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)

[Outline]

• DESCRIPTION
• ETIOLOGY

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: ~97% 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

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

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

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES

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.

FOLLOW-UP RECOMMENDATIONS

Per ophthalmologist

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• 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

ICD9

• 361.00 Retinal detachment with retinal defect, unspecified
• 361.81 Traction detachment of retina
• 361.9 Unspecified 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

[Outline]

• ICD9
• ICD10

• 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

Carl G. Skinner