneration”) or other
degenerative changes of the retina are also at increased risk. Patients who have
had cataract surgery have about a 1% to 2% chance of developing a retinal
detachment.

2
 CHAPTER II
THEORITICAL APPROACHING

1. Background
Next to central retinal artery occlusion and chemical burns to the eye,
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, intravitreal
gas, microscopic, laser, and cryotherapy techniques, rapid ED diagnosis and
treatment of a retinal detachment truly can be a vision-saving opportunity.

Pathophysiology

Picture 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:

3
 1) 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)
2) Traction from inflammatory or vascular fibrous membranes on the surface
of the retina, which tether to the vitreous
3) 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), 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.

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.

Tractional retinal detachment occurs as a result of adhesions between the

vitreous gel and the retina. Centripetal mechanical forces cause the separation of
the retina from the RPE without a retinal break. Advanced adhesion may result in
the 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. Vitreoretinal traction
increases with age, as the vitreous gel shrinks and collapses over time, frequently
causing posterior vitreous detachments in approximately two thirds of persons
older than 70 years.

4
 Epidemiology

Frequency
In United States, Although 6% of the general population have retinal
breaks, most of these are benign atrophic holes, which are without accompanying
pathology and do not lead to retinal detachment. Incidence of retinal detachment
is 1 in 15,000 population, with a prevalence of 0.3% in the US. The annual
incidence is approximately one in 10,000 or about 1 in 300 over a lifetime. 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.Certain groups have higher prevalence than others. Patients with
high myopia (>6 diopters), a condition that is more common in males than in
females have a 5% risk; individuals with aphakia (ie, cataract removal
without lens implant) have a 2% risk. Cataract extraction complicated by
vitreous loss during surgery has an increased detachment rate to 10%.
In 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
and bungee jumping) 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

Incidence of retinal detachment is relatively frequent in people of Jewish

ethnicity and relatively low in black persons.

5
 Sex

1. No predilection exists; overall, incidence is unchanged even when

corrections for the higher rate of ocular trauma in men is considered.
2. Of those younger than 45 years who have retinal detachment, 60% are
male and 40% are female.
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.

4. History
a. Initial symptoms commonly include the sensation of a flashing light

(photopsia) related to retinal traction and often accompanied by a shower

of floaters (RPE) and vision loss.
b. Over time, the patient may report a shadow in the peripheral visual field,
which, if ignored, may spread rapidly to involve the entire visual field in a
matter of days. Vision loss may be filmy, cloudy, irregular, or curtainlike.
c. Retinal tissue is stimulated by light but also responds to mechanical
disturbances. Flashing lights usually are caused by separation of the
posterior vitreous. As the vitreous gel separates from the retina, it
stimulates the retinal tissue mechanically, resulting in the release of
phosphenes and the sensation of light.
d. Pathologic stimulation of the retina and production of phosphenes cause
photopsia.
e. Patients often may note decreased visual acuity and a wavy distortion of
objects (metamorphopsia). If a RD involves the macula, acuity is severely
reduced.
f. Posterior vitreous detachment is usually a benign process; however, 12%
of symptomatic detachments reveal a peripheral tear in the retina. The
location of the light sensation in the patient's visual field has no correlation
to the location of a retinal tear.

6
g. Floaters are a very common visual symptom in the population; thus,
distinguishing their etiology requires eliciting a detailed history.
• The sudden onset of one large floater in the center of the visual
axis indicates posterior vitreous detachment (PVD). The patient
observes a circular floater when the vitreous detaches from its
annular ring surrounding the optic nerve.
• Numerous curvilinear opacities indicate vitreous degeneration,
which is considered a normal aspect of a mature eye. More
ominous and concerning is the description of hundreds of tiny
black specks appearing before the eye. This is pathognomonic for
vitreous hemorrhage, resulting from disruption of a retinal vessel
caused by a retinal tear or mechanical traction of a vitreoretinal
adhesion.
• A few hours after the initial shower of black spots, the patient can
note cobwebs that result from blood forming irregular clots.
• Generally, the new onset of floaters associated with flashing lights
indicates a retinal tear until proven otherwise.
h. Visual field defects are a late symptom of retinal detachment.
i. While symptoms of photopsia and floaters are not helpful in locating the
position of the retinal tear or detachment, the visual field defect is very
specific for locating the detachment.
j. Detachments anterior to the equator of the eye cannot be detected with
visual field testing.
k. Detachment posterior to the equator can be isolated with visual field
testing, but the patient usually is unaware of a defect until it involves the
posterior pole and macula.
l. Patients are less aware of a superior field defect (indicating an inferior
detachment) than an inferior field defect (indicating a superior retinal
detachment).
m. Inferior retinal detachment can be a long-standing condition that
progresses without symptoms until the detachment reaches the fovea.

7
 n. Bullous (ie, large ballooning) detachments produce dense visual field
defects (ie, blackness), and flat detachments produce relative field defects
(ie, grayness).
o. When a patient has an extensive detachment, inquiring about the initial
symptoms of the visual field loss is helpful to assist in localization of the
tear.
p. Onset of decreased visual acuity dates the duration of fovea involvement
of the detachment, which correlates with the prognosis for recovery of the
central vision.
q. Metamorphopsia is a macular fluid-based distortion of a visual image and
is commonly described by patients as waviness.
r. Inquire about history of trauma, including whether it occurred several
months before the symptoms or coincided with the onset of symptoms.
Documentation of head or ocular trauma may be subject to legal
investigation, especially in children.
s. Note previous surgery, including cataract extraction, intraocular foreign
body removal, and retinal procedures.
t. Question the patient about previous conditions, such as uveitis, vitreous
hemorrhage, amblyopia, glaucoma, and diabetic retinopathy. Query about
family history of eye disease because, although RDs usually are sporadic
events, certain pedigrees may be prone to detachment. Systemic diseases
associated with retinal detachment include the following:
• Diabetes
• Tumors (eg, breast cancer, melanoma)
• Angiomatosis of the CNS
• Sickle cell disease
• Leukemia
• Eclampsia
• Prematurity

5. Physical

a. Check visual acuity, correcting for refractive error.

8
b. Conduct an external examination for signs of trauma, checking the visual
field (usually a confrontation field examination is adequate). Visual fields
can help isolate the location of the retinal detachment.
c. Check pupil reaction (a fixed dilated pupil may indicate previous trauma; a
positive Marcus-Gunn pupil can occur with any disturbance of the afferent
pupillomotor pathway, including retinal detachment).
d. Administer slit-lamp biomicroscopy (the anterior segment is usually
normal).
e. Examine the vitreous for signs of pigment or tobacco dust (ie, Shafer
sign), which is pathognomonic for a retinal tear in 70% of cases with no
previous eye disease or surgery.
f. Check intraocular pressure measurement in both eyes (hypotony of >4-5
mm Hg less than the fellow eye is common).
g. Conduct a fundus examination with ophthalmoscopy (pupils must be
dilated or a panoptic may be used).
a. Indirect ophthalmoscopy is the definitive means of diagnosing
retinal detachment with the use of scleral depression in order to see
the anterior retina and definitively identify the location of the tear
or hole.
b. Direct funduscopy may detect vitreous hemorrhage and large
detachment of the posterior pole, but it is inadequate for complete
examination because of the lower magnification and illumination,
lack of stereopsis, and limited view of the peripheral retina.
c. A 3-mirror contact lens examination with a slit-lamp may
accomplish adequate examination without scleral depression.
d. Obvious detachment is observed as marked elevation of the retina,
which appears gray with dark blood vessels that may lie in folds.
e. The detached retina may undulate and appear out of focus. Shallow
detachments are much more difficult to detect; thus, comparing the
suspected area with an adjacent normal quadrant is helpful to
detect any change in retinal transparency. Binocular vision is
needed to do this well.

9
 f. A pigmented or nonpigmented line may demarcate the limit of a
detachment, and the retinal surface may have an orange-peel
appearance.
6. Differential diagnosis

Retinal Artery Occlusion

7. Laboratory Studies

Laboratory tests are generally unhelpful in detecting retinal detachment,

but they may be useful for patients who have underlying medical problems that
need to be managed. Subsequent testing may be necessary to detect underlying
causes or related illnesses.

Imaging Studies

a. Imaging techniques, such as orbital films, CT scans, or MRIs, are not

necessary or indicated to assist the diagnoses retinal detachment, but they
may be necessary to detect intraocular foreign bodies and tumors.
b. A prospective observational study on use of ultrasound scans by ED
physicians in patients with signs of retinal detachment showed a 97%
sensitivity (95% confidence interval [CI], 82-100%) and 92% specificity
(95% CI, 82-97%) on 92 examinations (29 retinal detachments).[3]
c. If the retina cannot be visualized because of corneal changes, cataracts, or
hemorrhage, ultrasonography is necessary.
a. A scan ultrasound and B scan ultrasound both can assist the
diagnoses of RD and differentiate it from posterior vitreous
detachment. They also can differentiate rhegmatogenous from
nonrhegmatogenous detachment.
b. In exudative detachments, the presence of underlying subretinal
tumors, choroidal hemorrhage, or detachment can be detected by
ultrasound.

8. Treatment
a. Prehospital Care

10
 Protecting the globe in cases of traumatic retinal detachment may be
important to prevent extrusion of intraocular contents (ie, uveal tissue), and can be
achieved with goggles or a metallic eye shield, if available. It is imperative to
avoid pressure on the globe.

b. Emergency Department Care

ED treatment of retinal detachment consists of evaluating the patient and

treating any unstable vital signs, preparing the patient for possible emergency
surgery.

The repair technique is dependent on the type, location, and size of the
detachment.

1. Laser therapy and cryotherapy are ambulatory outpatient procedures.

2. Use of intraocular gas (ie, pneumatic retinopexy) to tamponade the
detachment can be an outpatient procedure with close follow-up of the
intraocular pressure.
3. Scleral buckling, in which a silicone band indents the eye to approximate
the retina and RPE, is possible as an outpatient procedure. The tear is
closed with supplemental cryotherapy or laser.
4. Intraocular repair with pars plana vitrectomy may be necessary in
complicated tractional and exudative detachments. This procedure once
required hospitalization but is now being performed on an outpatient or
short-stay basis because of insurance restrictions.
5. Inflammatory retinal detachments (RDs) usually are treated medically.
6. An important study in 25 European centers comparing scleral buckling
versus primary vitrectomy in rhegmatogenous retinal detachment (SPR
Study) may answer questions as to the better therapy.
A recently conducted study of a large Medicare population showed that
scleral buckle patients had far fewer recurrent RDs than patients who underwent
retinopexy. This study also showed that patients undergoing pars plana vitrectomy
(PPV) had higher rates of complications, but these data must not be
misinterpreted. Since these are nonrandomized convenience samples, these results
are not definitive; they do not control for differences between treatment groups,

11
surgeons, settings, or important baseline differences between subjects.
Nonetheless, scleral buckle approaches emerge as an important consideration in
eligible patients and should be subject to further testing in properly controlled
randomized trials.

c. Consultations

1. When diagnosed or highly suspected, retinal detachment (RD) requires an

emergent ophthalmologic consultation for confirmation and treatment.
This is particularly true for RDs that threaten the fovea or central vision.
2. Ideally, patients with RD should be referred to a retinal-vitreous specialist
as soon as they are suspected. However, immediate retinal-vitreous
specialist consultation is not necessary in all cases because many general
ophthalmologists are capable of performing indirect ophthalmoscopy and
determining the need for further intervention.
3. Frequently, time is critical; however, the time frame is hours and not
minutes, and many cases do not require emergency surgery. Inflammatory
retinal detachments, for example, usually are treated medically. Acute
retinal breaks should be surgically repaired within 24 hours if at all
possible.

9. Complications

a. Loss of acuity and blindness is the most common complication of a retinal

detachment.
b. Loss of vision to hand motion or light perception is a frequent
complication of retinal detachments (RDs) that involve the macula.
10. Prognosis

a. Ultimate outcome depends upon the time the retina is detached, the
underlying mechanism of the RD, and whether the macula is involved.
b. Prognosis is related inversely to the degree of macular involvement
and the length of time the retina has been off.
CHAPTER III
THE PATIENT STATUS

12
A. HISTORY
Identity
Name : Mrs. R
Gender : Woman
Age : 36 years old
Address : Bakau Besar Laut
Occupation : House wife
Religion : Islam
Tribe/ Ethnic : Malay
Date of consult : April, 15, 2011
Anamnesis access on April, 15, 2011; at 10.00 o’clock

Major complaint
Suddenly vision loss in both eye.

Current medical history

Patient come to the eye centre with major complaint of suddenly
vision loss in both eye. This complaint is first happened and was started
at six weeks ago. The complaint happened in the morning after wake up
from sleep. The first symptom patient see a flashes of light and then
patient feel blurred vision start from left eye and follow to right eye.
The blurred vision is like a fog. After that, the patient not seeking a
medical care and after three days, the patient have vision loss in both of
eye.
At the complaint happened, there is no redness in both of eye,
there is no pain, no discharge and she said that there is no any trauma
before.

Last medical history

13
 • Patient never have similar complaint before
• The complaint about eye disorders is deny
• Patient deny about hypertension and Diabetes Mellitus
Family medical history
• In her family history there is no complaint like this.
• The complaint about eye disorders is deny.

B. GENERAL PHYSICAL EXAMINATION

Have been done on April, 15, 2011; 10.30 o’clock
General condition : health
Awareness : compos mentis
Vital sign : - BP: 120/80 mmHg
– HR: 88 x/menit
– RR: 18 x/menit
– T: unfebris

C. OPTHALMOLOGIC STATUS
Visus : OD : 1/-, good projection
OS : 1/300, good projection
Eye ball position : ortho
Eye ball movement : normal in four direction.
+ +

+ + + +

+ +

OD OS

Confrontation test : can’t be evaluated.

Intra Ocular Pressure : OD: in the palpation impressed smooth

OS : in the palpation impressed smooth

14
 OD OS
No swelling, ptosis (-), No swelling, ptosis (-),
Palpebra
lagoftalmus (-) lagoftalmus (-)
No discharge, injection No discharge, injection
Conjungtiva
(-), hiperemis (-) (-), hiperemis (-)
Clear, edema(-) Cornea Clear, edema (-)
Clear, hypopion (-), Clear, hypopion (-),
Anterior chamber
hifema (-) hifema (-)
Iris colour dark brown, Iris colour dark brown,
sinekia (-) Iris and pupil sinekia (-)
Pupil midriasis, Pupil midriasis,
Clear, Lens Clear,
Clear Vitreous Clear
papil with clear papil with clear
border,pale color, CDR border,pale color, CDR
Fundus
>0,5, retinal tear, >0,5, retinal tear,

Localis status of the eye

RD

papil

Blood vessel
OD OS

D. RESUME
A woman, 36 years old with major complaint of suddenly vision
loss in both eye. This complaint is first happened and was started at six

15
 weeks ago. The complaint happened in the morning after wake up from
sleep. The first symptom patient see a flashes of light and then patient feel
blurred vision start from left eye and follow to right eye. The blurred
vision is like a fog. After that, the patient not seeking a medical care and
after three days, the patient have vision loss in both of eye.
At the complaint happened, there is no redness in both of eye, there is no
pain, no discharge and she said that there is no any trauma before.
In the ophthalmology status, the visual acuity for OD 1/-, OS 1/300
with good projection. In the funduscopy there is papil with clear
border,pale color,CDR > 0,5 and retinal tear in both eye

E. DIAGNOSIS
Working diagnosis
OD : retinal detachment
OS : retinal detachment
Differential diagnosis
Retinal Artery Occlusion

F. DIAGNOSTIC EXAMINATION
Funduscopy and USG
Blood perifer
Blood sugar

G. THERAPY
Non-medicamentosa :

Medicamentosa :

16
 Therapy surgery:
Scleral buckling
Pneumatic retinopexy

H. PROGNOSIS
OD
Ad vitam : dubia at bonam
Ad functionam : dubia at malam
Ad sanactionam : dubia at malam

OS
Ad vitam : dubia at bonam
Ad functionam : dubia at malam
Ad sanactionam : dubia at malam

CHAPTER IV

DISCUSSION

17
 A women, 36 years old with major complaint of suddenly vision loss in
both eye since six weeks ago. At the complaint happened, there is no redness in
both of eye, there is no pain, no discharge and she said that there is no any trauma
before. From the anamnesis of major complaint, we can make the differential
diagnosis are retinal detachment and retinal artery occlusion and exclude the
disease from the infection because there is no discharge. In the retinal detachment,
we can find the symptom are photopsia (see flashes of light) and another
complaint like shadow vision or see in the fog before the vision is totally loss. In
the retinal artery occlusion usually stared with amaurosis fugaks and then the
vision become loss. The suspicion of happen retinal detachment from this patient
is proven by finding of detachment retina from funduscopy examination. For the
surely confirmation, we can make USG examination to see the retinal detachment.

The treatment for this patient is by surgical treatment, Scleral buckling

and Pneumatic retinopexy to make the retinal become detach to the retinal
pigment ephitelial. The prognosis for the visual acuition for this patient is dubia
ad malam because the length of time the retina has been off is to long, so the
retina become malnourished.

18