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Retinal detachment
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Exam Tips
- Classic viva clue: unilateral flashes + new floaters + a progressive peripheral curtain is retinal detachment until proven otherwise.
- Always state urgency: suspected retinal detachment needs same-day ophthalmology assessment, especially if symptoms are recent or worsening.
- Mention macula-on vs macula-off explicitly; this determines urgency and expected visual prognosis.
- Differentiate types in exams: rhegmatogenous usually has flashes/tear, tractional is slower and linked to diabetic fibrovascular membranes, exudative is fluid-leak driven and may resolve with treatment of cause.
- High-yield safety point after gas tamponade: no flying and no nitrous oxide anaesthesia.
- See Figure: horseshoe retinal tear with surrounding subretinal fluid and Figure: corrugated detached retina on fundoscopy (retina chapter image set).
Definition
Retinal detachment is separation of the neurosensory retina from the underlying retinal pigment epithelium, allowing liquefied vitreous or other fluid to collect in the subretinal space. It is an ophthalmic emergency because progressive detachment, especially once the macula is involved, causes rapid photoreceptor dysfunction and can lead to permanent visual loss despite later repair.
Pathophysiology
The commonest type is rhegmatogenous retinal detachment: age-related vitreous syneresis and posterior vitreous detachment create vitreoretinal traction, causing a retinal tear through which fluid tracks under the retina. Tractional detachment occurs when fibrovascular membranes (classically in proliferative diabetic retinopathy) contract and elevate retina without an initial break; combined traction-rhegmatogenous patterns can then occur if a tear forms. Exudative detachment is driven by breakdown of the blood-retinal barrier or choroidal leakage (for example uveitis or choroidal tumour), with subretinal fluid accumulation but no retinal break. Visual loss severity reflects extent/duration of macular detachment because outer retinal ischaemia and photoreceptor degeneration worsen over time. See Figure: retinal layers and subretinal fluid plane in a standard ophthalmology retina chapter; see also fundus image of corrugated detached retina with retinal tear.
Risk Factors
- Increasing age (posterior vitreous detachment becomes common with age)
- Myopia, especially > -3.00 dioptres
- Previous retinal break or retinal detachment (either eye)
- Family history of retinal detachment/retinal breaks
- Previous cataract surgery, especially complicated surgery
- Ocular trauma (particularly blunt trauma; delayed presentation possible)
- Proliferative diabetic retinopathy
- Inflammatory eye disease (for example uveitis, scleritis)
- Intraocular malignancy (for example choroidal melanoma, metastasis)
- Connective tissue/genetic disorders (for example Stickler syndrome, Marfan syndrome)
- Male sex
- Long axial length (notably in younger post-cataract male patients)
Clinical Features
Symptoms
- New floaters (dots, cobwebs, haze), often unilateral at onset
- Photopsia/flashes, often peripheral and more noticeable in dim light
- Painless progressive peripheral field loss described as a curtain/veil/shadow
- Blurred or distorted vision
- Sudden central vision reduction if macula detaches or major vitreous haemorrhage occurs
Signs
- Reduced visual acuity (may fall to counting fingers/hand movements if macula-off)
- Confrontational visual field defect, typically peripheral initially
- Relative afferent pupillary defect in extensive unilateral detachment
- Fundoscopy: elevated grey-white/opaque corrugated retina, retinal folds, possible retinal tear, vitreous pigment or haemorrhage
- Asymmetric red reflex; early/small detachments can have minimal fundus signs
Investigations
Visual acuity (Snellen or LogMAR) in both eyes:Reduced acuity; marked drop suggests macular involvement
Confrontation visual fields:Peripheral field defect consistent with area of detachment
Dilated fundus examination (indirect ophthalmoscopy/slit-lamp biomicroscopy):Detached, mobile retina; retinal break/tear; vitreous pigment or haemorrhage
Optical coherence tomography (OCT):Confirms subretinal fluid and macular status (macula-on vs macula-off)
B-scan ocular ultrasonography:Useful when media opacity limits view; shows detached retinal membrane and may detect associated vitreous haemorrhage
Management
Lifestyle Modifications
- Same-day urgent ophthalmology referral for suspected detachment; do not delay for routine outpatient review
- Advise no driving until specialist assessment because visual field/acuity may be unsafe
- Safety-net clearly: worsening curtain effect, central vision loss, or new symptoms in fellow eye requires emergency reassessment
- Assess both eyes because fellow-eye risk is increased
Surgical / Interventional
- Retinopexy for retinal tears/breaks before full detachment (laser photocoagulation or cryotherapy)
- Pneumatic retinopexy with intravitreal gas and strict posturing in selected rhegmatogenous cases
- Scleral buckle to close retinal breaks and relieve vitreoretinal traction
- Pars plana vitrectomy (often with gas or silicone oil tamponade), particularly for complex, posterior, or tractional cases
- Exudative retinal detachment: treat underlying cause (for example inflammatory or malignant disease), with surgery only if indicated
- Safety warnings/contraindications: intraocular gas tamponade requires avoidance of air travel and nitrous oxide anaesthesia until gas resolves; pneumatic retinopexy is generally unsuitable in significant proliferative vitreoretinopathy, giant retinal tears, many inferior breaks, or if the patient cannot posture reliably
Complications
- Permanent visual impairment or blindness, especially with delayed macular detachment
- Recurrent retinal detachment (new break, failed closure, or proliferative vitreoretinopathy)
- Proliferative vitreoretinopathy with traction/scarring
- Post-operative complications: endophthalmitis, cataract progression, refractive shift/myopia, raised intraocular pressure
- Fellow-eye retinal detachment
- Sympathetic ophthalmia (rare)
Prognosis
Time to treatment and macular status at repair are key predictors: macula-on detachment has the best visual outcome, while prolonged macula-off detachment has worse recovery. First-operation anatomical success in rhegmatogenous detachment is typically around three-quarters to four-fifths, with further procedures needed in some patients. Untreated symptomatic detachment usually progresses and risks irreversible vision loss.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Retinal detachment[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1615)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1268)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1268)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1089, 1090)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1343, 1344)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 28)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1089)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1100)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1267)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1267)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 633)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 633)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 633)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 88)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 87, 88)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 727, 728)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 649)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 648, 649)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 649, 650)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 330)[context]