Retinal Detachment

Retinal Detachment
SYMPTOMS Flashes, Floaters, Black curtain over vision, Relative visual field loss correlating to location of retinal detachment, Central vision loss if retinal detachment involves the macula
SIGNS Rhegmatogenous retinal detachment (most common type): Elevated gray-white tissue that is opaque and wrinkled (appears as "wet tissue paper"). Gray-white tissue may appear to undulate. Other signs include Masking of the underlying choroid, Dark retinal vasculature within the folds of the gray-white tissue, Decrease in IOP ( > 4-5mmHg lower relative to the other eye without the retinal detachment), Shafer sign, Presence of a retinal break, Intravitreal hemorrhages, Subhyaloid hemorrhages, Preretinal hemorrhages, Intraretinal hemorrhages
Tractional retinal detachment (Non-rhegmatogenous retinal detachment): Elevated gray-white tissue that is opaque and wrinkled (appears as "wet tissue paper"). Other signs include Vitreoretinal traction, Signs of retinopathy, Retinal neovascularization, Optic nerve neovascularization, Fibrovascular proliferation, Shafer sign, Intravitreal hemorrhages, Subhyaloid hemorrhages, Preretinal hemorrhages
Exudative retinal detachment (Non-rhegmatogenous retinal detachment): Elevated gray-white tissue that is opaque and wrinkled (appears as "wet tissue paper"). Other signs include Exudates, Signs of retinopathy, Shafer sign, Intravitreal hemorrhages, Subhyaloid hemorrhages, Preretinal hemorrhages
Shallow or subclinical retinal detachments can be difficult to see
The presence of a pigmented line (“watermark”) indicates the chronicity as well as the boundary limit of a retinal detachment
WORK-UP Full eye exam with dilated retinal exam, Scleral depression, Peripheral 90D, Gonioscopy 3-mirror (using retina mirrors), OCT, Peripheral visual field (kinetic is a better choice than static), B-scan ultrasound
TREATMENT Patient should sleep with their head elevated in presence of a preretinal, subhyaloid, and/or intravitreal hemorrhage
Consider discontinuing or lowering the dosage of any blood thinners in the presence of a preretinal, subhyaloid, and/or intravitreal hemorrhage (needs to be discussed with PCP)
Rhegmatogenous / Non-rhegmatogenous retinal detachment with macula-ON: Refer patient to retinal specialist within 24 hours (Urgent!!) for treatment which can include a scleral buckle and/or pneumatic retinopexy
Rhegmatogenous / Non-rhegmatogenous retinal detachment with macula-OFF: Refer patient to retinal specialist within 48-72 hours for treatment which can include a scleral buckle and/or pneumatic retinopexy
FOLLOW-UP Once retinal detachment is treated by a retinal specialist and the retina is stable, the patient should be seen back in 6-12 months
ADDITIONAL LAB | TESTS Rhegmatogenous retinal detachment: None
Non-rhegmatogenous retinal detachment (Tractional/Exudative): Lab testing should be directed at the etiology of the exudates, retinopathy, fibrovascular proliferation, retinal neovascularization, and optic nerve neovascularization
ETIOLOGY Rhegmatogenous retinal detachment: Occurs in the presence of a retinal break as fluid from the vitreous can seep in and cause a separation of the sensory retina from the RPE. Most commonly caused by a PVD
Tractional retinal detachment (Non-rhegmatogenous retinal detachment): Occurs due to adhesions and pulling that occur between the vitreous and fibrovascular traction on the retina which may eventually cause mechanical separation between the sensory retina and the RPE. There is typically no retinal break present
Exudative retinal detachment (Non-rhegmatogenous retinal detachment): Occurs due to leakage of exudates and fluid from retinal vasculature into the subretinal space which can cause separation between the sensory retina and the RPE. There is typically no retinal break present
DIFFERENTIAL DX Retinoschisis, Posterior vitreous detachment, Choroidal detachment, White without pressure
NOTES Non-rhegmatogenous retinal detachments can also develop a secondary rhegmatogenous retinal detachment if a retinal break develops
Retinal detachments can also be associated with congenital malformations, trauma, and choroidal tumors
Risk factors for the development of a retinal detachment include High myopia, Aphakia, Presence of retinal degenerations such as lattice degeneration, History of cataract surgery, Family history of a retinal detachment, and A retinal detachment in the other eye
33% of rhegmatogenous retinal detachments are associated with lattice degeneration
15% of patients with a retinal detachment in one eye will develop a retinal detachment in the other eye
Patients with a retinal detachment treated with a pneumatic retinopexy should NOT fly in a plane until there is no longer gas in the eye
Retinal Detachment: Retinal photo demonstrating a tractional retinal detachment (non-rhegmatogenous) secondary to proliferative diabetic retinopathy https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/traction-RD.htm

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