Retinal Detachments and Tears

By admin Last updated Oct 28, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Jorge O. Rodriguez

Adrian Lavina

Basics

The retina is a multilayer of neurons that line the back of the eye and convert photons into neural impulses that travel to the visual cortex.
Retinal detachment occurs when the neurosensory retina separates from the underlying retinal pigment epithelium and choroid.
Retinal detachments can be rhegmatogenous (caused by a break in the retina; rhegma is Greek for “tear”), exudative (caused by leakage or exudation from beneath the retina), or tractional (vitreous, fibrous, or fibrovascular traction pulling on the retina).

Description

3 distinct classifications of retinal detachments:
- Rhegmatogenous retinal detachment (RRD)
- Tractional retinal detachment (TRD)
- Exudative retinal detachment (ERD)
RRD:
- Most common
- Occurs when a break in the sensory retina allows fluid from the vitreous to separate the rods and cones from the villi of the pigment epithelium
- Occurs as an acute event, with symptoms of flashes owing to the separation of the nerve fibers and spots owing to bleeding from the rupturing of retinal blood vessels
- Posterior vitreous detachment (PVD) is the most common cause of RRD. A PVD occurs when the vitreous liquefies and then separates from the back of the eye. Although this is usually a normal part of aging, 2% of the time that a PVD occurs forcefully enough to cause symptoms, a retinal tear occurs (1).
TRD:
- Occurs because of contraction of fibrous vitreous bands pulling the sensory retina off of the pigment epithelium
- Chronic progressive disorder
- May remain without symptoms unless hemorrhage or retinal tear occurs
ERD:
- Abnormal collections of fluid are produced, separating the layer of the retina.
- Usually asymptomatic until involvement of the macula occurs, with impairment of central vision
- Occasionally, the retina can become so elevated and anteriorly displaced by underlying fluid as to be visible with a penlight just behind the lens.

Epidemiology

Incidence

Incidence increases with age
Predominant gender: Male > Female (3:2).
Nontraumatic RRD: 1/10,000 per year (1)

Prevalence

After cataract surgery, 1–3% of patients will develop a retinal detachment.

Risk Factors

Myopia
Cataract surgery
PVD and associated conditions (trauma, inflammation, aphakia); ages 50–75 yrs
Aphakia
Trauma
Retinal detachment in fellow eye
Lattice degeneration: Present in 6–8% of population and in 30% of patients with nontraumatic RRD (1)
Glaucoma
Vitreoretinal tufts: Caused by focal areas of vitreous traction
Meridional folds: Redundant retina
Family history of retinal detachment
Vitreohyaloidopathy: Hereditary abnormality of the vitreous body

Genetics

Most cases are sporadic.

General Prevention

Impossible to prevent spontaneous PVD
Patient education is key.
Early identification of retinal tears and treatment may prevent retinal detachment and significant vision loss.

Etiology

RRD occurs as a result of either structural or developmental abnormalities of the eye; by definition, they are caused by a full-thickness retinal hole or tear.
- High myopia
- Marfan syndrome
- Structural degeneration of the underlying anatomy of the eye (including the pigment epithelium, the sensory retina, and the vitreous body or occasionally as a result of trauma)
- PVD: Most common cause of RRD
- Traumatic retinal detachment: Much less common than spontaneous RRD
TRD occur in association with:
- Diabetes
- Vasculopathy
- Perforating injury
- Severe chorioretinitis
- Retinopathy of prematurity, sickle-cell retinopathy, or toxocariasis
ERD arise from
- Tumors of the choroid (eg, melanoma) or retina (eg, retinoblastoma)
- Inflammatory disorders such as Coats or Harada disease
- Central serous chorioretinopathy

Commonly Associated Conditions

Lattice degeneration
High myopia
Cataract surgery
Glaucoma
History of retinal detachment in other eye
Trauma

Diagnosis

History, especially:
- Age
- Speed of onset of symptoms
- Associated symptoms
- Previous episodes
Complete ophthalmologic examination, especially:
- Assessment of pupillary function
- Evaluation of the vitreous for cells
- Dilated retinal exam
- 360-degree scleral depressed examination using indirect ophthalmoscope
- B-scan US

History

Floaters
Sudden loss of vision
Bright flashes of light (photopsias)
Expanding shadow
Progressive peripheral visual field defect

Physical Exam

Slit-lamp exam
Dilated fundus exam with binocular indirect ophthalmoscopy

P.511

Diagnostic Tests & Interpretation

Visual field testing

Lab

As indicated for underlying disease

Imaging

B-scan US

Pathological Findings

Elevation of the neurosensory retina from the underlying retinal pigment epithelium
Elevation of retina associated with retinal tears in RRD or elevation of the retina without tears in exudative detachment
In 3–10% of patients with presumed RRD, no definite retinal break is found (2).
Tenting of the retina without retinal tears in traction detachment
Pigmented cells within the vitreous “tobacco dust” (1)[C]

Differential Diagnosis

Senile retinoschisis (retinoschisis, a splitting of the retina)
Juvenile retinoschisis
Choroidal detachment
Vitreous hemorrhage
Vitreous inflammation (eg, Toxoplasma chorioretinitis)
Ocular lymphoma
Intraocular foreign body

Treatment

Sports-related ocular trauma evaluated on site (3)
Obtain adequate history.
Best corrected visual acuity is checked with an eye chart.
Check confrontation visual fields.
Examine pupils.
Penlight exam of the anterior chamber
Ocular motility
External exam looking for orbital injury
Funduscopic exam
If suspecting globe rupture, place protective shield over the eye, put on NPO status, and refer.

ED Treatment

Bed rest
Urgent ophthalmologic consultation
A retina specialist ultimately will need to care for the patient if retinal detachment is present.

Additional Treatment

Referral

Sudden decrease in or loss of vision
Loss of field of vision
Pain on movement of the eye
Photophobia
Diplopia
Proptosis of the eye
Light flashes or floaters
Irregularly shaped pupil
Foreign-body sensation/embedded foreign body
Red and inflamed eye
Hyphema
Halos around light (corneal edema)
Laceration of the lid margin or near medial canthus
Subconjunctival hemorrhage
Broken contact lens or shattered eyeglasses
Suspected globe perforation

Surgery/Other Procedures

PVD management:
- Most patients who present with PVD and do not have any retinal breaks or tears require only reassurance and education.
- Full dilated exam with indirect ophthalmoscopy at least twice during the 6 wks following onset of symptoms
Retinal hole or tear: Laser photocoagulation or cryoretinopexy to prevent retinal detachment (1)[A]
RRD:
- Laser photocoagulation or cryoretinopexy for smaller detachments
- Pneumatic retinopexy
- Scleral buckle
- Vitrectomy
TRD: Pars plana vitrectomy (1)[C]
ERD (1)[C]: Identify and treat etiology; surgical repair is not recommended in most cases.

In-Patient Considerations

Bed rest prior to surgery
Postoperatively, if intraocular gas has been used, the patient may need specific head positioning and may need to avoid all air travel or high altitudes.

Initial Stabilization

N/A

Admission Criteria

RRDs require emergent referral to a retina specialist, particularly if the macula is not yet detached (macula on retinal detachment).
Surgery may be done in a hospital or ambulatory surgery center, and this will be the retinal specialist's decision.
Admission may be required until a retina specialist is found.

Discharge Criteria

RRDs that do not yet involve the macula (macula on retinal detachment) require repair within 24 hr.
RRDs involving the macula (macula off retinal detachment) may be repaired within 3–7 days because there is no evidence that urgent repair affects the outcome.
TRDs are repaired within 1–2 wks depending on the chronicity.
ERDs generally will resolve with successful treatment of the underlying condition.

Ongoing Care

Prognosis

RRD:

Pneumatic retinopexy is an in-office procedure for which certain patients are candidates.
Pneumatic retinopexy leads to successful retinal attachment 70–80% of the time after 1 procedure (1,4).
In cases of failure, treat with scleral buckle placement and/or vitrectomy.
Scleral buckle placement is successful 80–90% of the time after 1 procedure (1).
Failed cases usually are treated with vitrectomy (5).
Vitrectomy has an 80–90% success rate after 1 surgery (1).
In failed cases, more extensive vitreoretinal procedures are required.
Virtually all patients over age 50 will develop progressive cataract following vitrectomy (1).

References

1. Arroyo JG. (2009). Retinal tear and detachment. Retrieved June 17, 2009 from www.uptodate.com

2. Coffee RE, Westfall AC, Davis GH, et al. Sympto-matic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis. Am J Ophthalmol. 2007.

3. Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Am Fam Physician. 2003;67:1481–1488.

4. Chan CK, Lin SG, Nuthi AS, et al. Pneumatic retinopexy for the repair of retinal detachments: a comprehensive review (1986–2007). Surv Ophthalmol. 2008;53:443–478.

5. Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment: a prospective randomized multicenter clinical study. Ophthalmology. 2007;114:2142–2154.

Codes

ICD9

361.00 Retinal detachment with retinal defect, unspecified
361.01 Recent retinal detachment, partial, with single defect
361.02 Recent retinal detachment, partial, with multiple defects