Retinal detachment
👁️ Overview
- Retinal detachment = separation of the retina’s inner layers from the underlying retinal pigment epithelium (RPE) or choroid.
- ⚠️ Ophthalmic emergency → requires urgent intervention to prevent irreversible vision loss.
🧬 Etiology
- Most commonly due to a retinal hole, tear, or break allowing vitreous fluid to seep under the retina.
- Risk Factors: 👓 High myopia, 👶 prematurity, 👴 age, 👁️ diabetic retinopathy, 💉 cataract surgery, 🔥 intraocular inflammation, 🧠 trauma, vitreous traction bands, family history.
🔎 Types of Retinal Detachment
- Rhegmatogenous (most common) → Retinal break/tear → fluid passes under retina.
- Tractional → Scar tissue contracts and pulls retina off RPE (e.g., diabetes).
- Exudative → Fluid accumulates beneath retina (e.g., inflammation, tumours, trauma) without a break.
🩺 Clinical Presentation
- ⚡ Photopsia: Flashes of light.
- ⚫ Floaters: Dark spots or cobwebs in vision.
- 🪟 Visual field loss: “Curtain” or shadow descending across vision.
- 👓 Gradual, painless vision loss (cloudy or blurred).
- Exam: Afferent pupillary defect, abnormal red reflex, detached retina appears grey & wrinkled.
🧪 Investigations
- 🔍 Fundus exam: Indirect ophthalmoscopy with slit-lamp biomicroscopy = gold standard.
- 📊 OCT: Layered retinal imaging to confirm/exclude detachment.
- 📡 Ocular ultrasound: Useful if view is obscured by vitreous haemorrhage.
💊 Management
- 🚑 Emergency referral → ophthalmology same day.
- Surgical Options:
- 💨 Pneumatic Retinopexy: Gas bubble + cryotherapy/laser → seals tear (selected cases).
- 🔗 Scleral Buckling: Band around globe → relieves traction (extensive/rhegmatogenous).
- 🩺 Vitrectomy: Removes vitreous gel, replaces with gas/silicone → used in tractional/complex detachments.
- Post-op care: Positioning (often face-down) 🛏️ for days to keep retina reattached.
🛡️ Prevention & Follow-Up
- 👀 Regular monitoring in high-risk patients (high myopia, diabetic retinopathy, trauma, family history).
- ⚡ Treat precursor lesions (retinal tears/holes) with prophylactic laser/cryotherapy.
- 📅 Lifelong follow-up after repair → risk of recurrence or involvement of fellow eye.
📚 References
Cases - Retinal Detachment
- Case 1 - Rhegmatogenous detachment (tear-related) ⚡: A 58-year-old man with high myopia reports flashing lights, new floaters, and a “curtain” coming down over his right eye. Visual acuity reduced. Fundoscopy: retinal tear with detached retina. Diagnosis: rhegmatogenous retinal detachment. Managed with urgent referral for surgical repair (scleral buckle, vitrectomy, or pneumatic retinopexy).
- Case 2 - Tractional detachment (diabetic) 🍬: A 52-year-old woman with poorly controlled type 1 diabetes presents with gradual visual loss in the left eye. Exam: proliferative diabetic retinopathy with fibrovascular membranes pulling the retina away. Diagnosis: tractional retinal detachment. Managed with vitrectomy to relieve traction and laser photocoagulation of ischaemic retina.
- Case 3 - Exudative detachment 💧: A 45-year-old man with a history of malignant hypertension presents with blurred central vision. Fundoscopy: smooth, bullous retinal elevation without tears. OCT: subretinal fluid. Diagnosis: exudative retinal detachment secondary to hypertensive choroidopathy. Managed by treating the underlying cause (BP control) and monitoring retinal status.
Teaching Point 🩺: Retinal detachment = separation of neurosensory retina from underlying pigment epithelium.
Types:
- Rhegmatogenous: due to retinal tear (myopia, trauma, ageing).
- Tractional: fibrovascular tissue pulls retina (diabetes, sickle cell).
- Exudative: fluid beneath retina without a tear (tumour, inflammation, hypertension).
Symptoms: flashes, floaters, curtain/shadow, painless visual loss.
Management: urgent ophthalmology referral - surgery for rhegmatogenous/tractional, treat underlying cause in exudative.
