Retinal detachment

Background

• Separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE)
• Ophthalmologic emergency — requires urgent referral; macula-off detachments should be repaired within 24-72 hours
• Three types:
  • Rhegmatogenous (most common) — tear/break allows vitreous fluid under retina
  • Tractional — fibrous bands pull retina (diabetic retinopathy, sickle cell)
  • Exudative — fluid accumulation without a break (inflammation, tumor)
• Annual incidence: ~1 in 10,000

Risk Factors

• Myopia (nearsightedness) — strongest risk factor
• Prior cataract surgery
• Trauma (blunt or penetrating)
• Family history of retinal detachment
• Prior retinal detachment in fellow eye
• Lattice degeneration
• Age >50 (posterior vitreous detachment)

Clinical Features

• Painless visual symptoms (pain suggests alternative diagnosis)
• Photopsia — flashing lights (traction on retina)
• Floaters — sudden onset or dramatic increase
• Visual field deficit — described as a "curtain" or "shadow" moving across vision
• Decreased visual acuity if macula involved (macula-off detachment)
• Shafer sign (tobacco dust / pigment in anterior vitreous) is pathognomonic on slit lamp

Differential Diagnosis

• Posterior vitreous detachment (most common cause of flashes/floaters; benign)
• Vitreous hemorrhage
• Central retinal artery occlusion
• Central retinal vein occlusion
• Optic neuritis
• Migraine with visual aura
• Acute angle-closure glaucoma

Evaluation

• Bedside ocular ultrasound — high sensitivity (97%) for detecting retinal detachment
  • Undulating membrane tethered to the optic disc (distinguishes from posterior vitreous detachment)
• Fundoscopic exam: retinal elevation, tears, or folds
  • May be difficult to visualize in ED without pupil dilation
• Visual acuity — document in all patients
• Pupil exam — APD may be present

Management

• Emergent ophthalmology consultation
  • Macula-on detachment: repair within 24 hours (to preserve central vision)
  • Macula-off detachment: repair within 24-72 hours; outcomes less time-sensitive
• Restrict activity and avoid Valsalva maneuvers
• If a superior detachment, position patient upright (to slow progression)
• If inferior detachment, supine positioning
• No specific ED treatment will reverse detachment — definitive repair is surgical
• Surgical options (for ophthalmology): pneumatic retinopexy, scleral buckle, vitrectomy

Disposition

• Emergent ophthalmology referral for all suspected retinal detachments
• Macula-on: same-day evaluation and likely same-day repair
• Macula-off: urgent repair within days; outpatient if ophthalmology comfortable
• Posterior vitreous detachment without retinal break: outpatient ophthalmology follow-up within 1-2 weeks

See Also

• Posterior vitreous detachment
• Vitreous hemorrhage
• Central retinal artery occlusion
• Acute angle-closure glaucoma
• Eye emergencies