Author:
Robyn R.Essendrop
Carl G.Skinner
Description
- 3 types 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 band s, 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:
- Trauma
- ERD:
- Malignant hypertension, preeclampsia
- Tumors of the choroid or retina (melanoma, retinoblastoma)
- Inflammatory disorders (Coats or Harada disease, posterior scleritis)
Signs and Symptoms
- Flashes of light, floaters
- Curtain-like vision loss
- Peripheral/central vision loss, 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
- Slit-lamp exam: Anterior vitreous pigment granules (“tobacco dust”) suggest retinal tear
Essential Workup
Diagnostic Tests & Interpretation
Lab
As needed to work up underlying diseases
Imaging
Ocular US: ∼97% sensitive by trained EM physicians
- Highly echogenic flap, low mobility with kinetic scan
- Remains attached at optic nerve and ora serrata
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
- Optic neuritis or ischemic optic neuropathy
- Other retinal or CNS disease
Prehospital
- 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
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
- Symptomatic “macula-on” detachments (preserved central vision) typically require more emergent repair (≤24 hr)
- Visual acuity outcomes may also be better for “macula-off” detachments if surgically repaired within 3 d of symptom onset
Follow-up Recommendations
Per ophthalmologist
- BagheriN, WajdaB, CalvoC, et al. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2016.
- Van BusselEM, Van der ValkR, BijlsmaWR, et al. Impact of duration of macula-off retinal detachment on visual outcome: Systematic review and meta-analysis of literature . Retina. 2014;34(10):1917-1925.
- VrablikME, SneadGR, MinniganHJ, et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: A systematic review and meta-analysis . Ann Emerg Med. 2015;65(2):199-203.
- WooMY, HechtN, HurleyB, et al. Test characteristics of point-of-care ultrasonography for the diagnosis of acute posterior ocular pathology . Canadian J Ophth. 2016;51(5):336-341.
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