Retinal Detachment

BASICS

Definition: Separation of sensory retina from retinal pigment epithelium
Types:
Rhegmatogenous RD (RRD): Most common; fluid vitreous enters subretinal space via a break
Exudative/Serous RD: No retinal break; associated with inflammation or tumor
Traction RD: Mechanical pull from vitreoretinal adhesions (e.g., proliferative diabetic retinopathy)

Most common: Traction from posterior vitreous detachment (PVD)
Aging: Vitreous gel liquefies and separates, leading to tears
Other causes:
Exudative: Tumors, inflammatory diseases, drugs, hypertension
Traction: Diabetic retinopathy, retinopathy of prematurity, sickle-cell retinopathy, trauma, PVR

Genetics: Increased risk with family history, especially high myopia

Monitor at-risk patients; prophylactic treatment for some high-risk retinal lesions

Pediatrics: Usually due to vitreoretinal disorders/retinopathy of prematurity

Visual field: Differentiates RRD from retinoschisis
Ultrasound: For cases where fundus is not visible (e.g., cataract, hemorrhage)
OCT: Detects PVD and RD
Fluorescein angiography: Exudative cases

Intraoperative: Intraocular gases (air, perfluoropropane, sulfur hexafluoride), perfluorocarbon liquids, silicone oil
Contraindication: Poorly controlled glaucoma
Caution: Avoid high altitudes and nitrous oxide anesthesia with gas bubble
Steroids: For some exudative cases (caution: can worsen central serous retinopathy)

Timing:
Macula-on: Repair ideally within 24 hours
Macula-off: Repair within 10 days
Techniques: Demarcation laser, pneumatic retinopexy (PR), scleral buckle (SB), pars plana vitrectomy (PPV)
Combination PPV + SB for high PVR risk
Early PPV for macula-sparing or complicated cases
Postoperative: Head positioning if gas used; avoid high altitude

Follow-up: Watch for new floaters/flashes, vision loss; re-examine after PVD, especially if vitreous hemorrhage
Monitoring: Warn of warning signs; serial indirect ophthalmoscopy
Ultrasound: If poor visualization

RRD:
90% success in reattachment after ≥1 surgeries
Visual outcome best if macula is not detached pre-op
87% with macula-on achieve 20/50+ vision; 37% with macula-off
Risk factors for repair failure: choroidal detachment, hypotony, PVR, large/giant breaks, >1 break, inferior breaks
18% require second procedure within 90 days (PR highest reoperation rate)
Tractional RD: Observe unless fovea threatened
Exudative RD: Treat underlying condition; prognosis good if managed

PVR: Most common cause of failed repair; 10–15% redetach after initial surgery
Vision loss: Macular detachment, PVR, macular edema/pucker, optic neuropathy
Other: SB-related conjunctival erosion/infection, need for repeat surgery