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Retinal Detachment, Emergency Medicine

Basics

Description

- TRD: - Proliferative diabetic retinopathy - Vasculopathy - Perforating injury - Chorioretinitis: - Retinopathy of prematurity, sickle cell disease, or toxocariasis

- ERD: - Malignant hypertension, preeclampsia - Tumors of the choroid or retina (melanoma, retinoblastoma) - Inflammatory disorders (Coats or Harada disease, posterior scleritis)

- Symptoms onset, course, description: - May progress over hours or weeks - Dark curtain or veil - Usually begins peripherally

  • 3 types of retinal detachments with common final pathway:Rhegmatogenous retinal detachments (RRD)Tractional retinal detachments (TRD)Exudative retinal detachments (ERD)
  • RRD:Most commonBreak or tear of sensory retina allows vitreous fluid to separate the sensory and pigmented parts of retina from each other.Acute event, flashes secondary to tearing of nerve fibers, floaters secondary to bleeding
  • TRD:Contraction of fibrous vitreous bands, as a result of previous insult, pulls the sensory retina off the pigmented retina.Chronic and progressiveAsymptomatic unless hemorrhage or retinal tear occurs
  • ERD:Subretinal fluid accumulates and separate retinal layers without violating either layer.Do not usually require surgeryUsually secondary systemic disease such as severe acute hypertension, sarcoid, cancer

Etiology

  • RRD:MyopiaCataract surgeryMarfan syndromeStructural degeneration of underlying anatomy of vitreous body, sensory or pigmented retinaTrauma
  • TRD:Proliferative diabetic retinopathyVasculopathyPerforating injuryChorioretinitis:Retinopathy of prematurity, sickle cell disease, or toxocariasisTrauma
  • ERD:Malignant hypertension, preeclampsiaTumors of the choroid or retina (melanoma, retinoblastoma)Inflammatory disorders (Coats or Harada disease, posterior scleritis)

Diagnosis

Signs and Symptoms

  • Flashes of light
  • Floaters
  • Curtain-like vision loss
  • Peripheral/central vision loss or other visual field defects
  • Asymptomatic

History

  • Symptoms onset, course, description:May progress over hours or weeksDark curtain or veilUsually begins peripherally
  • Associated symptoms: Flashing lights, floaters, painless
  • Ophthalmologic history:Baseline eyesight, myopia, surgery, eye disease, trauma
  • Systemic disease

Physical Exam

  • Visual acuity, visual fields by confrontation " prior to dilation:May have normal visual acuity if macula sparedDetachment is on opposite side of field defect
  • May have afferent pupillary defect
  • May have loss of red reflex
  • Fundoscopy:Pale, opaque, wrinkled retinaCannot rule out detachment on fundoscopy alone
  • Slit-lamp exam: Anterior vitreous pigment granules ( "tobacco dust " ) suggest retinal tear.

Essential Workup

  • Complete ophthalmologic exam
  • Thorough neurologic exam to exclude cerebrovascular accident/transient ischemic attack

Diagnosis Tests & Interpretation

Lab

As needed to work up underlying diseases

Imaging

Ocular US: ’ Ό97% sensitive by trained EM physicians

Diagnostic Procedures/Surgery

  • Intraocular pressure (IOP) measurement: IOP usually lower in the affected eye
  • Dilating pupil with short-acting mydriatic carries very low risk of acute angle-closure glaucoma.

Differential Diagnosis

  • Central retinal artery or vein occlusion
  • Vitreous hemorrhage
  • Migraine with or without aura
  • Choroidal detachment
  • Methanol poisoning
  • Other retinal or CNS disease

Treatment

Pre-Hospital

  • Bed rest
  • Consider transport to hospital with neurology and ophthalmology availability.

Initial Stabilization/Therapy

If suspected ERD, treat systemic disease.

Ed Treatment/Procedures

  • Bed rest:Rest head on pillow with side of detachment down, side opposite of field defect
  • Emergent ophthalmologic consultation

Follow-Up

Disposition

Admission Criteria

Need for surgical repair

Discharge Criteria

  • Any patient with retinal detachment seen by an ophthalmologist and deemed safe to go home
  • Chronic retinal detachments are repaired over the same time course as it took to create them.
  • ERD resolves with treatment of the underlying problem.

Issues for Referral

Detachments with macula involvement require repair within 1 day.

Followup Recommendations

Per ophthalmologist

Pearls and Pitfalls

  • Fundoscopy alone does not provide sufficient visualization to rule out detachment.
  • Early recognition of retinal tears allows possible prophylactic:90% risk of retinal tear with "tobacco dust "
  • Do not fail to recognize central retinal artery occlusion (CRAO):Increased risk of stroke for patient with CRAO in setting of carotid disease or cardioembolic disease

Additional Reading

  • Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
  • Kang HK, Luff AJ. Management of retinal detachment: A guide for non-ophthalmologists. BMJ. 2008;336:1235 " 1240.
  • Pandya HK, Tewari A. "Retinal Detachment. " eMedicine. WebMD, updated Jan 29, 2013. Accessed Mar 26, 2013.
  • Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med. 2011;40(1):53 " 57; Jul 21 2009; Epub ahead of print.

See Also (Topic, Algorithm, Electronic Media Element)

  • Visual Loss
  • Vitreous Hemorrhage

Codes

ICD9

  • 361.00 Retinal detachment with retinal defect, unspecified
  • 361.81 Traction detachment of retina
  • 361.9 Unspecified retinal detachment
  • 361.2 Serous retinal detachment
  • 361.89 Other forms of retinal detachment

ICD10

  • H33.009 Unsp retinal detachment with retinal break, unspecified eye
  • H33.20 Serous retinal detachment, unspecified eye
  • H33.40 Traction detachment of retina, unspecified eye
  • H33.8 Other retinal detachments

SNOMED

  • 42059000 Retinal detachment (disorder)
  • 19620000 rhegmatogenous retinal detachment (disorder)
  • 34711008 traction detachment of retina (disorder)
  • 38599001 Serous retinal detachment (disorder)
  • 95690009 Retinal tear