Basics
Description
- 3 types of retinal detachments with common final pathway:
- Rhegmatogenous retinal detachments (RRD)
- Tractional retinal detachments (TRD)
- Exudative retinal detachments (ERD)
- RRD:
- Most common
- Break 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 progressive
- Asymptomatic unless hemorrhage or retinal tear occurs
- ERD:
- Subretinal fluid accumulates and separate retinal layers without violating either layer.
- Do not usually require surgery
- Usually secondary systemic disease such as severe acute hypertension, sarcoid, cancer
Etiology
- RRD:
- Myopia
- Cataract surgery
- Marfan syndrome
- Structural degeneration of underlying anatomy of vitreous body, sensory or pigmented retina
- Trauma
- TRD:
- Proliferative diabetic retinopathy
- Vasculopathy
- Perforating injury
- Chorioretinitis:
- Retinopathy of prematurity, sickle cell disease, or toxocariasis
- Trauma
- ERD:
- Malignant hypertension, preeclampsia
- Tumors 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 weeks
- Dark curtain or veil
- Usually 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 spared
- Detachment is on opposite side of field defect
- May have afferent pupillary defect
- May have loss of red reflex
- Fundoscopy:
- Pale, opaque, wrinkled retina
- Cannot 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