Retinal Detachment

Risk factors

• High myopia (axial length >26 mm)
• Prior cataract or other intraocular surgery (especially with posterior capsule rupture)
• Posterior vitreous detachment (PVD) — most common trigger
• Lattice degeneration of the peripheral retina
• Blunt or penetrating ocular trauma
• Prior retinal detachment in fellow eye (~10% risk)
• Family history
• Proliferative diabetic retinopathy (tractional)
• Stickler, Marfan, Ehlers-Danlos syndromes
• Retinitis pigmentosa, retinoschisis

Pathophysiology

Rhegmatogenous: posterior vitreous detachment exerts traction on the retina, causing a horseshoe tear or operculated hole; liquefied vitreous passes through the break into the subretinal space, lifting the retina. Tractional: fibrovascular membranes (e.g., diabetic PDR) contract and pull the retina off the RPE. Exudative: breakdown of the blood-retinal barrier (uveitis, choroidal tumor, Coats disease, severe hypertension) allows serous fluid into the subretinal space without a break.

Clinical presentation

Differential diagnosis

• Posterior vitreous detachment without tear — Flashes and floaters but normal retina on exam; observe and re-examine in 4-6 weeks
• Vitreous hemorrhage — Sudden floaters/decreased vision; cause includes PDR, retinal tear, trauma; B-scan ultrasound if unable to view fundus
• Retinoschisis — Splitting within the retina; usually inferotemporal; absolute scotoma; no breaks
• Central or branch retinal vein occlusion — Sudden vision loss with hemorrhages and edema; no retinal tear
• Migraine with aura — Transient zig-zag visual phenomena, headache; normal retina
• Vitreoretinal lymphoma or choroidal tumor — Mass on B-scan, vitreous cells
• Central serous chorioretinopathy — Localized serous detachment of macula in younger male; no retinal break

Diagnostic workup

Diagnostic algorithm

flowchart TD
  A[Flashes / floaters /<br/>curtain or shadow] --> B[Urgent dilated exam]
  B --> C{Retinal break or<br/>detachment?}
  C -->|Break only| D[Laser or cryo<br/>retinopexy]
  C -->|Detachment| E{Macula status?}
  E -->|Macula ON| F[Surgery within<br/>24-72 hours]
  E -->|Macula OFF| G[Surgery within<br/>~7 days]
  F --> H[Pneumatic retinopexy /<br/>scleral buckle /<br/>vitrectomy]
  G --> H
  C -->|No break, only PVD| I[Re-examine<br/>4-6 weeks]
  H --> J[Postop positioning<br/>± gas tamponade<br/>no air travel]

Treatment

Complications

• Permanent vision loss if untreated
• Macula-off detachment — even with successful reattachment, central vision often does not fully recover
• Proliferative vitreoretinopathy (PVR) — leading cause of failed reattachment; scar tissue causes redetachment
• Cataract (especially after vitrectomy)
• Elevated IOP, hypotony, endophthalmitis (rare)
• Diplopia (scleral buckle), refractive change
• Recurrent detachment requiring repeat surgery

PANCE pearls

• Photopsias + floaters + curtain over vision = retinal detachment until proven otherwise — same-day ophthalmology.
• MACULA-ON vs MACULA-OFF is the key triage question — macula-on detachments need surgery within 24-72 hours to preserve central vision; macula-off can be repaired within ~1 week.
• Shafer sign (pigment in anterior vitreous, 'tobacco dust') after acute PVD is highly specific for a retinal break.
• After cataract surgery the risk of RD increases ~5-fold, particularly in young myopic eyes — counsel patients to report flashes/floaters.
• Proliferative vitreoretinopathy is the major cause of redetachment after surgery — anatomic success rates per single surgery are ~85-90%.
• Tractional detachments (diabetic) usually progress slowly and are repaired non-emergently when threatening the macula; do not treat like a rhegmatogenous detachment.

References

• AAO 2019 — American Academy of Ophthalmology. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern. Ophthalmology 2020;127(1):P146-P181
• Hollands 2009 — Hollands H et al. Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA 2009;302(20):2243-2249
• PIVOT — Hillier RJ et al. The Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT). Ophthalmology 2019;126(4):531-539