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***LISTEN TO THE PODCAST HERE***

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Definition

A retinal detachment is defined as a separation of the multilayer neurosensory retina from the underlying retinal pigment epithelium and choroid.

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Epidemiology

Retinal detachments have been reported to occur in 6-20 per 100,000 population worldwide, but there is wide variability in incidence between the types.  Risk factors include:

• Myopia (most common)
• Age (50-75yr)
• Previous eye surgery or injury
• Use of fluoroquinolones
• History of glaucoma
• Family history of retinal detachment
• Diabetes
• Hypertension

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Pathophysiology and Types

There are 2 main types of retinal types and the pathophysiology is slightly different.

• Rhegmatogenous (most common)
  • Full-thickness tear caused by vitreous traction on the retina
    • Not to be confused with tractional detachment
      • RRD à tear 1^st, then vitreous traction forces fluid in
      • TRD à traction pulls the layers away, but no tear
    • Most common site is a posterior vitreous detachment
      • Typically take weeks to months to fully develop
    • Traumatic retinal detachment can occur from surgery or injury
• Nonrhegmatogenous
  • Tractional
    • Vitreous traction separates the layers and neovascularization from DM, HTN, sickle cell causes fluid to accumulate
  • Exudative
    • Fluid accumulation from inflammatory states or ocular malignancies causes the separation of layers

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Signs and Symptoms

• Mostly slow onset (weeks to months), but can be acute if traumatic
• Increase, or worsening of floaters
  • Multiple, cob-web like
  • Single, large
    • Romans called this “mosca volante” –> large housefly
• Gradual loss of peripheral vision (“curtain pulled over eye”)
• Decrease in visual acuity once the macula is involved

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Physical Exam

All patients with any eye complaint should have visual acuity checked and documented.  If you suspect a detachment from the history, visual fields should be assessed.  Fundoscopic exam should be performed to look for any gross retinal defects.  All patients with a suspected retinal detachment should be referred for urgent evaluation by an ophthalmologist for dilated retinal exam with slitlamp.  The test of choice is a 360^o scleral depressed examination using an indirect ophthalmoscope.

 

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Imaging

Ultrasound technology is getting better and better and ocular scanning can see detachments at the bedside in the hands of a competent provider.

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Treatment

• Detachment without tear
  • Reassurance that floaters with resolve over 3-12 months
• Tear without detachment
  • Risk of detachment is around 30% if left untreated
  • 2 options
    • Laser Retinopexy
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    • Cryoretinopexy
      • (see below scleral buckling video)
    • Both take approximately 2 weeks to form strong adhesions
  • Tear with detachment
    • Without treatment, will progress to complete vision loss
    • Small tears
      • Laser or cryoretinoplexy
    • Large tears
      • Pneumatic retinopexy (office)
        • Cryoretinopexy with injection of gas bubble and head position to tamponade the tear
        • 24-48hr for fluid reabsorption and retinal re-attachment
        • 70-80% 1^st time success
      • Scleral buckle (OR)
        • Cryoretinopexy with suturing of an exoplant to the outside of the sclera, which causes an indentation in the wall of the eye
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        • 80-90% 1^st time success
      • Vitrectomy
        • Removal of central and peripheral vitreous humor with gas or liquid injection
        • 80-90% 1^st time success

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References

1. Mitry D, Charteris DG, Fleck BW, Campbell H, Singh J. The epidemiology of rhegmatogenous retinal detachment: geographical variation and clinical associations. The British Journal of Ophthalmology. 2010;94(6):678-84. [pubmed]
2. Wilkes SR, Beard CM, Kurland LT, Robertson DM, O’Fallon WM. The incidence of retinal detachment in Rochester, Minnesota, 1970-1978. American Journal of Ophthalmology. 1982;94(5):670-3. [pubmed]
3. Haimann MH, Burton TC, Brown CK. Epidemiology of retinal detachment. Archives of Ophthalmology (Chicago, Ill. : 1960). 1982; 100(2):289-92. [pubmed]
4. Risk factors for idiopathic rhegmatogenous retinal detachment. The Eye Disease Case-Control Study Group. American Journal of Epidemiology. 1993;137(7):749-57. [pubmed]
5. Pasternak B, Svanström H, Melbye M, Hviid A. Association between oral fluoroquinolone use and retinal detachment. JAMA. 2013;310(20):2184-90. [pubmed]
6. Go SL, Hoyng CB, Klaver CC. Genetic risk of rhegmatogenous retinal detachment: a familial aggregation study. Archives of Ophthalmology (Chicago, Ill. : 1960). 2005;123(9):1237-41. [pubmed]
7. Hikichi T, Trempe CL, Schepens CL. Posterior vitreous detachment as a risk factor for retinal detachment. Ophthalmology. 1995;102(4):527-8. [pubmed]
8. Wolfensberger TJ, Tufail A. Systemic disorders associated with detachment of the neurosensory retina and retinal pigment epithelium. Current Opinion in Ophthalmology. 2000;11(6):455-61. [pubmed]
9. Hollands H, Johnson D, Brox AC, Almeida D, Simel DL, Sharma S. Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA. 2009;302(20):2243-9. [pubmed]
10. Byer NE. Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment. Ophthalmology. 1994;101(9):1503-13. [pubmed]
11. Coffee RE, Westfall AC, Davis GH, Mieler WF, Holz ER. Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis. American Journal of Ophthalmology. 2007;144(3):409-413. [pubmed]
12. D’Amico DJ. Clinical practice. Primary retinal detachment. The New England Journal of Medicine. 2008;359(22):2346-54. [pubmed]
13. Hilton GF, Tornambe PE. Pneumatic retinopexy. An analysis of intraoperative and postoperative complications. The Retinal Detachment Study Group. Retina (Philadelphia, Pa.). 1991;11(3):285-94. [pubmed]
14. Tornambe PE, Hilton GF. Pneumatic retinopexy. A multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling. The Retinal Detachment Study Group. Ophthalmology. 1989;96(6):772-83. [pubmed]