Retinal Detachment

Aka: Retinal Detachment, Detached Retina

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II. Definitions

  1. Retinal Detachment
    1. Retinal neurosensory layer separates from the underlying pigmented epithelium

III. Epidemiology

  1. Incidence (U.S.): 10 per 100,000 per year (most over age 50 years old)
  2. Lifetime risk: 1 in 300 patients
  3. Age over 50 years old (peaks 60 to 70 years old)
  4. Gender: Twice as common in men

IV. Pathophysiology

  1. Retina is normally fixed to underlying epithelium by negative fluid pressure
  2. In Retinal Detachment, Retina detaches from underlying epithelium
    1. Affected Neurons are separated from the Choroid, their vascular supply
    2. Vision Loss in affected Neurons is permanent if not corrected within 24 to 72 hours
    3. Retinal Detachments often start localized but may progress to larger area without treatment
    4. Even a fully Detached Retina, will still be fixed to the region of the Optic Nerve Head and the ora serrata

V. Types

  1. Rhegmatogenous Retinal Detachment (most common)
    1. Posterior Vitreous Detachment is initiating event
      1. Peripheral Retina (at the globe's equator) is thinnest, allowing for tear as vitreous separates
      2. Vitreous seeps via tear in Retina under the Neuronal layer into the subretinal space
      3. Posterior Vitreous Detachment confers 10-15% risk of progression to Retinal Detachment
      4. Other precipitating events include Trauma or focal Retinal thinning (latice degeneration)
    2. Common age >50-60 years old (with related increased traction at vitreous attachments)
    3. Vitreous pulls on Retina causing brief flashing lights (Photopsias)
    4. Vitreous Detachment will result in shadows forming on the Retina (visual Floaters)
  2. Exudative Retinal Detachment or serous Retinal Detachment
    1. Subretinal inflammation or mass lesion attracts increased fluid into subretinal space
    2. Causes include sarcoid Uveitis, Severe Hypertension and neoplasms
  3. Tractional Retinal Detachment
    1. Fibrosis due to Trauma, infection, inflammation or Retinopathy
    2. Most commonly due to traction from neovascularization (e.g. proliferative Diabetic Retinopathy)

VI. Risk Factors

  1. Most common risks
    1. Myopia (Near-sightedness, due to egg-shaped globe)
      1. Myopia with >3 diopter Refractive Error confers 10x increased risk
    2. Eye Trauma
      1. Rarely complicated by Retinal Detachment (0.2 in 10,000 per year)
    3. Coagulopathy
    4. Older age (especially age > 50-60 years)
    5. Prior Cataract surgery (decreases vitreous via liquefaction): 0.1 to 1% risk
    6. History of prior Retinal Detachment in the contralateral eye
    7. Prior Retinal Detachment (10% risk of Retinal Detachment in other eye within 4 years)
  2. Other risk factors
    1. Diabetic Retinopathy
    2. Retinopathy of Prematurity
    3. Congenital Cataracts
    4. Congenital Glaucoma
    5. Retinal Detachment Family History

VII. Symptoms

  1. Classic triad: Flashes, Floaters and Visual Field Defect
  2. Unilateral Photopsia (Light Flashes)
    1. Each light flash lasts <1 second
    2. Occurs with vitreous pulling on the Retina (see above)
    3. Occurs with either Vitreous Detachment or Retinal Detachment
      1. Suggests Retinal Detachment or signficant bleeding if accompanied by Vision Loss
    4. Extraocular Movement may be provocative
  3. Unilateral increase in number of Floaters
    1. Occurs with Vitreous Detachment (see above)
  4. Acute, painless Vision Loss
    1. Develops peripherally and progresses centrally
    2. Develops over a course of hours to days
    3. Ultimately may involve the Macula (Macula-Off Retinal Detachment)
      1. Significantly worse prognosis for Vision in the affected eye
      2. Persistent severe Vision Loss even with surgery
  5. Altered Visual Field
    1. Light gray shadow or curtain Sensation falls over affected region of eye (typically from lateral edge)
    2. Shadow location does not move with a change in gaze
    3. Vision may be cloudy, or completely lost as in cases associated with severe bleeding
    4. Progresses as Retina peels away from the underlying Choroid
    5. Metamorphopsia (wavy distortion of Vision)

VIII. Signs

  1. Visual Field Exam by Confrontation
    1. Visual Field Deficits may be subtle
  2. Funduscopic Exam with Pupil Dilation (direct and indirect)
    1. Careful exam by a skilled examiner focused on the peripheral Retina
    2. Affected Retina will have the pale billowing appearance of a parachute
    3. Vitreous bleeding may occur if small Retinal vessels are torn
  3. Afferent Pupillary Defect
    1. Typically normal pupil response unless severe Retinal Detachment

IX. Differential Diagnosis

  1. See Floaters (Entopsias)
  2. See Flashing Lights (Photopsias)
  3. See Acute Vision Loss
  4. Vitreous Detachment

X. Imaging: Ocular Ultrasound

  1. Indications
    1. Emergency Department evaluation of Retinal Detachment
    2. Ophthalmoscopy (Fundoscopy) is non-diagnostic
  2. Findings
    1. Hyperechoic Retina floats freely within vitreous chamber, and moves with Extraocular Movement
  3. Efficacy
    1. in non-dilated Eye Exam, Ocular Ultrasound has better sensitivity
      1. Test Sensitivity: 97-100%
      2. Test Specificity: 83-100%
    2. Bedside Ultrasound in ED has high accuracy with training (Test Sensitivity 91%, Test Specificity 96%)
      1. Jacobsen (2016) West J Emerg Med 17(2): 196-200 +PMID: 26973752 [PubMed]

XI. Management

  1. Emergent, immediate ophthalmology referral
    1. Normal Visual Acuity with suspected new Retinal Detachment confers a higher urgency
    2. Goal is to intervene early to maintain that Visual Acuity
      1. Macula-on (fovea sparing) Retinal Detachment repair within 3 days
      2. Macula-off Retinal Detachment repair within 6 to 7 days
  2. Ophthalmology management
    1. Retina fixed in place (pneumatic retinopexy)
      1. Air or gas injected into the posterior vitreous cavity
      2. The gas tamponades the loose segment of Retina back in place
      3. Forces out trapped fluid beneath the Retinal tear (or that fluid is removed with vitrectomy)
    2. Reattachment of Retina
      1. Ophthalmologist locates the Retinal tear
      2. Cryotherapy, diathermy or laser photocoagulation applied to Retinal tear
      3. Reattaches, or tacks down the Retina
    3. Reduce vitreous tension at attachment to Retina (may not be required)
      1. Scleral buckling involves the suturing of constricting silicone band to external Sclera
      2. Results in indentation of Sclera, decreasing globe diameter, and decreasing vitreous traction
      3. Allows ocular wall to recontact the Retina at the site of the Retinal break
        1. On recontact, Retinal epithelium resorbs subretinal fluid, and reattaches within days
    4. Posterior vitrectomy (with Scleral buckling)
      1. Intraocular procedure to extract vitreous gel from the Retinal break region
      2. Followed by pneumatic retinopexy (see above) to hold the Retina in place
      3. Posterior vitrectomy is performed with Scleral buckling in Macula-Off Retinal Detachment

XII. Prognosis

  1. Surgical Repair has a good prognosis in Macula-on (fovea sparing) Retinal Detachment
    1. Overall surgery is successful in 95% of cases if performed within 3 days of onset
    2. Vision 20/40 or better in 75 to 80% of cases unless central Macula involvement
  2. Predictors of worse outcome
    1. Delayed repair (>3 days for Macula-on, >6 to 7 days for Macula off)
    2. Detachment involving Macula (Macula-off)
      1. Vision 20/40 in <60% of patients even with prompt repair

XIII. Complications

  1. Proliferative vitreoretinopathy
    1. Fibrosis forms within weeks of repair
  2. Retinal Detachment in contralateral eye (25% risk)

XIV. Prevention

  1. Sports Eye Protection
  2. Posterior Vitreous Detachment
    1. May require laser "tacking" of Retina
    2. Aggressively follow patients with new onset
    3. Higher risk if increase in Floaters present
  3. Contralateral eye Retinal Detachment
    1. Periodic Eye Exams by ophthalmology in those with Retinal Detachment history

XV. References

  1. Sales, Patel and Patel (2019) Crit Dec Emerg Med 33(12): 3-13
  2. Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
  3. Trobe (2012) Physicians Guide to Eye, p. 151-3
  4. Yu and Jasani (2024) Crit Dec Emerg Med 38(1): 27-34
  5. Banker (2001) Ophthalmol Clin North Am 14(4):695-704 [PubMed]
  6. Gariano (2004) Am Fam Physician 69:1691-8 [PubMed]
  7. Gelston (2020) Am Fam Physician 102(9):539-45 [PubMed]
  8. Gelston (2013) Am Fam Physician 88(8):515-9 [PubMed]

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Related Studies

Ontology: Retinal Detachment (C0035305)

Definition (MEDLINEPLUS)

The retina is a layer of tissue in the back of your eye that senses light and sends images to your brain. It provides the sharp, central vision needed for reading, driving, and seeing fine detail. A retinal detachment lifts or pulls the retina from its normal position. It can occur at any age, but it is more common in people over age 40. It affects men more than women and whites more than African Americans. A retinal detachment is also more likely to occur in people who

  • Are extremely nearsighted
  • Have had a retinal detachment in the other eye
  • Have a family history of retinal detachment
  • Have had cataract surgery
  • Have other eye diseases or disorders
  • Have had an eye injury

Symptoms include an increase in the number of floaters, which are little "cobwebs" or specks that float about in your field of vision, and/or light flashes in the eye. It may also seem like there is a "curtain" over your field of vision.

A retinal detachment is a medical emergency. If not promptly treated, it can cause permanent vision loss. If you have any symptoms, see an eye care professional immediately. Treatment includes different types of surgery.

NIH: National Eye Institute
Definition (NCI_CTCAE) A disorder characterized by the separation of the inner retina layers from the underlying pigment epithelium.
Definition (NCI) An eye emergency condition which may lead to blindness if left untreated. It is characterized by the separation of the inner retina layers from the underlying pigment epithelium. Causes include trauma, advanced diabetes mellitus, high myopia, and choroid tumors. Symptoms include sudden appearance of floaters, sudden light flushes, and blurred vision.
Definition (MSH) Separation of the inner layers of the retina (neural retina) from the pigment epithelium. Retinal detachment occurs more commonly in men than in women, in eyes with degenerative myopia, in aging and in aphakia. It may occur after an uncomplicated cataract extraction, but it is seen more often if vitreous humor has been lost during surgery. (Dorland, 27th ed; Newell, Ophthalmology: Principles and Concepts, 7th ed, p310-12).
Definition (CSP) separation of the inner layers of the retina from the pigment epithelium.
Concepts Acquired Abnormality (T020)
MSH D012163
ICD9 361.9
ICD10 H33.2
SnomedCT 42059000, 155103005, 193347002
English RETINA DETACHMENT, Detachment, Retinal, Detachments, Retinal, Retinal Detachments, Unspecified retinal detachment, retina detachment, Retina Detachment, Sensory retinal detachment, RETINA, CONGENITAL NONATTACHMENT OF, RETINAL DETACHMENT, Retinal Detachment, retinal detachment, retinal detachment (physical finding), detached retina, retinal detachment (diagnosis), Detachment retinal, Retinal detachment NOS, Retinal Detachment [Disease/Finding], retinal detachments, Detachment;retinal, retina detached, Retinal detachment NOS (disorder), DETACHED RETINA, RETINA, DETACHED, Retinal detachment, RD - Retinal detachment, Detached retina, Retinal detachment (disorder), detachment; retina, retina; detachment, Retinal detachment, NOS, Amotio retinae
German NETZHAUTABLOESUNG, Abloesung der Netzhaut, abgeloeste Netzhaut, unspezifische Netzhautabloesung, Amotio retinae, Netzhautabloesung, Ablatio retinae, Netzhautablösung
Italian Distacco retinico, Distacco di retina, Distacco retinico non specificato, Distacco della retina
Dutch amotio retinae, niet-gespecificeerde retinaloslating, losgelaten retina, loslating retina, loslating; retina, retina; loslating, retinaloslating, Ablatio retinae, Netvliesloslating
French Rétine décollée, Décollement de la rétine (amotio retinae), Décollement rétinien non précisé, DECOLLEMENT DE LA RETINE, Décollement de la rétine, Décollement rétinien
Portuguese Amotio retinae (descolamento da retina), Descolamento da retina NE, Retina descolada, DESCOLAMENTO DA RETINA, Descolamento de Retina, Descolamento do Epitélio Pigmentar da Retina, Descolamento da retina, Descolamento Retiniano
Spanish Desprendimiento retiniano, Desprendimiento de retina no especificado, Amotio retinae, RETINA, DESPRENDIMIENTO, desprendimiento de retina, SAI, desprendimiento de retina, SAI (trastorno), desprendimiento de retina (trastorno), desprendimiento de retina, desprendimiento retiniano, Desprendimiento de retina, Desprendimiento de Retina
Japanese 網膜剥離, 詳細不明の網膜剥離, ﾓｳﾏｸﾊｸﾘ, ｼｮｳｻｲﾌﾒｲﾉﾓｳﾏｸﾊｸﾘ
Swedish Näthinneavlossning
Finnish Verkkokalvon irtauma
Russian SETCHATKI OTSLOIKA, PIGMENTNOGO EPITELIIA SETCHATKI OTSLOIKA, ПИГМЕНТНОГО ЭПИТЕЛИЯ СЕТЧАТКИ ОТСЛОЙКА, СЕТЧАТКИ ОТСЛОЙКА
Czech Odchlípená sítnice, Amotio retinae, Odchlípení sítnice, Blíže neurčené retinální odchlípení, odchlípnutí sítnice, odchlípení sítnice, amotio retinae, retina - odchlípení, amoce
Croatian RETINALNA ABLACIJA
Polish Odwarstwienie siatkówki
Hungarian Retina leválás, Levált retina, Nem meghatározott retinaleválás, Retinaleválás, Ideghártya-leválás
Norwegian Netthinneløsning, Retinaløsning
Derived from the NIH UMLS (Unified Medical Language System)

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