11/14/24, 10\:46 AM Retinal Detachment

Retinal Detachment

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Key points ⚡
Succinct notes to superpower your revision
Retinal detachment\: separation of the neurosensory retina from the retinal pigment epithelium; sight-threatening and an
ocular emergency requiring urgent referral to ophthalmology.
Anatomy\: retina composed of 10 layers, with photoreceptors (rods and cones) in the neurosensory retina converting light
into neural impulses.
Aetiology\: commonly due to full-thickness retinal tear (rhegmatogenous); other types include tractional (e.g. diabetic
retinopathy) and exudative (e.g. exudative tumours, in
Risk factors\: age >40, male, myopia, family history, previous ocular surgery, trauma, detachment in the contralateral eye.
Symptoms\: painless vision loss,
Clinical examination\: poor visual acuity, relative a

'Tobacco dust' appearance (Shafer’s sign).
Di
Investigations\: slit lamp with triple mirror, indirect ophthalmoscopy, ultrasound (if vitreous haemorrhage).
Management\:
Preventative\: laser photocoagulation for retinal tears.
Surgical\: vitrectomy (draining vitreous and subretinal
injection and laser/cryotherapy), scleral buckle (silicone band and cryotherapy/laser).
Complications\: partial or complete unilateral vision loss; involvement of the macula results in poorest visual outcomes.
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A comprehensive topic overview

Introduction

Retinal detachment occurs when the layers of the retina separate - speci
pigment epithelium. This is a sight-threatening condition and considered an ocular emergency warranting an urgent
referral to ophthalmology.

Anatomy

The retina is a structure of cells lining the back of the eye (Figure 1). It is comprised of 10 separate layers which can be
broadly split into the inner neurosensory retina and the outer retinal pigment epithelium.
Within the neurosensory retina lies the photoreceptors (rods and cones) which are responsible for converting light into
neural impulses, which are then transmitted to the brain for the formation of images. The retina is bound by Bruch’s
membrane, the choroid (externally) and the vitreous (internally).
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Figure 1. Anatomy of the eye, including retina
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Aetiology

Retinal detachment most commonly occurs secondary to a full-thickness retinal tear which enables the build-up of
vitreous 2
This is known as a rhegmatogenous retinal detachment (Figure 2).
Other causes/types of retinal detachment can be classed as follows\:
Tractional\: vitreous membranes pull on the retina which separates it from the epithelial layer beneath. There are no tears
or holes formed. This is more common in patients with diabetic retinopathy.
Exudative\: an underlying retinal disease leads to the build-up of exudative
tumours, in
Of note, posterior vitreous detachment (PVD) often precedes retinal detachment. This is where the vitreous gel separates
from the retina and is due to trauma or ageing. About 1 in 10 will go on to develop a retinal tear, which if left untreated will
develop into a full retinal detachment.
3
Figure 2. Rhegmatogenous retinal detachment
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Risk factors

Risk factors for rhegmatogenous retinal detachment (most common), include\:
Age >40
Male
Myopia (near-sightedness)
Family history of retinal detachment
Previous ocular surgery
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Trauma
Retinal detachment in the contralateral eye

Clinical features

History

Typical symptoms of retinal detachment include\:
Painless loss of vision
Flashing lights and
“Cobwebs” in the peripheral vision
Shadow or grey curtain moving across the

Clinical examination

In the context of suspected retinal detachment a complete assessment of the eyes and vision should be performed.
Clinical
Poor visual acuity
Relative a
Altered red re
Reduced visual acuity (if the macula is involved)
Visual
A sheet of sensory retina billowing towards the centre of the globe
Slit lamp examination may reveal a ‘Tobacco dust’ appearance of the anterior vitreous\: a result of pigment cells migrating
through a tear in the retina (also known as Shafer’s sign)

Di

Possible di
Retinoschisis\: split within the neurosensory layer (no Tobacco dust sign or corrugated appearance on fundoscopy)
Choroidal mass\: solid mass associated with
vitreous)

Investigations

Further investigation under a slit lamp with a triple mirror is used to assess for anterior breaks (Figure 3).
Indirect ophthalmoscopy will also reveal the location and number of retinal tears and the amount of underlying
Ultrasound can also be used if there is a vitreous haemorrhage caused by a tear involving a retinal vessel.
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Figure 3. Horseshoe retinal tear causing retinal detachment
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Management

Preventative management

Patients with symptoms of an acute PVD or a retinal tear should be examined without delay. If a retinal tear is found, this
can be treated with laser photocoagulation in the clinic and to reduce the risk of a detachment occurring.
The majority of cases are treated at this point and do not progress to a retinal detachment.

Surgical management

There are three main surgical techniques for managing retinal detachment.
Vitrectomy
Vitrectomy is the most common treatment of RD.
The vitreous (the gel that
against the underlying epithelium.
Cryotherapy or laser therapy is used to seal the retinal tear and the eye is then
bubble to hold it in place.
This technique also requires the patient to maintain a head position after surgery with post-op patients unable to
months and not suitable for any anaesthetics involving nitric oxide.
Pneumatic retinopexy
Pneumatic retinopathy is suitable for straightforward cases and involves a 2-step process.
An expansile gas is injected into the vitreous which
Laser or cryotherapy retinopexy then creates an adhesive scar which holds the retina in place and prevents the vitreous

This procedure can be performed in-clinic but requires the patient to maintain a speci
ensure reattachment occurs.
Scleral buckle
Cryotherapy or laser photocoagulation is used to create a scar around the retinal break.
A silicone band is then sutured onto the sclera, and this indents the retina to close the retinal break and relieve traction.
The scleral buckle remains around the eye permanently in most cases.
This technique is now less common, although can be applied following retinal dialysis (a circumferential break often
caused by blunt trauma) (Figure 4).
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Figure 4. Scleral buckle sutured around the eye to indent the
retina and close the break
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Complications

Complications of retinal detachment include\:
Partial or complete unilateral vision loss
Retinal detachment involving the macula carries the worst prognosis and results in the poorest visual outcomes.

Related notes

References

Acute Angle-Closure Glaucoma
Age-related Macular Degeneration (ARMD)
OpenStax College. S t r u c t u r e o f t h e e y e . Published in 2013. Licence\: [CC BY-3.0]. Available from\: [LINK]
Amblyopia
Timothy L. Jackson. M o o r [LINK]
Ametropia
The Royal College of Ophthalmologists. P o s t e r i o r v i t r e o u s d e t a c h m e n t . Published in 2020. Available from\: [LINK]
Anisocoria
Erin Silversmith. H u m a n e y e c r o s s-s e c t i o n d e t a c h e d r e t i n a . Licence\: [CC BY-3.0]. Available from\: [LINK]
Jesse Vislisel, MD. R h e g m a t o g e n o u s r e t i n a l d e t a c h m e n t . Licence\: [CC BY-3.0]. Available from\: [LINK]

Test yourself

Erin Silversmith. H u m a n e y e c r o s s-s e c t i o n s c l e r a l b u c k l e . Licence\: [CC BY-3.0]. Available from\: [LINK]

Reviewer

Contents

Mr Kashani
Introduction
Consultant Ophthalmologist
Anatomy
Aetiology
Risk factors
Clinical features
Di
Investigations
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