Review Article

Retinal Detachment
Subhadra Jalali MS TRD are diabetes, Eales’s disease,
Consultant sickle cell retinopathy and trauma.
Smt Kannuri Santhamma 3. Exudative and serous retinal detach-
Retina Vitreous Centre ments occur due to abnormalities in
L V Prasad Eye Institute water transport across the bed of the
L V Prasad marg, Banjara Hills retina (retinal pigment epithelium) or in
Hyderabad – 500 034 its blood supply.
India
Tractional and exudative/serous retinal

D etachment of the retina is a serious

event, which may result in complete
blindness. The outer segments of the
detachments are less common and will not
be discussed in this paper. Fig. 2 Shallow retinal detachment with
traumatic dialysis misdiagnosed as serous
macular detachment due to central serous
photoreceptors receive oxygen and nutri- Symptoms and Signs retinopathy – can be managed by simple
tion from the choroid. If the retina scleral buckling
The commonest presenting symptom of Photo: Subhadra Jalali
is detached from the choroid, the photo-
RD is sudden, painless loss of vision or
receptors will fail. The fovea has no retinal can be seen with stereoscopic visualisation
blurring of vision in the affected eye. Some
blood vessels and depends wholly on the
patients with partial RD notice field loss, of the retinal vessels that cast a shadow on
choroid for its oxygen, so detachment of
i.e., loss of vision in only one part of the the underlying retinal pigment epithelium
the macula leads to permanent damage to
visual field and describe this as a veil or (Figure 2).
the cones and rods at the posterior pole,
shadow in one area of their vision. Flashes It is important to assess the state of the
and loss of vision. If the macula is not
and floaters may occur in the affected eye a macula. If the macula is still attached, this
detached, then good vision can be retained
few days or weeks before the loss of vision. is a medical emergency, and the patient
if the retina is re-attached promptly.
This is due to vitreous degeneration and its should have surgery within 24 hours in
traction on the retina. Inferior retinal order to prevent macular detachment and
Types of Retinal Detachment
detachments can often be silent and slowly permanent loss of vision. If the macula is
Retinal detachment (RD) is broadly classi- progressive so that the onset of RD goes already detached, then surgery should be
fied into three types based on the clinical unnoticed until it reaches the posterior carried out within a week or two.
appearance and underlying aetiology. pole. Sometimes RD is accompanied by In eyes with opaque media, ocular B-
mild discomfort and redness due to associ- scan ultrasonography is useful for diagnos-
1. Rhegmatogenous retinal detachment ated uveitis and hypotony, and this may be ing RD and associated pathology, like pro-
(RRD) where the RD develops due to a mistakenly diagnosed as idiopathic anteri- liferative vitreoretinopathy (PVR), intraoc-
retinal break (‘rhegma’, meaning a rent or uveitis. In children and young adults, ular foreign bodies, etc. Ultrasonography
or a fissure) (Figure 1). Fluid, from the RD may be asymptomatic initially and is also rules out many lesions associated with
vitreous cavity, passes through the reti- diagnosed only after the affected eye exudative retinal detachments such as
nal break into the potential space under develops squint, or redness, or a white tumours, posterior scleritis, etc.
the retina, leading to separation of the pupillary reflex due to rapid progression of
retina from the underlying choroid. This cataract. Predisposing Causes
requires surgical treatment. In developing countries, retinal detach-
ment frequently presents late, and this Although RD can occur in any eye, certain
2. Tractional retinal detachment (TRD)
means that the macula is detached in eyes are predisposed to develop detach-
which occurs due to pre-retinal mem-
approximately 90% of eyes at presentation. ment. The risk factors are given in Table 1.
brane formation and scarring that pulls
Patients are more likely to have scarring All eyes that are predisposed to RD should
the retina from its attachment. This may
and fibrosis of the retina, and other prob- undergo periodical, dilated retinal exami-
require surgery depending on the extent
lems associated with long-standing retinal nation (including the retinal periphery by
of the RD. The commonest causes of
detachment. Because the abnormalities that scleral depression), to detect any retinal
caused the detachment are often bilateral, breaks/areas of lattice degeneration, that
up to a third of patients may be blind in can predispose to RD. Early detection of
their other eye at presentation – often some of these conditions can give an
because of untreated retinal detachment.1 opportunity for prophylactic treatment.

Management
Diagnosis of Retinal Detachment
Most retinal detachments progress to total
The best method of diagnosing RD is by retinal detachments and complete loss of
binocular indirect ophthalmoscopy with vision. If the retina is not re-attached
scleral indentation. An obvious RD is promptly (usually less than a week after
recognised by loss of the red fundus macular detachment), then visual recovery
reflex and marked elevation of the retina is progressively affected. Also, long-stand-
(Figure 1). The retina appears grey, and ing retinal detachments start to develop
Fig 1: Recent subtotal rhegmatogenous
retinal detachment shows folds and undulations. Shallow scarring, called ‘proliferative vitreo-
Photo: Subhadra Jalali detachments are difficult to diagnose but retinopathy’ (PVR) that can prevent re-
Community Eye Health Vol 16 No. 46 2003 25
Retinal Detachment
Table 1: Risk Factors for Rhegmatogenous Retinal Detachment*
1. Axial myopia.
2. Post cataract surgery (aphakia/pseudophakia) especially if the posterior capsule is ruptured
during surgery and/or there is vitreous loss.
3. Yag laser capsulotomy.
4. Lattice degeneration of the retina.
5. Symptomatic (flashes/floaters) retinal tears.
6. Ocular trauma.
7. RD in one eye.
8. Family history of RD.
9. Certain genetic disorders such as Marfan’s syndrome, Stickler’s syndrome.
10. Pre-existing retinal diseases like coloboma choroid, retinoschisis.
11. Following acute retinal infections as in acute retinal necrosis syndrome (ARN) or CMV retinitis. Fig. 3b: Same eye after re-attachment
surgery with vitrectomy and silicone oil
* Excludes causes that result in combined rhegmatogenous and tractional retinal injection
detachment Photo: Subhadra Jalali

attachment. Besides PVR changes, chronic countries. However, vitrectomy techniques 2. Lattice degeneration with or without
retinal detachments can develop other have revolutionised retinal detachment holes and with or without vitreous trac-
complications such as hypotony, pigmen- surgery, giving a higher rate of successful tion (risk of progression uncertain).
tary glaucoma, new iris vessels, cataract re-attachment than previously.
and uveitis, which can compromise visual To ‘treat or not to treat’ depends on other
outcome. Rarely, the detachment does not Results of Treatment factors that predispose to a high risk of ret-
progress, either due to spontaneous closure inal detachment (Table 1) and on theknown
of the retinal break or by development of RD is no longer an incurable condition. complications of prophylactic treatment.
demarcation lines. Surgical results have improved consider- Methods of prophylactic treatment include
The principle of retinal re-attachment ably in the last two decades.2,3 In develop- cryotherapy, laser photocoagulation and,
surgery is to close all the retinal breaks and ing countries, the final re-attachment very rarely, prophylactic scleral buckling.
create strong chorioretinal adhesions so rates vary from 77–87% with the use of
that these breaks do not open and new modern technology.1 The anatomical suc- Conclusion
breaks do not occur. cess depends on a variety of factors includ-
Two approaches are established to ing the type of retinal detachment, age Retinal detachment is a vision threatening
achieve this objective. One is an external of patient and surgical expertise. Unfortu- condition that requires early surgery. It can
approach using scleral indentation with sil- nately, visual results do not always match be diagnosed best by retinal examination
icone material called ‘scleral buckling’. the anatomical success. If the macula has using indirect ophthalmoscopy. Treatment
This approach needs minimal instrumenta- been detached for a long time, central outcomes have improved with modern sur-
tion and materials, and is widely available. vision will not be regained, however, the gical techniques, but the key to successful
It is suitable for uncomplicated forms of patient will usually obtain useful naviga- re-attachment is early detection and prompt
retinal detachment, with a high success tional vision. In India, 80% of successfully referral by primary eye care workers. More
rate. However, this surgery is not appropri- re-attached retinas obtained a vision of widespread availability of trained human
ate for complicated retinal detachments 6/60 or better.1 resources and equipment is essential to
such as those with PVR (Figures 3a, 3b), manage and prevent retinal detachments
giant retinal tears, coloboma choroid, pene- Prophylaxis that can cause unilateral and, not uncom-
trating ocular trauma, etc. monly, bilateral permanent blindness.
It is important to prevent RD, since 5–15%
In these situations, an internal approach of retinal re-attachment operations are
called `vitrectomy’ is used. This requires References
unsuccessful and only 55–60% eyes with
expensive and complex equipment and is re-attached retinas get good visual out- 1 Yorston D, Jalali S. Retinal detachment in devel-
available in few centres in developing comes.3,4 Also RD surgery is more expen- oping countries. Eye 2002; 16: 353–358.
2 Thompson J A, Snead M P, Billington B M,
sive than prophylactic treatment and can be Barrie T, Thompson J R, Sparrow J M. National
associated with serious complications. audit of the outcomes of primary surgery for
Most rhegmatogenous RDs are due to rhegmatogenous retinal detachment. Eye 2002;
16: 771–777.
retinal tears that occur from vitreoretinal 3 Johnson Z, Ramsay A, Cottrell D, Mitchell K,
traction in areas of abnormally firm vitreo- Stannard K. Triple cycle audit of primary retinal
retinal adhesions. Exceptions are post- detachment surgery. Eye 2002; 16(3): 513–518.
traumatic tears and round holes in areas of 4 Wilkinson CP, Rice TA. Prevention of retinal
detachment. In: Michel’s Retinal Detachment,
lattice degeneration in myopic eyes of 2nd edition. 1997; pages 1128–1133.
young patients. Prophylactic treatment 5 Hilton GF, McLean EB, Chuang EL. Retinal
aims to create strong chorioretinal adhe- Detachment. Ophthalmology monograph,
American Academy of Ophthalmology, 5th edi-
sions in areas of retinal tears or areas of tion. 1989; pages 89–95.
strong vitreoretinal traction. Visible lesions
that could be considered for prophylactic ✩ ✩ ✩
treatment include: 4,5
Fig. 3a: Chronic retinal detachment with
advanced PVR and large horse-shoe tear 1. Horseshoe tears (high risk of progres-
Photo: Subhadra Jalali sion to RD without treatment).
26 Community Eye Health Vol 16 No. 46 2003