For the full versions of these articles see bmj.

com
CLINICAL REVIEW

Management of retinal detachment:

a guide for non-ophthalmologists
Hyong Kwon Kang, A J Luff

Eye Unit, Southampton University Patients with retinal detachment often present to their Pathogenesis of retinal detachment
Hospital NHS Trust, Southampton general practitioner, emergency department, or opto- Retinal detachments can be caused by scarring of the
SO16 6YD metrist after central vision has been compromised. vitreous and retina (tractional) or leakage of fluid into
Correspondence to: H K Kang,
3 Colleen Close, Cherrybrook, NSW This delay is unfortunate because early repair results in the subretinal space (exudative), but most follow the
2126, Australia little or no visual loss. Once the detachment extends development of breaks in the retina (box 1), which
[email protected] across the fovea (the central macula), permanent visual allows fluid in the vitreous cavity to enter the subretinal
BMJ 2008;336:1235-40 impairment is almost inevitable. Thorough examina- space (fig 2). Such detachments are called rhegmato-
doi:10.1136/bmj.39581.525532.47 tion of the retina needs equipment that is rarely genous (from the Greek word rhegma, meaning a
available to non-ophthalmologists. Recognition of break, rent, or fissure).
symptoms and awareness of the risk factors for retinal Most retinal breaks form when the vitreous separates
detachment may help in making speedy referrals and from the retina as part of the normal ageing process.
saving vision. This event, posterior vitreous detachment, is the result
of a lifetime process of degenerative liquefaction and
What is retinal detachment? shrinkage of the vitreous (fig 2). 8 Although posterior
Retinal detachment is separation of the neurosensory vitreous detachment is benign in most people and may
retina from the underlying retinal pigment epithelium go unnoticed, those with symptoms carry a 10-15% risk
(fig 1). In health, the potential subretinal space of developing retinal breaks. 9 10 Posterior vitreous
between these two layers is closed by the retinal detachment is rare before the age of 40, but the
pigment epithelium actively pumping fluid across the prevalence increases steadily thereafter, to around 40%
retina and into the choroid. 1 Cellular interdigitation in the seventh decade. By the ninth decade, up to 86%
and extracellular matrix provide additional adhesion. of the population develop a partial or complete
Retinal detachment occurs when the forces of retinal posterior vitreous detachment. 11
attachment are overcome and fluid accumulates in the
What symptoms should alert me to a threatened retinal
subretinal space.
detachment?
Flashes and floaters
How common is retinal detachment and why should it
Photopsia and floaters can occur in conditions other
interest non-ophthalmologists?
than posterior vitreous detachment (box 2). Photopsia
Large, population based studies of retinal detachment
associated with posterior vitreous detachment results
find an annual incidence of around 1 in 10 000, and a
from traction on the retina as the vitreous pulls away. It
familial aggregation study estimated a lifetime risk of
is usually described as recurrent, brief flashes in the
3% at age 85.2 3 White and Asian populations have
similar rates, with a lower incidence among blacks.4 5
The average age of presentation is around 60, with the
sexes affected equally.2 Methods
The modest incidence belies the importance of For an overview in the current management of retinal
retinal detachment as a true ophthalmic emergency. detachment we consulted textbooks and proceedings of
Although most detachments can be repaired surgically, meetings in the field of retinal surgery. We searched
only those treated early avoid permanent Medline and Cochrane Review databases for retinal
visual impairment.6 Many patients first present to detachment, retinal break, retinal tear, retinal hole,
general practitioners, emergency departments, and vitreous detachment, lattice, retinal tuft, vitrectomy,
optometrists. Retinal detachment is therefore of scleral buckle, and retinopexy, and we searched the
internet for reviews and perspectives on retinal
clinical (and possibly medicolegal) interest to non-
detachment.
ophthalmologists.7

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CLINICAL REVIEW

images. It is commonly described as a dark curtain or

shadow, appearing first in the periphery and moving to
the centre over hours, days, or even weeks as the
detachment extends. Visual acuity decreases when
the macula becomes detached, and the patient may
notice distortion of images. Without prompt treatment,
total retinal detachment and blindness are almost
inevitable.

Who is at risk of developing retinal detachment?

Retinal detachment occurs more commonly with age
as posterior vitreous detachment becomes more
prevalent. Cataract surgery is thought to accelerate
vitreous liquefaction and posterior vitreous
detachment.14 A retrospective, population based
study found that the eight year cumulative risk of
retinal detachment approached 1% after cataract
surgery, almost nine times higher than expected.15

Fig 1 | The retina lines the internal surface of the posterior two
thirds of the globe. It is thickest around the optic nerve and ends Box 1 Types of retinal detachment
at the ora serrata, 5-7 mm behind the limbus. The macula lies
temporal to the optic nerve, bordered by the vascular arcades; Rhegmatogenous
the fovea is a depression at its centre that provides fine visual Caused by breaks in the retina
acuity. The outermost layer of the retina contains
Associated with:
photoreceptors (rods and cones), loosely attached to the retinal
pigment epithelium; they depend on the retinal pigment Age
epithelium and choroid for support. The vitreous completely Myopia
fills the vitreous cavity and is firmly attached to the retina near
the ora serrata, over the optic nerve and macula, along the blood Cataract surgery
vessels, and around degenerative retinal lesions Trauma
Degenerative retinal lesions
Sticklers syndrome
temporal peripheral field, but can occur anywhere.
Juvenile X-linked retinoschisis
Floaters are caused by vitreous opacities casting
shadows on the retina. Posterior vitreous detachment Marfans syndrome
makes them more mobile and thus more noticeable. Tractional
Vitreous condensation around the optic nerve often Caused by chronic traction from scars on the retinal
manifests as an irregular ring or crescent shaped surface and across the vitreous cavity
opacity (Weiss ring) after posterior vitreous detach- Associated with:
ment (fig 2). Some patients recall a dramatic event of Proliferative diabetic retinopathy
bright flashes accompanied by showers of black dots
Proliferative vitreoretinopathy
that later coalesced into strands, cobwebs, or
cloudy haze. Such descriptions suggest vitreous Retinopathy of prematurity
haemorrhage from avulsed blood vessels (fig 2) or the Penetrating eye injury
liberation of retinal pigment epithelial cells through Sickle cell retinopathy
retinal breaks. Retinal vein occlusion
Symptomatic posterior vitreous detachment carries Exudative
a considerable risk of breaks that are likely to progress
Caused by leakage of fluid into the subretinal space
to retinal detachment. Autopsy studies have shown that
4-9% of the population will develop asymptomatic Associated conditions:
retinal breaks in their lifetime, most of which do not Inflammatory (uveitis, scleritis)
progress to detachment.8 12 In contrast, a retrospective Hydrostatic (malignant hypertension, toxaemia of
case series of 295 patients presenting with photopsia or pregnancy)
floaters found retinal detachment in 61% of 80 eyes that Neoplastic (choroidal melanoma, haemangioma,
had developed retinal breaks.13 metastasis)
Vascular (Coats disease, retinal macroaneurysm)
Visual field defects, blurring, and distortion
Maculopathy (neovascular macular degeneration, central
When the retina is separated from the retinal pigment serous choroidoretinopathy)
epithelium, the visual field defect is opposite the site of
Congenital disorders (nanophthalmos, optic disc pit)
the detachment because of the optical inversion of

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 CLINICAL REVIEW

Cataract surgery in very myopic patients carries a

particularly high risk of detachment.19
Many retrospective studies have shown that trauma
is an important cause of retinal detachment in young
patients.20 21 A direct blow to the eye induces breaks in
the retina, usually in the form of retinal dialysis (lifting
of the retinal edge at the periphery), and tears and
atrophic holes from retinal contusion can also develop.
Ocular trauma induces premature posterior vitreous
detachment, possibly through liquefaction of the
vitreous from leakage of blood and protein.22
Prospective and retrospective case series report
retinal detachment in up to 23% of second eyes as the
features that played a role in the previous detachment
are replicated.23 24 Family history is also a risk factor
because features such as increased axial length and
degenerative retinal lesions are heritable traits.25

How to assess a patient with suspected retinal

Fig 2 | Rhegmatogenous retinal detachment. Hyaluronic acid in
detachment
the vitreous holds water and keeps insoluble collagen fibrils
dispersed in the gel matrix. Awith aging, changes to If the presenting symptoms and risk factor profile
hyaluronic acid cause pockets of liquefied vitreous, leaving the suggest retinal breaks or detachment, further ophthal-
collagen fibrils to condense into larger fibre bundles, which mic assessment is indicated. The completeness of the
appear as chronic floaters. Bpockets of liquid vitreous assessment will depend on the availability of equip-
coalesce to form larger spaces. Defects in the vitreous cortex let ment and the skills of the examiner (fig 3).
liquid into the plane between the vitreous cortex and retina, Visual acuity should be assessed before the pupil is
initiating posterior vitreous detachment. Cthe collapsing
dilated. Decreased visual acuity usually indicates
vitreous exerts mechanical traction on the retina and optic
nerve, which may be perceived as flashing lights; condensation macular detachment, but vitreous haemorrhage may
of the vitreous around the optic nerve may appear as a crescent also reduce vision. A confrontational visual field test
shaped floater (Weiss ring). Vitreous traction may lead to may show an asymptomatic peripheral field defect.
avulsion of blood vessels or formation of retinal breaks. D Extensive retinal detachment will produce a relative
fluid enters the subretinal space through the retinal break and afferent pupillary defect. This can be tested by shining a
retinal detachment develops bright torch alternately on one eye for two seconds,
then rapidly swinging it on to the other eye. This can be
The risk increases further if vitreous is lost during tested by shining a bright torch on each eye for two
surgery.16 seconds, several times in quick succession. The pupils
Myopic patients (with increased axial length) are will dilate when the torch is swung on to the affected eye
more likely to develop posterior vitreous detachment
at a younger age.11 The peripheral retina in these eyes is
less robust and commonly habours degenerative
lesions, such as lattice, where the retina is thinned and Box 2 Causes of photopsia and floaters
firmly adherent to the vitreous.17 Retinal detachment Photopsia (perception of light not attributable to an
from atrophic holes, without posterior vitreous detach- incident light)
ment, is relatively common in highly myopic people.18 Posterior vitreous detachment
Flick phosphene
Migraine
Postural hypotension
Recent flashes and floaters
Choroidal tumours
Visual blurring or field defects? Optic nerve pathology
Yes No Transient ischaemic attacks
Floaters (perception of mobile spots, lines, or haze due
Slit lamp Ophthalmoscopy to vitreous opacities)
Pigmented granules in Retinal detachment visible?
anterior vitreous? Vitreous haemorrhage? Age related macular degeneration
Yes No No Yes Posterior vitreous detachment
Referral within a few days Vitreous haemorrhage (diabetic retinopathy, trauma)
Asteroides hyalosis
Immediate referral
Uveitis
Retinitis pigmentosa
Fig 3 | Management of retinal detachment

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 CLINICAL REVIEW

ADDITIONAL EDUCATIONAL RESOURCES

Review articles
Brucker AJ, Hopkins TB. Retinal detachment surgery: the
latest in current management. Retina
2006;26(suppl 6):S28-33.
Gariano RF, Kim CH. Evaluation and management of
suspected retinal detachment. Am Fam Physician
2004;69:1691-8.
Ghazi NG, Green WR. Pathology and pathogenesis of
retinal detachment. Eye 2002;16:411-21.
Scott JD. Future perspectives in primary retinal
detachment repair. Eye 2002;16:349-52.
Fig 4 | Funduscopic appearance of rhegmatogenous retinal
detachment. The patient noticed blurred vision in her left eye Internet resources
three days earlier. A sector of retina is attached superiorly; Emedicinewww.emedicine.com/emerg/topic504.htm
shallow retinal detachment over the macula and nasally (Larkin GL. Retinal detachment. April 2008.)
appears pale and featureless owing to the masking of the
Handbook of Ocular Disease Managementwww.
choroidal pattern. The fovea appears dark against the pallor of
detached macula, and the bullous retinal detachment inferiorly revoptom.com/handbook/sect5r.htm (Sowka JW,
appears pale, opaque, and wrinkled. The detachment was Gurwood AS, Kabat AG. Retinal detachment. 2001.)
caused by a single superotemporal retinal tear

and constrict when it shines on the unaffected eye, as a ophthalmoscope; the detached retina will appear pale,
result of less brightness signal being sent to the brain opaque, and wrinkled, with masking of the underlying
from the eye with the detachment. choroidal pattern (fig 4).
Dilating the pupil with a short acting mydriatic Retinal detachment cannot be excluded by direct
(tropicamide 1%, for example) is safe, and the risk of ophthalmoscopy owing to the narrow field of view. Slit
inducing acute angle closure glaucoma is extremely lamp or indirect ophthalmoscopy with a consdensing
low. The red reflex should be examined with a direct lens is needed to examine the peripheral retina and
ophthalmoscope at 1 metre for loss caused by retinal locate retinal breaks. A slit lamp is needed to assess the
detachment or vitreous haemorrhage. If a detachment anterior vitreous for pigment granules (tobacco
is near the macula it may be visible through the direct dust), which correlate with a 90% risk of retinal
breaks.26 The anterior vitreous is best visualised with an
oblique slit beam through a dilated pupil.
Macroscopic vitreous haemorrhage is associated
with a 70% risk of retinal breaks.27 When dense vitreous
haemorrhage precludes examining the fundus, ultra-
sonography can identify the detachment. Because
ultrasound does not image the retinal periphery well,
retinal breaks there cannot be diagnosed with certainty
by this method.

ONGOING RESEARCH
The scleral buckling versus primary vitrectomy in
rhegmatogenous retinal detachment study (SPR study)
aims to determine the best approach for managing more
Fig 5 | Surgery for retinal detachment. Ain scleral buckle surgery, the retinal break is treated with complex retinal detachments
cryotherapy or laser therapy, and an explant (usually a silicone band or strip) is sutured on the Sutureless vitrectomy systems promise less invasive
outer surface of the sclera to indent the wall of the globe. This interrupts the flow of fluid through surgery and reduced discomfort
the break, allowing it to close. Subretinal fluid is drained through a small sclerotomy or left to be
Pharmacological vitreolysis may simplify repairs of
absorbed into the choroid. Bthe vitrectomy approach involves removing the vitreous through
difficult tractional detachment
sclerotomies made in the pars plana. Subretinal fluid is drained internally, and laser therapy or
cryotherapy is applied around the flattened retinal break. The vitreous cavity is filled with a Tissue adhesives designed to seal retinal breaks may
tamponade (usually gas but occasionally silicone oil) to hold the retina in place while scarring obviate the need for intraocular tamponade
develops around the break. In some cases, pneumatic retinopexy may be less invasive: a bubble of Research continues in ways to prevent proliferative
gas is injected into the vitreous cavity, and the patients head is positioned to place the bubble on vitreoretinopathy, which remains the leading cause of
the retinal break; once the retina is flattened, the break can be treated with laser therapy or failed surgery
cryotherapy

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Decisions to refer: when, to whom, and how urgently?

SUMMARY POINTS
All patients with a recent onset of retinal detachment
should be referred immediately. Time can be saved by Retinal detachment affects 1 in 10 000 people each year, but
referring the patient directly to the ophthalmologist the incidence is much higher in association with myopia,
cataract surgery, trauma, previous retinal detachment, and
who will perform the surgery. In some countries,
family history
retinal detachments are mostly repaired by specialist
vitreoretinal surgeons. If immediate referral is not Most retinal detachments can be repaired successfully, but
possible, the patient should be instructed to lie down the key to optimum visual recovery is prompt diagnosis and
treatment
with the face on the side of the detachment to the pillow
(opposite the field defect) to minimise the detachment Photopsia and new floaters are symptoms of posterior
extending towards the macula. vitreous detachment, which precedes retinal detachment
There is no general consensus on how soon patients Retinal detachment should be considered in any patient
presenting with a symptomatic posterior vitreous presenting with an acute onset of visual symptoms, and
detachment and no other visual symptoms should be these patients should be referred urgently
referred for a definitive examination. The referral If symptoms are accompanied by decreased vision or visual
should be made as soon as possible, certainly within field loss, referral should be immediate
days, in view of the considerable risk of retinal breaks
associated with the presentation. The patient should be
instructed to return earlier if symptoms worsen or a
visual field defect develops. reattachment of the retina does not always correlate
with a good visual outcome, and patients presenting
Treatment of retinal break and detachment with poorer vision are less likely to achieve good final
Retinal breaks caused by posterior vitreous detach- visual acuity. 6 Macular detachment has a poorer visual
ment are treated using laser therapy or cryotherapy to outcome, and the chance of regaining good vision
create a scar adhesion between the retina and retinal diminishes with the duration of detachment. 6 Results
pigment epithelium. This treatment is almost 100% are best when the detachment is repaired before the
successful, but new breaks can develop elsewhere.28 macula becomes involved, and this can be achieved
Prophylactic treatment of asymptomatic breaks or only through early diagnosis and urgent referral.
degenerative retinal lesions has not been shown to
reduce the risk of retinal detachment.29 Postoperative care
Once the retina is detached, additional surgical After the operation, topical antibiotics and corticoster-
procedures are required to reattach it and seal the oids are routinely prescribed, and cycloplegics and
breaks. Most retinal detachments not involving the ocular hypotensive agents may be prescribed in some
macula are repaired on the same day or the following patients. If intraocular gas has been instilled, vision will
day. For patients presenting with the macula already be poor. As the gas is resorbed over weeks to months,
detached, the macula should be reattached within five the gas-fluid interface will become apparent to the
days, but the urgency of the surgery is influenced by patient as an undulating line that moves downward.
individual factors such as the duration of symptoms, Worsening vision is not expected and should be
the height of macular detachment, and visual acuity.6 reported to the surgeon immediately. Severe pain is
Scleral buckling and vitrectomy with gas tamponade also unusual and should be reported. Headache and
are the most common surgical approaches to repairing nausea suggest an acute rise in intraocular pressure.
retinal detachment (fig 5). Pneumatic retinopexy can Patients with intraocular gas are usually asked to
be performed in some cases, but enthusiasm for this maintain a certain head posture, typically for one week.
technique outside North America has been minimal. In Air travel must be avoided while the gas remains, and
95% of cases the retina will be reattached, sometimes intraocular gas is a contraindication for volatile gas
after more than one operation. 3 0 Successful anaesthesia.
HKK and AJL were involved in all stages of the manuscript preparation.
HKK is guarantor.
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.
INFORMATION RESOURCES FOR PATIENTS
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Macula Centerwww.maculacenter.com/EyeConditions/ 2005;123:1237-41.
3 Polkinghorne PJ, Craig JP. Northern New Zealand rhegmatogenous
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Medicine Netwww.medicinenet.com/ Experiment Ophthalmol 2004;32:159-63.
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retinal detachment in Singapore. Arch Ophthalmol
Medline Pluswww.nlm.nih.gov/medlineplus/ency/ 1999;117:379-83.
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22 Hikichi T, Akiba J, Ueno N, Yoshida A, Chakrabarti B. Cross-linking of
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25 Murakami F, Ohba N. Genetics of lattice degeneration of the retina.
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On the nose
While on holiday in France from my work in Thailand, Meanwhile, I wasnt allowed anthelmintics in France
I thought I had a left upper molar infection. I wished Id because I was lactatingwhereas our bamboo clinic in
stocked up on some antibiotics (far too easy to purchase in Thailand uses mebendazole and albendazole routinely for
resource poor settings, where they can least afford women in their second and third trimesters and
problems with drug resistance). The next day I diagnosed postpartum if they have positive stool results or
left maxillary sinusitis. The following day the supposed migrating superficial skin lesions, in line with the WHO
sinusitis was now on the left side of my nose as a 1.5 cm, red, Millennium Development Goals.1 So I was unable to
slightly raised, circular lesion. access a basic drug in a resource rich country (France)
In Thailand superficial migrating skin lesions are caused when we dispensed it liberally in our resource poor setting
by helminths. The commonest is cutaneous larva migrans, and it was available over the counter in my native
where humans are accidental hosts for the cat and dog Australia.
hookworm. Strongyloides cause larva currens from Back at the nose, things were getting uncomfortable
autoinfection of larvae penetrating the perianal skin. as the helminth wormed its way to the bridge:
Gnathastomiasis is acquired by eating uncooked foods theres not a lot of space for objects under the skin in that
such as fish, shellfish, frog, or chicken. My lesion was not area. I turned to our household cure-all, tea tree oil,
the classic, erythematous, tunnel-like lesions of cutaneous soaked on to a dressing on my nose while I slept.
larva migrans as shown in textbooks. Skin lesions from In the morning there was no sign of further movement,
strongyloides tend to be fleeting and itchy, which mine and within 48 hours the lesion was completely gone.
wasnt, whereas gnathastomiasis tends to present as After this palaver, I looked up the medicinal
migratory skin swellings or subcutaneous lesions. properties of the oil (Melaleuca alternifolia): it can
I went to the local pharmacy to buy some anthelmintics be useful for various skin infections,2 but this is the
albendazole or topical thiabendazole. Cest first report I know of treating a superficial helminth
impossibleno easy, over the counter options for wormy infection.
things in France. Welcome back to Western medicine.
Later that day a courteous and concerned French general Rose McGready research physician
practitioner with an enthusiasm for blood tests checked me Shoklo Malaria Research Unit, Mae Sot, Thailand
for eosinophilia, C reactive protein, and, to top it off, [email protected]
Gnathostoma spinigerum antigen.
I waited a few days for the results of raised eosinophils
1 World Health Organization. The evidence is in: deworming helps
and slightly raised C reactive protein and a few months
meet the Millennium Development Goals. 2005. http://whqlibdoc.
for the antigen result, which was negative. It turned out that who.int/hq/2005/WHO_CDS_CPE_PVC_2005.12.pdf.
the lab in France had sent the sample to Thailand for 2 Carson CF, Hammer KA, Riley TV. Melaleuca alternifolia (tea tree) oil:
testing; the result went back to France, by which time I was a review of antimicrobial and other medicinal properties. Clin
back in Thailand. Microbiol Rev 2006;19(1):50-62.

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