OcuLearning › Retina

Retinal Detachment

CRITICAL — Retina

Symptoms

  • photopsias (flashes): peripheral light flickers from vitreoretinal traction
  • floaters: sudden "cobwebs" or a "shower of black dots" (suggests hemorrhage)
  • peripheral curtain: a dark shadow or veil progressing toward central vision
  • central vision loss: occurs once the macula detaches ("macula-off")
  • shifting field: in exudative RD, the vision defect may move with head position

Clinical Findings

Rhegmatogenous (RRD) - the most common

  • corrugated appearance: opaque, convex retina that undulates with eye movement
  • retinal break: horseshoe tear, operculated hole, or dialysis seen on depression
  • shafer sign ("tobacco dust"): pigment cells in the anterior vitreous

Tractional (TRD)

  • concave & immobile: retina tented up by fibrovascular membranes (e.g., in diabetes)
  • no breaks: unless it is a combined tractional-rhegmatogenous detachment

Exudative/serous (ERD)

  • smooth & bullous: subretinal fluid shifts with gravity and head position
  • no breaks: often reveals underlying mass, inflammation, or vascular leakage

General signs

  • intraocular pressure (iop): typically lower in the affected eye
  • rapd: may be present in large or total detachments

Etiology

RRD (breaks)

  • liquid vitreous enters subretinal space through a break (PVD, lattice, trauma)

TRD (tension)

  • proliferative membranes pull retina off (Diabetes, Sickle Cell, ROP, PVR)

ERD (fluid)

  • neoplastic: choroidal melanoma or metastasis
  • inflammatory: VKH syndrome or posterior scleritis
  • vascular: malignant hypertension, preeclampsia, or Coats disease

Red Flags

  • macula-on rrd: a surgical emergency; must be repaired within 24h to save central vision
  • sudden floater shower + flashes: requires urgent dilated exam to find a pre-RD tear
  • bilateral serous rd + hearing loss/meningismus: suspect VKH syndrome
  • bullous rd in pregnancy: immediate workup for preeclampsia/eclampsia

Investigations

The gold standard

  • dilated indirect ophthalmoscopy with 360° scleral depression of both eyes

Imaging

  • b-scan ultrasound: mandatory if the retina is obscured by blood or cataract
  • oct macula: confirms "on" vs. "off" status and identifies tractional membranes

Systemic (for ERD)

  • blood pressure and urinalysis (to rule out hypertensive emergencies)
  • fluorescein angiography (fa) to localize leakage sites or tumors

Treatment

RRD repair

  • pneumatic retinopexy: gas bubble + head positioning (for superior breaks)
  • scleral buckle: silicone band around the globe (ideal for young/phakic patients)
  • pars plana vitrectomy (ppv): removal of vitreous + gas/oil tamponade + laser

TRD/ERD management

  • trd: vitrectomy with membrane peeling; prp laser for underlying ischemia
  • erd: do not operate on the retina; treat the systemic/inflammatory cause

Clinical Pearl

Rhegmatogenous RD requires a full-thickness retinal break; tractional RD is tented by fibrovascular traction; exudative RD shifts with gravity and has no break. Shafer sign (pigmented anterior vitreous cells) is the classic pointer to an occult break. Macula status drives urgency: macula-on RRD should be repaired within 24 h. PVR is the leading cause of surgical failure.

Differential Diagnosis

  • • retinoschisis: smooth dome, absolute scotoma, no undulating movement
  • • choroidal detachment: dark brown, solid appearance, lower iop
  • • vitreous hemorrhage: may occur with or without a detachment

Related Retina Conditions