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Retinal detachment

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Retinal detachment
Cross section of retinal detachment
SpecialtyOphthalmology Edit this on Wikidata

Retinal detachment is a disorder of the eye in which the retina peels away from its underlying layer of support tissue.[1] Initial detachment may be in a very small region, but without rapid treatment the entire retina may detach, leading to vision loss and blindness. It is a surgical emergency.[2]

The retina is a thin layer of light-sensitive tissue on the back wall of the eye. The optical system of the eye focuses light on the retina much like light is focused on the film in a camera. The retina translates that focused image into neural impulses and sends them to the brain via the optic nerve. Occasionally, posterior vitreous detachment, injury or trauma to the eye or head may cause a small tear in the retina. The tear allows vitreous fluid to seep through it under the retina, and peel it away like a bubble in wallpaper.

Symptoms of retinal detachment include a sudden increase in floaters, flashes of light, changes in the visual field or a shadow, blurred vision that comes on suddenly.

For all retinal detachments, immediate medical attention is necessary to reduce the risk of permanent vision loss. Treatments depend on the extent of detachment and cause and include lazer treatment, surgery, or in some cases Vitrectomy.

Mechanism and classification

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The retina is a thin layer of tissue located at the back of the eye.[1][3] It processes visual information and transmits it to the brain.[3] Retinal detachment occurs when the retina separates from the layers underneath it.[4] This impairs its function, potentially leading to vision loss.[4][5] Retinal detachment often requires urgent medical intervention to prevent permanent vision loss.[2]

Retinal detachments are divided into three main types based on their distinct causes.[6]

  • Rhegmatogenous retinal detachment is caused by a tear or break in the retina.[6][7] This allows vitreous fluid, which normally sits in the center of the eye, to build up behind the retina.[6][7] As a result, the retina can eventually separate from the tissues underneath it.[6][7][8] This is the most common type of retinal detachment.[6]
  • Tractional retinal detachment occurs when scar tissue on the retina exerts a pulling force, leading to detachment.[6][8] This is occurs in the absence of retinal tears or breaks and is most commonly associated with abnormal blood vessel growth due to proliferative diabetic retinopathy.[6][7][8] Other causes include trauma, retinal vein occlusion, sickle cell retinopathy, and retinopathy of prematurity.[7][8][9][10]
  • Exudative retinal detachment occurs when fluid accumulates beneath the retina, causing it to detach.[6][8][9] This occurs in the absence of retinal tears or breaks. Common causes include age-related macular degeneration, inflammatory diseases, ocular tumors, and injuries to the eye.[6][7][8][9]

Signs and symptoms

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Retinal detachment is typically painless, with symptoms often starting in the peripheral vision.[2][7][8]

Symptoms of retinal detachment, as well as posterior vitreous detachment (which often, but not always, precedes it), may include:[2][5][7][8][11]

  • Floaters suddenly appearing in the field of vision or a sudden increase in the number of floaters. Floaters may resemble cobwebs, specks of dust, or shapes such as ovals or circles
  • Flashes of light in vision (photopsia)
  • Experiencing a "dark curtain" or shadow moving from the peripheral vision toward the central vision
  • Sudden blurred vision

Rarely, a retinal detachment may be caused by atrophic retinal holes, in which case symptoms such as floaters or flashes of light may not occur.[7][8]

Causes and risk factors

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Rhegmatogenous retinal detachments are most often caused by posterior vitreous detachment (PVD).[1][2] This occurs when the vitreous begins to liquefy and shrink, pulling away from the retina.[12][13] While this process is typically harmless and often presents without symptoms, it can lead to retinal holes or tears that may progress to a full retinal detachment if left untreated.[14][10]

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Factors that increase the likelihood of PVD and therefore, retinal detachment, include:

  • Age: The vitreous liquefies as a normal part of aging, increasing the risk for subsequent detachment.[7][14][15]
  • Myopia (nearsightedness): Individuals with myopia have a longer axial length of the eyeball, which increases their risk of developing PVD.[8][15]
  • Trauma: Blunt and penetrating trauma to the eye can disrupt the vitreous, leading to PVD.[15][16]
  • Cataract surgery: Previous cataract surgery, particularly when associated with vitreous loss, is linked to shifts in the vitreous, increasing the risk of PVD.[7][16][17]
  • Inflammation: Inflammatory eye conditions, such as uveitis, are associated with an increased risk of PVD.[7][16]
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Less frequently, rhegmatogenous retinal detachments can occur without PVD. Risk factors for retinal detachment that are not related to PVD include:

  • Family history of retinal detachment[8]
  • Previous retinal detachment in the other eye[7][8][10]
  • Lattice degeneration: Thinning of the retina, which increases its susceptibility to breaks or tears.[7][8][18]
  • Cystic retinal tuft: A small, raised spot present on the retina from birth that increases the risk for tears and detachment.[7][8]

Diagnosis

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Ultrasound of a retinal detachment in a patient presenting with complete vision loss and light perception only

Imaging

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Ultrasound, MRI, and CT scan are commonly used to diagnose retinal detachment.[citation needed]

Treatment of rhegmatogenous retinal detachment

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General principles

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  1. Find all the retinal breaks
  2. Seal all the retinal breaks
  3. Relieve present (and future) vitreoretinal traction

There are several methods of treating a detached retina which all depend on finding and closing the breaks which have formed in the retina.

  • Cryopexy and laser photocoagulation
Cryotherapy (freezing) or laser photocoagulation are occasionally used alone to wall off a small area of retinal detachment so that the detachment does not spread.[citation needed]
  • Scleral buckle surgery
Scleral buckle surgery is an established treatment in which the eye surgeon attaches one or more silicone bands (bands, tyres) to the sclera (the white outer coat of the eyeball). The bands push the wall of the eye inward against the retinal hole, closing the break or reducing fluid flow through it and reducing the effect of vitreous traction thereby allowing the retina to re-attach. Cryotherapy (freezing) is applied around retinal breaks prior to placing the buckle. Often subretinal fluid is drained as part of the buckling procedure. The buckle remains in situ indefinitely unless a buckle related complication such as exposure or infection develops. The most common side effect of a scleral operation is myopic shift. That is, the operated eye will be more short sighted after the operation due to the buckle causing the axial length to increase. A radial scleral buckle is occasionally indicated to U-shaped tears or fishmouthing tears. Circumferential scleral buckling is indicated when there are multiple breaks. Encircling buckles are indicated to breaks involving more than 2 quadrant of retinal area, lattice degeneration located in more than 2 quadrants, undetectable breaks, and where there is proliferative vitreous retinopathy.[citation needed]
  • Pneumatic retinopexy
This operation is generally performed in the doctor's office under local anesthesia. It is another method of repairing a retinal detachment in which a gas bubble (SF6 or C3F8 gas) is injected into the eye after which laser or freezing treatment is applied to the retinal hole. The patient's head is then positioned so that the bubble rests against the retinal hole. Patients may have to keep their heads tilted for several days to keep the gas bubble in contact with the retinal hole. The surface tension of the gas/water interface seals the hole in the retina, and allows the retinal pigment epithelium to pump the subretinal space dry and suck the retina back into place.[clarification needed] This strict positioning requirement makes the treatment of the retinal holes and detachments that occurs in the lower part of the eyeball impractical. This procedure is always combined with cryopexy or laser photocoagulation. The one operation reattachment rate may be slightly lower with pneumatic retinopexy but in spite of this, the final visual acuity may be better.[citation needed]
  • Vitrectomy
Vitrectomy is an increasingly used treatment for retinal detachment. It involves the removal of the vitreous gel and is usually combined with filling the eye with either a gas bubble (SF6 or C3F8 gas) or silicone oil. Advantages of using gas in this operation is that there is no myopic shift after the operation and gas is absorbed within a few weeks. Silicone oil is almost always removed after a period of 2–8 months depending on surgeon's preference. Silicone oil is more commonly used in cases associated with proliferative vitreo-retinopathy (PVR). Silicone oil may be light or heavy depending on the position of the breaks requiring tamponade. A disadvantage is that a vitrectomy always leads to more rapid progression of a cataract in the operated eye. In many places vitrectomy is the most commonly performed operation for the treatment of retinal detachment.[citation needed]

Prognosis

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9/10 people are estimated to respond well to treatment after detached retina.[19] 85 percent of cases will be successfully treated with one operation with the remaining 15 percent requiring 2 or more operations.[citation needed] After treatment people gradually regain their vision over a period of a few weeks, although the visual acuity may not be as good as it was prior to the detachment, particularly if the macula was involved in the area of the detachment. However, if left untreated, total blindness will occur in a matter of weeks.[citation needed]

A retinal detachment or tear can lead to an increased risk of vitreomacular traction syndrome.[20]

Prevention

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Retinal detachment can sometimes be prevented. The most effective means is by educating people to seek ophthalmic medical attention if they have symptoms suggestive of a posterior vitreous detachment.[21] Early examination allows detection of retinal tears which can be treated with laser or cryotherapy. This reduces the risk of retinal detachment in those who have tears from around 1:3 to 1:20.[citation needed]

There are some known risk factors for retinal detachment. There are also many activities which at one time or another have been forbidden to those at risk of retinal detachment, with varying degrees of evidence supporting the restrictions.[citation needed]

Cataract surgery is a major cause, and can result in detachment even a long time after the operation. The risk is increased if there are complications during cataract surgery, but remains even in apparently uncomplicated surgery. The increasing rates of cataract surgery, and decreasing age at cataract surgery, inevitably lead to an increased incidence of retinal detachment.[citation needed]

Trauma is a less frequent cause. Activities which can cause direct trauma to the eye (boxing, kickboxing, karate, etc.) may cause a particular type of retinal tear called a retinal dialysis. This type of tear can be detected and treated before it develops into a retinal detachment. For this reason governing bodies in some of these sports require regular eye examination.[citation needed]

Individuals prone to retinal detachment due to a high level of myopia are encouraged to avoid activities where there is a risk of shock to the head or eyes, although without direct trauma to the eye the evidence base for this may be unconvincing.[22] Some doctors recommend avoiding activities that suddenly accelerate or decelerate the eye, including bungee jumping and skydiving but with little supporting evidence. Retinal detachment does not occur as a result of eye strain, bending, or heavy lifting. [attribution needed]

See also

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References

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  1. ^ a b c "Detached retina (retinal detachment)". www.nhs.co.uk. NHS. 2020-12-16. Retrieved 2023-05-04.
  2. ^ a b c d e "Retinal detachment". MedlinePlus Medical Encyclopedia. National Institutes of Health. 2005. Retrieved 2006-07-18.
  3. ^ a b "Retina". American Academy of Ophthalmology. 2020-09-08. Retrieved 2024-12-04.
  4. ^ a b "Detached Retina". American Academy of Ophthalmology. 2024-10-11. Retrieved 2024-12-04.
  5. ^ a b "Retinal Detachment | National Eye Institute". www.nei.nih.gov. Retrieved 2024-12-04.
  6. ^ a b c d e f g h i "Types and Causes of Retinal Detachment | National Eye Institute". www.nei.nih.gov. Retrieved 2024-12-04.
  7. ^ a b c d e f g h i j k l m n o Kanski's Synopsis of Clinical Ophthalmology. Elsevier. 2023. doi:10.1016/c2013-0-19108-8. ISBN 978-0-7020-8373-0.
  8. ^ a b c d e f g h i j k l m n Blair, Kyle; Czyz, Craig N. (2024), "Retinal Detachment", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31855346, retrieved 2024-12-04
  9. ^ a b c Basic and Clinical Science Course Section 12: Retina and Vitreous. American Academy of Ophthalmology. 2023–2024.
  10. ^ a b c Lin, Jonathan B.; Narayanan, Raja; Philippakis, Elise; Yonekawa, Yoshihiro; Apte, Rajendra S. (2024-03-14). "Retinal detachment". Nature Reviews Disease Primers. 10 (1): 1–13. doi:10.1038/s41572-024-00501-5. ISSN 2056-676X. PMID 38485969.
  11. ^ "Posterior Vitreous Detachment - Patients - The American Society of Retina Specialists". www.asrs.org. Retrieved 2024-12-06.
  12. ^ Walls, Ron M.; Hockberger, Robert S.; Gausche-Hill, Marianne; Rosen, Peter, eds. (2023). Rosen's emergency medicine: concepts and clinical practice. Philadelphia, PA: Elsevier. ISBN 978-0-323-75789-8.
  13. ^ Yanoff, Myron; Duker, Jay S., eds. (2023). Ophthalmology (Sixth ed.). London New York Oxford Philadelphia St. Louis Sydney: Elsevier. ISBN 978-0-323-79515-9.
  14. ^ a b "What Is a Posterior Vitreous Detachment?". American Academy of Ophthalmology. 2024-11-07. Retrieved 2024-12-06.
  15. ^ a b c Flaxel, Christina J.; Adelman, Ron A.; Bailey, Steven T.; Fawzi, Amani; Lim, Jennifer I.; Vemulakonda, G. Atma; Ying, Gui-shuang (January 2020). "Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern®". Ophthalmology. 127 (1): P146–P181. doi:10.1016/j.ophtha.2019.09.027. ISSN 0161-6420. PMID 31757500.
  16. ^ a b c Ahmed, Faryal; Tripathy, Koushik (2024), "Posterior Vitreous Detachment", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 33085420, retrieved 2024-12-06
  17. ^ Sadda, SriniVas R.; Wilkinson, Charles P.; Wiedemann, Peter; Schachat, Andrew P., eds. (2023). Ryan's Retina. Volume 3 / editor-in-chief SriniVas R. Sadda, MD (Professor of Ophthalmology, Doheny Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA) (Seventh ed.). London New York Oxford Philadelphia St Louis Sydney: Elsevier. ISBN 978-0-323-72213-1.
  18. ^ "Lattice Degeneration - Patients - The American Society of Retina Specialists". www.asrs.org. Retrieved 2024-12-06.
  19. ^ "Retinal Detachment | National Eye Institute". www.nei.nih.gov. Retrieved 2024-12-04.
  20. ^ "Vitreomacular Traction Syndrome - Patients - The American Society of Retina Specialists". www.asrs.org. Retrieved 2024-12-04.
  21. ^ Byer NE (1994). "Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment". Ophthalmology. 101 (9): 1503–13, discussion 1513–4. doi:10.1016/s0161-6420(94)31141-9. PMID 8090453.
  22. ^ "eMedicine – Retinal Detachment: Article by Gregory Luke Larkin, MD, MSPH, MSEng, FACEP". Archived from the original on 2008-01-14. Retrieved 2007-06-04.
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