Retinal Detachment

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PVD
Cataract surgery

Pediatric Considerations

Usually associated with underlying vitreoretinal disorders and/or retinopathy of prematurity

COMMONLY ASSOCIATED CONDITIONS

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

Pregnancy Considerations

Preeclampsia/eclampsia may be associated with exudative retinal detachment. No intervention is indicated, provided hypertension is controlled. Prognosis is usually good.

DIAGNOSIS

HISTORY

Sudden flashes (photopsia)
Shower of floaters
Visual field loss: "curtain coming across vision "
Central vision will be preserved if the macula is not detached.
Poor visual acuity (20/200 or worse), with loss of central vision when macula is detached.

PHYSICAL EXAM

Slit-lamp exam
Dilated fundus exam with binocular indirect ophthalmoscopy

DIFFERENTIAL DIAGNOSIS

Retinoschisis (splitting of the retina)

Vitreous cells and vitreous hemorrhage are found rarely in the vitreous with retinoschisis, whereas they are seen commonly in RRD.
Retinoschisis usually has a smooth surface and is dome-shaped, whereas RRD often has a corrugated, irregular surface.

DIAGNOSTIC TESTS & INTERPRETATION

Visual field testing: differentiates RRD from retinoschisis. An absolute scotoma is seen in retinoschisis, whereas RRD causes a relative scotoma.
Initial Tests (lab, imaging)

US can demonstrate a detached retina and may be helpful when the retina cannot be visualized directly (e.g., with cataracts).
Fluorescein dye leakage can be seen in exudative retinal detachment; caused by central serous retinopathy and other inflammatory conditions

Test Interpretation

Elevation of the neurosensory retina from the underlying retinal pigment epithelium
Elevation of retina associated with ≥1 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.
Tenting of the retina without retinal tears in traction detachment
Pigmented cells within the vitreous ( "tobacco dust " )

TREATMENT

GENERAL MEASURES

Not all retinal tears or breaks need to be treated:
- Flap or horseshoe tears in symptomatic patients (e.g., patients with flashes or floaters) are treated frequently.
- Operculated holes in symptomatic patients are treated sometimes.
- Atrophic holes in symptomatic patients are treated rarely.
Lattice degeneration with or without holes within the lattice in an asymptomatic patient with prior retinal detachment in the fellow eye may be treated prophylactically.
Flap retinal tears in asymptomatic patients frequently are treated prophylactically.
Exudative detachments usually are managed by treating underlying disorder.
Traction detachments usually are managed by observation. If the fovea is involved, a vitrectomy is needed.

MEDICATION

First Line

Intraocular gases
- Air
- Perfluoropropane (C3F8)
- Sulfur hexafluoride (SF6)
Perfluorocarbon liquids
Silicone oil
Contraindications to intraocular gas: patients with poorly controlled glaucoma
Precautions with intraocular gas: Expanding intraocular gas bubble increases intraocular pressure; therefore, avoid higher altitudes.
Significant possible interactions with intraocular gas: Nitrous oxide used in general anesthesia can expand an intraocular gas bubble.

Second Line
Steroids may cause worsening of central serous retinopathy.

SURGERY/OTHER PROCEDURES

Timing of repairs
- Macula attached: within 24 hours. If the detachment is peripheral and does not have features suggestive of rapid progression (e.g., large and/or superior tears), repair can be performed within a few days.
Macula recently detached: within 10 days of development of a macula-off retinal detachment (1)[B]
- Old macular detachment: elective repair within 2 weeks
If a retinal break has led to the development of a retinal detachment, surgery is needed. Surgical options (and combinations) include the following:
- Demarcation laser treatment
- Pneumatic retinopexy: Head positioning is required postoperatively.
- Scleral buckle
- Vitrectomy
- Perfluorocarbon liquids for giant tears (circumferential tears ≥90 degrees)
- Silicone oil for complex repairs
Anesthesia: local or general
RRD may have >1 break. If any retinal break is not closed at the time of surgery, the surgery will fail.
Additional surgery may be required if the retina redetaches secondary to a new retinal break or because of proliferative vitreoretinopathy (PVR).
Adjuvant combination therapy using 5-fluorouracil (5-FU) and low-molecular-weight heparin (LMWH) may reduce the incidence of PVR in patients undergoing vitrectomy for RRD who are at a greater risk of developing PVR, such as patients with uveitis, but does not seem to be of benefit in cases of established PVR.
If a vitreous hemorrhage is present, presumably from a retinal tear and the fundus cannot be well visualized, consideration can be given for early vitrectomy (2)[C].
There is a trend toward primary vitrectomy in the management of RRD. Eyes undergoing pars plana vitrectomy (PPV) for primary RRD repair may not need the addition of a scleral buckle (3)[B].
There is no statistical difference in the primary reattachment rate between eyes treated with PPV and scleral buckle for RRD in both phakic and pseudophakic/aphakic eyes (4)[A].
Patients with RRD who are at high risk for PVR (retinal detachment in two or more quadrants, retinal tears >1 clock hour, preoperative PVR, or vitreous hemorrhage). PPV-scleral buckle was associated with higher rates of anatomical success compared to PPV alone (5)[B].
There is a reduced incidence of intraoperative retinal tear formation using a transconjunctival cannulated PPV system compared to the standard 20-gauge system requiring suture closure.

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Recognition of condition is key (see "Diagnosis " ).
Refer to an ophthalmologist for exam and treatment, if indicated.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Bed rest prior to surgery.
Postoperatively, if intraocular gas has been used, the patient may need specific head positioning and should not travel to high altitudes.

Patient Monitoring

Alert ophthalmologist if there is new onset of floaters or flashes, increase in floaters or flashes, sudden shower of floaters, curtain or shadow in the peripheral visual field, or reduced vision.
Patients with acute symptomatic PVD should be reexamined by the ophthalmologist in 3 to 4 weeks. The development of a retinal detachment is unlikely if no retinal tears are present on reexamination in 3 to 4 weeks.
If acute symptomatic PVD is associated with gross vitreous hemorrhage that interferes with complete visualization of the retinal periphery by indirect ophthalmoscopy, the patient should be reexamined at short intervals with indirect ophthalmoscopy until the entire retinal periphery can be observed.
If the examiner is not certain whether the retina is detached in the presence of opaque medium, US should be performed.

DIET

NPO if surgery is imminent.

PATIENT EDUCATION

American Academy of Ophthalmology, 655 E. Beach Street, San Francisco, CA 94109-1336

PROGNOSIS

RRD
- 90% of retinal detachments can be reattached successfully after ≥1 surgical procedures. Postoperative visual acuity depends primarily on the status of the macula preoperatively. Also important is the length of time between the detachment and the repair (75% of eyes with macular detachments of <1 week will obtain a final visual acuity of 20/70 or better).
- 87% of eyes with a retinal detachment not involving the macula attain a visual acuity of 20/50 or better postoperatively. 37% of eyes with a detached macula preoperatively attain 20/50 or better vision postoperatively.
- In 10 " 15% of successfully repaired retinal detachments not involving the macula preoperatively, visual acuity does not return to the preoperative level. This decrease is secondary to complications such as macular edema and macular pucker.
Risk factors associated with primary RRD repair failure include choroidal detachment, significant hypotony, grade C-1 PVR, 4 detached quadrants, and large or giant retinal breaks (6)[B]. Additional risk factors associated with primary RRD repair failure include increased number of breaks and inferior location of retinal breaks (7)[B].Tractional retinal detachment: When not involving the fovea, the patient usually can be observed because it is uncommon for these to extend into the fovea.
Exudative retinal detachment
- Management is usually nonsurgical.
- The presence of shifting fluid is highly suggestive of an exudative retinal detachment. Fixed retinal folds, which are indicative of PVR, are seen rarely in exudative retinal detachment. If the underlying condition is treated, the prognosis generally is good.

COMPLICATIONS

PVR is the most common cause of failed retinal detachment repair; 10 " 15% of retinas that reattach initially after retinal surgery will redetach subsequently, usually within 6 weeks, as a result of cellular proliferation and contraction on the retinal surface.
Partial or total loss of vision due to macular detachment and/or PVR
Moderate to severe forms of PVR usually are treated with PPV and fluid " gas exchange. If a segmental scleral buckle was placed at the initial procedure, it may need to be revised.
Primary retinectomy can be used in cases of PVR without a scleral buckle (8)[C].
Scleral buckles may erode the overlying conjunctiva and lead to an infection.
Optic neuropathy after PPV for macula-sparing primary RRD

REFERENCES

11 Hassan TS, Sarrafizadeh R, Ruby AJ, et al. The effect of duration of macular detachment on results after the scleral buckle repair of primary, macula-off retinal detachments. Ophthalmology. 2002;109(1):146 " 152.22 Tan HS, Mura M, Bijl HM. Early vitrectomy for vitreous hemorrhage associated with retinal tears. Am J Ophthalmol. 2010;150(4):529 " 533.33 Kinori M, Moisseiev E, Shoshany N, et al. Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment. Am J Ophthalmol. 2011;152(2):291.e2 " 297.e2.44 Soni C, Hainsworth DP, Almony A. Surgical management of rhegmatogenous retinal detachment: a meta-analysis of randomized controlled trials. Ophthalmology. 2013;120(7):1440 " 1447.55 Storey P, Alshareef R, Khuthaila M, et al. Pars plana vitrectomy and scleral buckle versus pars plana vitrectomy alone for patients with rhegmatogenous retinal detachment at high risk for proliferative vitreoretinopathy. Retina. 2014;34(10):1945 " 1951.66 Adelman RA, Parnes AJ, Michalewska Z, et al. Clinical variables associated with failure of retinal detachment repair: the European vitreo-retinal society retinal detachment study report number 4. Ophthalmology. 2014;121(9):1715 " 1719.77 Williamson TH, Lee EJ, Shunmugam M. Characteristics of rhegmatogenous retinal detachment and their relationship to success rates of surgery. Retina. 2014;34(7):1421 " 1427.88 Tan HS, Mura M, Oberstein SY, et al. Primary retinectomy in proliferative vitreoretinopathy. Am J Ophthalmol. 2010;149(3):447 " 452.

CODES

ICD10

H33.001 Unspecified retinal detachment with retinal break, right eye
H33.019 Retinal detachment with single break, unspecified eye
H33.20 Serous retinal detachment, unspecified eye
H33.40 Traction detachment of retina, unspecified eye
H33.059 Total retinal detachment, unspecified eye
H33.8 Other retinal detachments
H33.22 Serous retinal detachment, left eye
H33.21 Serous retinal detachment, right eye
H33.42 Traction detachment of retina, left eye
H33.052 Total retinal detachment, left eye
H33.43 Traction detachment of retina, bilateral
H33.41 Traction detachment of retina, right eye
H33.011 Retinal detachment with single break, right eye
H33.23 Serous retinal detachment, bilateral
H33.051 Total retinal detachment, right eye
H33.002 Unspecified retinal detachment with retinal break, left eye
H33.009 Unsp retinal detachment with retinal break, unspecified eye
H33.012 Retinal detachment with single break, left eye
H33.013 Retinal detachment with single break, bilateral
H33.021 Retinal detachment with multiple breaks, right eye
H33.022 Retinal detachment with multiple breaks, left eye
H33.023 Retinal detachment with multiple breaks, bilateral
H33.029 Retinal detachment with multiple breaks, unspecified eye
H33.003 Unspecified retinal detachment with retinal break, bilateral

ICD9

361.9 Unspecified retinal detachment
361.00 Retinal detachment with retinal defect, unspecified
361.2 Serous retinal detachment
361.81 Traction detachment of retina
361.06 Old retinal detachment, partial
361.01 Recent retinal detachment, partial, with single defect
361.04 Recent retinal detachment, partial, with retinal dialysis
361.07 Old retinal detachment, total or subtotal
361.03 Recent retinal detachment, partial, with giant tear
361.02 Recent retinal detachment, partial, with multiple defects
361.05 Recent retinal detachment, total or subtotal

SNOMED

42059000 Retinal detachment (disorder)
56202001 Retinal detachment with retinal defect (disorder)
38599001 Serous retinal detachment (disorder)
34711008 traction detachment of retina (disorder)
31181000119100 Old retinal detachment (disorder)
19620000 rhegmatogenous retinal detachment (disorder)

CLINICAL PEARLS

If a patient complains of the new onset of floaters or flashes of light, the patient should undergo a dilated eye exam to rule out a retinal tear or retinal detachment.
There is an increased risk of retinal detachment after cataract surgery.
PVR can result in redetachment of the retina after an initially successful repair.

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