Retinal Detachment

Question 1

What is retinal detachment?

Answer 1

A typically progressive condition in which the neuroretina separates (detaches) from the retinal pigment epithelium

Question 2

What are the types of retinal detachment?

Answer 2

• Rhegmatogenous

- Non-rhegmatogenous

Question 3

What is the most common type of retinal detachment?

Answer 3

Rhematogenous

Question 4

What are rhegmatogenous retinal detachments preceded by?

Answer 4

Posterior vitreous detachment (PVD)

Question 5

How can posterior vitreous detachment lead to retinal detachment?

Answer 5

The PVD causes traction on the retina, and potentially a retinal tear. The liquified vitreous can then seep under the retina, causing it to detach

Question 6

Are rhegmatogenous retinal detachments localised?

Answer 6

They may initially be localised, but without treatment may progress

Question 7

What might the progression of rhegmatogeous retinal detachments lead to?

Answer 7

Irreversible vision loss

Question 8

What is a less common type of retinal detachment?

Answer 8

Non-rhegmatogenous retinal detachment

Question 9

What are the subtypes of non-rhegmatogenous retinal detachment?

Answer 9

• Exudative (serous or secondary)

- Tractionsl

Question 10

What is exudative non-rhegmatogenous retinal detachment?

Answer 10

When primary damage of the underlying RPE (retinal pigment epithelium) allows subretinal fluid to leak into the subretinal space pushing the retina off

Question 11

What is tractional non-rhegmatogenous retinal detachment?

Answer 11

When fibres of the vitreous contract and pull the sensory retina away

Question 12

What is the underlying cause of rhegmatogenous retinal detachment?

Answer 12

Preceded by PVD which is caused by age related degenerative liquefaction and shrinkage of the vitreous

Question 13

What is the underlying cause of exudative retinal detachment?

Answer 13

Accumulation of serous and/or haemorrhagic fluid in the subretinal space

Question 14

What can cause accumulation of blood or serous fluid in the subretinal space?

Answer 14

• Hydrostatic factors e.g. severe acute hypertension
• Inflammation e.g. sarcoid uveitis
• Neoplastic effusions

Question 15

What can cause tractional retinal detachment?

Answer 15

Mechanical forces on the retina usually due to fibrotic tissue

Question 16

What can cause fibrotic tissue in the vitreous?

Answer 16

• Previous haemorrhage
• Injury
• Surgery
• Infection
• Inflammation

Question 17

What do risk factors for retinal detachment depend upon?

Answer 17

Type and site of detachment

Question 18

What are some general risk factors for retinal detachment?

Answer 18

• Myopia (increases risk of PVD)
• Family history
• Previous history of retinal detachment

Question 19

What are some risk factors of rhegmatogenous retinal detachment?

Answer 19

• Age
• Aphakia
• Previous retinal break
• Marfan’s syndrome
• Lattice degeneration

Question 20

What is a lattice degeneration?

Answer 20

The peripheral retina becomes thinned or atrophic in a lattice pattern making it prone to damage

Question 21

What % of the population is lattice degeneration present in?

Answer 21

10%

Question 22

Why is lattice degeneration important?

Answer 22

It is a cause of retinal detachment in young myopic individuals (usually bilaterally)

Question 23

What are the risk factors for tractional retinal detachment?

Answer 23

• Proliferative diabetic retinopathy
• Penetrating eye injury
• Retinal vein occlusion

Question 24

What are the risk factors for exudative retinal detachment?

Answer 24

• Inflammatory disease e.g. uveitis
• Vascular disease e.g. severe hypertension
• Congenital abnormalities e.g. coloboma

Question 25

How can retinal detachment present?

Answer 25

- New onset floaters - New onset flashes - Sudden onset painless, progressive visual field loss

Question 26

What causes floaters?

Answer 26

Blood or pigment cells entering the vitreous cavity casting shadows on the retina

Question 27

How can posterior vitreous and retinal detachment floaters be differentiated from lifetime floaters?

Answer 27

They occur more abruptly and dramatically

Question 28

What are flashes in the vision known as?

Answer 28

Photopsia

Question 29

What can sudden onset visual field loss in retinal detachment often be described as?

Answer 29

Dark curtain or shadow, usually starts in periphery and progresses towards the centre

Question 30

Over what time period can visual loss spread in retinal detachment?

Answer 30

Hours to weeks

Question 31

What are the important parts of an examination in patients with retinal detachment?

Answer 31

- Pupil assessment - Visual acuity - Dilated fundus examination

Question 32

What will a pupil present with in retinal detachment?

Answer 32

RAPD (relative afferent pupillary defect)

Question 33

What is an RAPD?

Answer 33

The affected pupil appears to dilate when light is shone on it during the swinging light test

Question 34

Why does the affected pupil appear to dilate in an RAPD?

Answer 34

The pupil constricts more when light is shone in the other eye (due to unaffected afferents) and constricts less (so appears to dilate) when shone in the affected eye (as less light is registered to due to affected afferents)

Question 35

What does poor visual acuity suggest in suspected retinal detachment?

Answer 35

Involvement of the macula

Question 36

What can be seen on a dilated fundus examination in retinal detachment?

Answer 36

- Altered red reflex - Sheet of retina billowing towards centre (in large detachments) - Potentially visible tear

Question 37

How may the retina be altered in retinal detachment?

Answer 37

Can have a grey or folded appearance

Question 38

What investigations can be useful in assessing retinal detachment?

Answer 38

- Slit lamp examination | - USS or OCT

Question 39

What can USS or OCT be used for in retinal detachment?

Answer 39

To assess type and extent of the detachment as well as associated tears or comorbidities

Question 40

What are the differentials for retinal detachment based on?

Answer 40

- Conditions causing photopsia | - Conditions causing floaters

Question 41

What are some conditions that can cause photopsia?

Answer 41

- PVD - Atypical/ocular migraine - Optic nerve pathology e.g. optic neuritis - Stroke/TIA

Question 42

What are some conditions that can cause floaters?

Answer 42

- PVD - Vitreous haemorrhage - Age-related macular degeneration - Uveitis - Retinitis pigmentosa

Question 43

How can the risk of retinal detachment following PVD be reduced?

Answer 43

Prophylactic laser treatment

Question 44

If a patient has an asymtpomatic retinal hole/tear without detachment, what treatment options are available?

Answer 44

Monitoring or prophylactic laser treatment

Question 45

How is symptomatic retinal tear/hole treated?

Answer 45

Holes are sealed by cryopexy or laser retinopexy

Question 46

What is the first line treatment for rhegmatogenous retinal detachment?

Answer 46

Scleral buckle and/or vitrectomy

Question 47

What is scleral buckling?

Answer 47

A piece of silicone is placed on the scleral surface, secured under the conjuctiva to push the wall of the eye close to the detached retina and helping it to reattach

Question 48

What is a vitrectomy?

Answer 48

A substance is injected into the vitreous space to help flatten the retina and helps to relieve traction

Question 49

What is the first line treatment for tractional retinal detachment?

Answer 49

Vitrectomy with or without scleral buckle

Question 50

How is exudative retinal detachment treated?

Answer 50

Treat underlying cause

Question 51

What is the main complication of retinal detachment?

Answer 51

Can lead to visual loss if untreated