Retinal detachment

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Retinal detachment
Human eye cross section detached retina.svg
Cross section of retinal detachment
Specialty Ophthalmology   OOjs UI icon edit-ltr-progressive.svg

Retinal detachment is a condition where the retina pulls away from the tissue underneath it. [1] [2] [3] It may start in a small area, but without quick treatment, it can spread across the entire retina, leading to serious vision loss and possibly blindness. [4] Retinal detachment is a medical emergency that requires surgery. [2] [3]

Contents

The retina is a thin layer at the back of the eye that processes visual information and sends it to the brain. [5] When the retina detaches, common symptoms include seeing floaters, flashing lights, a dark shadow in vision, and sudden blurry vision. [1] [3] The most common type of retinal detachment is rhegmatogenous, which occurs when a tear or hole in the retina lets fluid from the center of the eye get behind it, causing the retina to pull away. [6]

Rhegmatogenous retinal detachment is most commonly caused by posterior vitreous detachment, a condition where the gel inside the eye breaks down and pulls on the retina. [4] [7] Risk factors include older age, nearsightedness (myopia), eye injury, cataract surgery, and inflammation. [7] [8]

Retinal detachment is usually diagnosed through a dilated eye exam. [4] If needed, additional imaging tests can help confirm the diagnosis. [8] Treatment involves surgery to reattach the retina, such as pneumatic retinopexy, vitrectomy, or scleral buckling. [2] Prompt treatment is crucial to protect vision. [8]

Mechanism and classification

Diagram of the eye highlighting the retina, vitreous humor, and other key structures. Three Internal chambers of the Eye.svg
Diagram of the eye highlighting the retina, vitreous humor, and other key structures.

The retina is a thin layer of tissue located at the back of the eye. [1] [5] It processes visual information and transmits it to the brain. [5] Retinal detachment occurs when the retina separates from the layers underneath it. [2] This impairs its function, potentially leading to vision loss. [2] [4] Retinal detachment often requires urgent medical intervention to prevent permanent vision loss. [3]

Retinal detachments are divided into three main types based on their distinct causes. [6]

Signs and symptoms

Visual representation of eye floaters seen against a blue sky Floaters.png
Visual representation of eye floaters seen against a blue sky

Retinal detachment is typically painless, with symptoms often starting in the peripheral vision. [3] [9] [10]

Symptoms of retinal detachment, as well as posterior vitreous detachment (which often, but not always, precedes it), may include: [3] [4] [9] [10] [12]

Rarely, a retinal detachment may be caused by atrophic retinal holes, in which case symptoms such as floaters or flashes of light may not occur. [9] [10]

Causes and risk factors

Rhegmatogenous retinal detachments are most often caused by posterior vitreous detachment (PVD). [1] [3] This occurs when the vitreous begins to liquefy and shrink, pulling away from the retina. [13] [14] While this process is typically harmless and often presents without symptoms, it can lead to retinal holes or tears that may progress to a full retinal detachment if left untreated. [8] [15]

Factors that increase the likelihood of PVD and therefore, retinal detachment, include:

Other Risk Factors

Less frequently, rhegmatogenous retinal detachments can occur without PVD. Risk factors for retinal detachment that are not related to PVD include:

Diagnosis

Fundus photograph showing a retinal detachment Distacco di retina.jpg
Fundus photograph showing a retinal detachment
Ultrasound showing a retinal detachment Retinal Detachment.jpg
Ultrasound showing a retinal detachment

The gold standard for diagnosing retinal detachment is a dilated fundus examination to check the back of the eye using an indirect ophthalmoscope. [8] [10] [13] This often involves a technique called scleral depression, which helps provide a clear view of the entire retina. [8] [10] [14] A slit lamp examination of the front of the eye may also reveal small pigment particles, called Shafer's sign, which may indicate a retinal tear. [8] [9] [10]

If the view of the retina is not clear, imaging techniques such as ultrawide-field fundus photography, B-scan ultrasonography, and optical coherence tomography (OCT) may help to identify a detachment. [8] [13] [14] MRI and CT scans are less commonly used for the diagnosis of retinal detachment, but they may be useful in certain cases. [8] [10] In an emergency department setting, bedside ultrasonography can also be used for diagnosis. [8] [13] [14]

Treatment

Rhegmatogenous retinal detachment typically requires prompt surgical intervention to preserve vision. [3] [8] [9] [10] The 3 main options include pneumatic retinopexy, vitrectomy, and scleral buckle. [2] These are selected based on how the patient presents, including the number, location and size of retinal tears, surgeon preference, and cost. [8] [10] [19]

Pneumatic retinopexy

Pneumatic retinopexy is a minimally invasive, office-based procedure often used for small and uncomplicated retinal detachments, particularly those involving a single tear in the superior part of the retina. [9] [10] A gas bubble is injected into the vitreous cavity to push the retina back into place against the back of the eye. [2] [9] [20] Additionally, cryotherapy or laser photocoagulation is used to seal the retinal tears and prevent further detachment. [9] [10] [20] Following the procedure, patients are advised to maintain a specific head position to ensure the gas bubble remains in place over the tear and to facilitate proper healing. [8] [20] Patients must also avoid air travel, high altitudes, and scuba diving until the gas bubble dissolves. [20] Over time, the gas bubble will be naturally replaced by the eye’s vitreous fluid. [2]

Vitrectomy

Three-Port Vitrectomy: Three small ports are made to access and remove the vitreous gel. Vitrectomy-23g.jpg
Three-Port Vitrectomy: Three small ports are made to access and remove the vitreous gel.
Vitrectomy is a surgical procedure used to treat complicated retinal detachments. [8] It is especially useful for large retinal tears or tears that are not easily visible. [8] Vitrectomy is also used for proliferative vitreoretinopathy, which is the growth of scar tissue on the retina that can occur after a retinal detachment. [8] [21] [22] In this technique, the vitreous gel is removed from the eye to relieve the pulling force on the retina. [8] [10] Subretinal fluid is drained, and retinal tears are sealed using cryotherapy or laser photocoagulation, similar to pneumatic retinopexy. [8] [10] The removed vitreous is then replaced with either a gas bubble or silicone oil, which stabilizes the retina. [8] [10] [23] Patients treated with a gas bubble are advised to maintain a face-down position and refrain from air travel, high altitudes, and scuba diving. [8] [10] [23] [24] In patients treated with silicone oil, a follow-up surgery is required to remove the oil. [8] [10] [24] For patients who have not previously undergone cataract surgery, vitrectomy increases the risk of developing a cataract in the treated eye. [8] [10] [24]

Scleral buckle surgery

Scleral buckle surgery is a procedure in which one or more silicone bands are placed around the outer layer of the eye, known as the sclera. [1] [8] The procedure typically begins with cryotherapy to seal retinal tears. [10] [19] Next, the silicone band is placed to create an indentation on the sclera, applying inward pressure that helps reattach the retina to the back of the eye. [1] [2] [8] [9] The band typically remains in place permanently unless complications occur. [8] During the procedure, subretinal fluid may also be drained, though it is sometimes left to reabsorb naturally. [8] [9] This approach is often preferred for younger patients, those who have not undergone cataract surgery, those without posterior vitreous detachment (PVD), and those with retinal dialysis, a type of tear commonly caused by trauma. [8] [9] [14] [19] Possible complications of this procedure include missed retinal breaks, improper positioning of the buckle, infection, inflammation, and double vision immediately after surgery, which typically resolves on its own. [8] [9] [19] Scleral buckling can also be combined with vitrectomy for specific cases. [10] [14]

Prognosis

If left untreated, retinal detachment can lead to permanent vision loss. [2]

Rhegmatogenous retinal detachment repair has a success rate of approximately 95%, meaning the retina is successfully reattached in most cases. [14] It is important for the repair to be successful the first time, as the chances of reattachment and good vision decrease with each additional surgery. [14]

Visual outcomes may vary even after successful reattachment. [3] The results for a patient’s vision depend greatly on whether the macula, the central part of the retina responsible for detailed vision, remains attached. [10] [14] If the macula detaches, the risk of poor vision increases, particularly if surgery is delayed. [10] [14]

Other factors that can affect the prognosis include the extent of the detachment and the timing of surgery, with earlier treatment generally leading to better outcomes. [3] [16]

Common causes of failure in retinal detachment repair include missed or poorly sealed retinal breaks, new retinal breaks, and proliferative vitreoretinopathy (PVR). [10] [14] PVR, a condition where scar tissue grows on the retina, occurs in approximately 8–10% of patients undergoing treatment for retinal detachment. [10]

Prevention

Patients at high risk for rhegmatogenous retinal detachment, such as those with myopia (nearsightedness), those who have had cataract surgery, those with a previous detachment in the other eye, and those with lattice degeneration or posterior vitreous detachment (PVD), should be educated on the symptoms and warning sings of retinal detachment and seek urgent treatment if they occur. [8] [16]

They should also have regular eye exams, even if they are not experiencing symptoms. [8]

Individuals with certain types of retinal tears or breaks may require treatments such as laser photocoagulation or cryotherapy to prevent detachment. [8] [10]

Additionally, these patients are advised to avoid contact sports, eye trauma, and other high-risk activities, and to wear protective eyewear to reduce the risk of eye injury. [3] [8]

Epidemiology

Rhegmatogenous retinal detachment affects between 5.3 and 12.6 individuals per 100,000 each year, depending on the geographic region. [14] The highest rates are seen in Europe, followed by the Western Pacific and then the Americas. [8] [25] Additionally, the prevalence of rhegmatogenous retinal detachment is increasing alongside the rising rates of myopia worldwide. [14]

See also

Related Research Articles

<span class="mw-page-title-main">Cataract</span> Clouding of the lens inside the eye, causing poor vision

A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision of the eye. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colours, blurry or double vision, halos around light, trouble with bright lights, and difficulty seeing at night. This may result in trouble driving, reading, or recognizing faces. Poor vision caused by cataracts may also result in an increased risk of falling and depression. Cataracts cause 51% of all cases of blindness and 33% of visual impairment worldwide.

<span class="mw-page-title-main">Floater</span> Deposits within the eyes vitreous humour

Floaters or eye floaters are sometimes visible deposits within the eye's vitreous humour, which is normally transparent, or between the vitreous and retina. They can become particularly noticeable when looking at a blank surface or an open monochromatic space, such as blue sky. Each floater can be measured by its size, shape, consistency, refractive index, and motility. They are also called muscae volitantes, or mouches volantes. The vitreous usually starts out transparent, but imperfections may gradually develop as one ages. The common type of floater, present in most people's eyes, is due to these degenerative changes of the vitreous. The perception of floaters, which may be annoying or problematic to some people, is known as myodesopsia, or, less commonly, as myodaeopsia, myiodeopsia, or myiodesopsia. It is not often treated, except in severe cases, where vitrectomy (surgery), laser vitreolysis, and medication may be effective.

<span class="mw-page-title-main">Vitrectomy</span> Surgery to remove vitreous humor from the eye

Vitrectomy is a surgery to remove some or all of the vitreous humor from the eye.

Retinopathy of prematurity (ROP), also called retrolental fibroplasia (RLF) and Terry syndrome, is a disease of the eye affecting prematurely born babies generally having received neonatal intensive care, in which oxygen therapy is used because of the premature development of their lungs. It is thought to be caused by disorganized growth of retinal blood vessels and may result in scarring and retinal detachment. ROP can be mild and may resolve spontaneously, but it may lead to blindness in serious cases. Thus, all preterm babies are at risk for ROP, and very low birth-weight is an additional risk factor. Both oxygen toxicity and relative hypoxia can contribute to the development of ROP.

<span class="mw-page-title-main">Eye surgery</span> Surgery performed on the eye or its adnexa

Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.

This is a partial list of human eye diseases and disorders.

<span class="mw-page-title-main">Cataract surgery</span> Removal of opacified lens from the eye

Cataract surgery, also called lens replacement surgery, is the removal of the natural lens of the eye that has developed a cataract, an opaque or cloudy area. The eye's natural lens is usually replaced with an artificial intraocular lens (IOL) implant.

<span class="mw-page-title-main">Posterior vitreous detachment</span> Eye condition where vitreous membrane detaches from the retina

A posterior vitreous detachment (PVD) is a condition of the eye in which the vitreous membrane separates from the retina. It refers to the separation of the posterior hyaloid membrane from the retina anywhere posterior to the vitreous base.

A scleral buckle is one of several ophthalmologic procedures that can be used to repair a retinal detachment. Retinal detachments are usually caused by retinal tears, and a scleral buckle can be used to close the retinal break, both for acute and chronic retinal detachments.

<span class="mw-page-title-main">Intermediate uveitis</span> Medical condition

Intermediate uveitis is a form of uveitis localized to the vitreous and peripheral retina. Primary sites of inflammation include the vitreous of which other such entities as pars planitis, posterior cyclitis, and hyalitis are encompassed. Intermediate uveitis may either be an isolated eye disease or associated with the development of a systemic disease such as multiple sclerosis or sarcoidosis. As such, intermediate uveitis may be the first expression of a systemic condition. Infectious causes of intermediate uveitis include Epstein–Barr virus infection, Lyme disease, HTLV-1 virus infection, cat scratch disease, and hepatitis C.

<span class="mw-page-title-main">Epiretinal membrane</span> Eye disease

Epiretinal membrane or macular pucker is a disease of the eye in response to changes in the vitreous humor or more rarely, diabetes. Sometimes, as a result of immune system response to protect the retina, cells converge in the macular area as the vitreous ages and pulls away in posterior vitreous detachment (PVD).

<span class="mw-page-title-main">Optic pit</span> Medical condition

Optic pit, optic nerve pit, or optic disc pit (ODP) is rare a congenital excavation (or regional depression) of the optic disc (also optic nerve head), resulting from a malformation during development of the eye. The incidence of ODP is 1 in 10,000 people with no predilection for either gender. There is currently no known risk factors for their development. Optic pits are important because they are associated with posterior vitreous detachments (PVD) and even serous retinal detachments.

<span class="mw-page-title-main">Intraocular hemorrhage</span> Medical condition

Intraocular hemorrhage is bleeding inside the eye. Bleeding can occur from any structure of the eye where there is vasculature or blood flow, including the anterior chamber, vitreous cavity, retina, choroid, suprachoroidal space, or optic disc.

Proliferative vitreoretinopathy (PVR) is a disease that develops as a complication of rhegmatogenous retinal detachment. PVR occurs in about 8–10% of patients undergoing primary retinal detachment surgery and prevents the successful surgical repair of rhegmatogenous retinal detachment. PVR can be treated with surgery to reattach the detached retina but the visual outcome of the surgery is very poor. A number of studies have explored various possible adjunctive agents for the prevention and treatment of PVR, such as methotrexate, although none have yet been licensed for clinical use.

<span class="mw-page-title-main">Scleral reinforcement surgery</span>

Scleral reinforcement is a surgical procedure used to reduce or stop further macular damage caused by high myopia, which can be degenerative.

<span class="mw-page-title-main">Vitreous hemorrhage</span> Leakage of blood into the internal fluid of the eye

Vitreous hemorrhage is the extravasation, or leakage, of blood into the areas in and around the vitreous humor of the eye. The vitreous humor is the clear gel that fills the space between the lens and the retina of the eye. A variety of conditions can result in blood leaking into the vitreous humor, which can cause impaired vision, floaters, and photopsia.

<span class="mw-page-title-main">Vitreomacular adhesion</span> Human medical condition

Vitreomacular adhesion (VMA) is a human medical condition where the vitreous gel of the human eye adheres to the retina in an abnormally strong manner. As the eye ages, it is common for the vitreous to separate from the retina. But if this separation is not complete, i.e. there is still an adhesion, this can create pulling forces on the retina that may result in subsequent loss or distortion of vision. The adhesion in of itself is not dangerous, but the resulting pathological vitreomacular traction (VMT) can cause severe ocular damage.

Sickle cell retinopathy can be defined as retinal changes due to blood vessel damage in the eye of a person with a background of sickle cell disease. It can likely progress to loss of vision in late stages due to vitreous hemorrhage or retinal detachment. Sickle cell disease is a structural red blood cell disorder leading to consequences in multiple systems. It is characterized by chronic red blood cell destruction, vascular injury, and tissue ischemia causing damage to the brain, eyes, heart, lungs, kidneys, spleen, and musculoskeletal system.

Retinal tuft is a disorder or degeneration of the retina in the eye. Retinal tufts are classified as a peripheral retinal degenerations and can be categorized as either cystic or zonular tractional. Retinal tufts can be visualized or diagnosed using a dilated eye examination and indirect ophthalmoscope or a widefield retinal scan. A retinal tuft is a gliotic degeneration of the retina composed of focal adhesions in the extracellular matrix joining the retina and the posterior hyaloid of the eye.

Vitreomacular traction syndrome (VTS) is a medical condition in the eye that is the result of tractional forces (pulling) being placed on the retina. VTS is common in people who have an incomplete posterior vitreous detachment, a type of retinal detachment at the periphery of the retina. In these cases the retina is still attached to the retina in some places and this results in a pulling or 'tractional' force that causes VTS that includes lesions on retina.

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