Retinal Detachment
Retinal detachment is a sight-threatening ophthalmic emergency where the neurosensory retina separates from the underlying retinal pigment epithelium.
This updated UKMLA guide to retinal detachment is based on NICE CKS, which covers: retinal tears, posterior vitreous detachment, types of retinal detachment, risk factors, symptoms, diagnosis, and management.
Terms and Definitions
| Term / condition | Description |
|---|---|
| Retinal tear / break | A small, localised defect in the neurosensory retina, usually caused by traction from the vitreous
It often precedes rhegmatogenous retinal detachment, as fluid can pass through the break into the subretinal space |
| Retinal detachment | Separation of the neurosensory retina from the underlying retinal pigment epithelium
This allows fluid to accumulate in the subretinal space and can cause progressive visual loss. If the macula becomes detached, permanent central visual loss may occur |
| Posterior vitreous detachment | The vitreous gel shrinks and separates from the retina as part of the normal ageing process
Common in older adults and often benign, but it can cause vitreoretinal traction, leading to one or more retinal tears |
Causes and Risk Factors
Key risk factors:
- Myopia (~10x risk if >-3.00)
- Previous cataract surgery (~9x risk)
- Personal / family history of retinal break or detachment
- Eye trauma (esp. blunt trauma e.g. due to boxing)
- Congenital eye diseases (e.g. glaucoma, cataracts, retinopathy of prematurity)
- Genetic disorders (e.g. Marfan syndrome, Stickler syndrome)
- Proliferative diabetic retinopathy
- Inflammatory eye conditions (e.g. uveitis, scleritis)
- Malignancy (e.g. choroidal melanoma, ocular metastasis)
Non-modifiable risk factors:
- Advancing age
- Caucasian and Asian populations
Types of Retinal Detachment
| Type of retinal detachment | Core mechanism | Important causes / association |
|---|---|---|
| Rhegmatogenous | A retinal tear / break allows vitreous fluid to enter the subretinal space causing the separation | Most common type of retinal detachment
Associated with most classic risk factors |
| Tractional | Fibrovascular/scar tissue contracts and pulls the retina away from the underlying retinal pigment epithelium | Proliferative diabetic retinopathy |
| Exudative | Vitreous fluid leaks into the subretinal space without a retinal tear or traction | Inflammatory causes (e.g. uveitis, scleritis)
Malignant causes (e.g. choroidal melanoma, ocular metastasis) |
Clinical Features
Flashes and floaters often occur due to preceding posterior vitreous detachment or retinal tear formation
Once retinal detachment develops:
- Sudden onset, painless visual field loss (that is often progressive)
- Often described as a dark curtain or shadow – starting in the periphery and progressing towards the centre
- If the macula detaches → severely reduced visual acuity
Prognosis:
- Retinal detachment is a preventable cause of permanent visual loss
- The outcome of surgery for retinal detachment depends on the type, duration, and site of detachment
- Once the detachment extends across the macula, permanent visual loss is almost inevitable, even with successful reattachment of the retina
Posterior vitreous detachment in isolation does NOT cause visual field loss.
It typically presents with new flashes and floaters, and a Weiss ring may be seen on fundoscopy.
However, posterior vitreous detachment can cause vitreoretinal traction, which may lead to a retinal tear and subsequent rhegmatogenous retinal detachment.
Investigation and Diagnosis
Primary Care Assessment
| Examination / assessment | Finding in retinal detachment |
|---|---|
| Pupil assessment | RAPD (Marcus Gunn pupil) may be present if there is extensive detachment |
| Visual acuity assessment (Snellen chart) | Reduced
Vision may be reduced to finger counting or hand movements if the macula is detached |
| Visual field assessment | Visual field loss (often described as a curtain or shadow over part of the vision) |
| Fundoscopy |
|
Given the high risk of retinal detachment in the other eye, both eyes should be evaluated.
Referral Criteria
Arrange immediate referral to ophthalmology if there are signs of sight-threatening disease, such as:
- Change in visual acuity
- Visual field loss
- Fundoscopic signs of retinal detachment or vitreous haemorrhage
If a person is experiencing new-onset flashes and/or floaters and a diagnosis of retinal detachment is suspected, but immediate referral is not indicated → urgent referral to a practitioner competent in the use of slit lamp examination and indirect ophthalmoscopy to be seen within 24 hours
Vitreous haemorrhage is a warning feature because it may indicate an underlying retinal tear, which can progress to retinal detachment.
Furthermore, vitreous haemorrhage may obscure visualisation of the retina on fundoscopy, so referral for further imaging (e.g. B-scan ultrasound) may be required.
Secondary Care Assessment
Definitive assessment is usually by slit-lamp examination
Other imaging modalities [Ref]
- B-scan ultrasound – can be used when the fundus cannot be visualised clearly (e.g. due to vitreous haemorrhage or dense cataract)
- OCT – can be used to assess all 3 types of retinal detachment and may be used to assess macular involvement or subretinal fluid when the retina can be adequately imaged
- CT / MRI – if intra-ocular mass or malignancy is suspected
Management
Most retinal detachments is managed surgical (specifically rhegmatogenous and tractional), 3 main surgical techniques:
- Vitrectomy
- Scleral buckling
- Pneumatic retinopexy
Exudative retinal detachment is usually not managed surgically in the same way as above. Management focuses on identifying and treating the underlying retinal or choroidal cause. [Ref]
Retinal tears or breaks without retinal detachment may be treated with laser photocoagulation or cryotherapy to seal the break and reduce the risk of progression to retinal detachment.