Retinal Detachment

Question 1

Risk Factors of Retinal Detachment (8).

Answer 1

1. Posterior Vitreous Detachment (accelerated by previous surgery for cataracts).
2. Diabetic Retinopathy.
3. Trauma to Eye (e.g. Boxing).
4. Retinal Malignancy.
5. Older Age.
6. Family History.
7. Myopia (Near-Sightedness).
8. Previous History of Retinal Break/Detachment in Either Eye.

Question 2

Epidemiology of Retinal Detachment (2).

Answer 2

1. Less Significant Cause of Blindness (compared to Diabetic Retinopathy or Macular Degeneration - can be repaired with little effect on vision early on).
2. Commonest Type : Rhegmatogenous Retinal Detachment (60% of patients above 80, diabetics, traumatic patients) - traction by vitreous humour causes tears which can proceed to detachment.

Question 3

Aetiology of Retinal Detachment.

Answer 3

Retinal tear allows vitreous fluid to get under Retina and fill space between Retina and choroid - neurosensory tissues come away from the underlying pigment epithelium so it is a sight-threatening emergency.

Question 4

Clinical Presentation of Retinal Detachment (5).

Answer 4

1. Peripheral Vision Loss (Sudden Dense Shadow/Vein/Curtain that starts peripherally and progresses towards central vision).
2. Blurred/Distorted Vision (Straight Lines - Curved).
3. Flashes (traction on Retina) and Floaters (Pigment cells on Vitreous Space).
4. If Macula is also involved, central visual acuity and visual outcomes are worse.
5. Infants : with Squint or White Pupillary Reflex - suspect if history of ocular trauma in older kids (unlikely to comment on visual changes).

Question 5

Differential Diagnoses of Sudden Painless Loss of Vision (4).

Answer 5

1. Vascular/Ischaemic Causes (Amaurosis Fugax - like a curtain coming down).
   1A. Large Artery Disease e.g. TIA, Dissection.
   1B. Small Artery Occlusive Disease e.g. Anterior Ischaemic Optic Neuropathy - occlusion of short posterior ciliary arteries (damage optic nerve); Central Retinal Artery/Vein Occlusion.
2. Vitreous Haemorrhage.
3. Retinal Detachment.
4. Retinal Migraine.

Question 6

Examination Findings of Retinal Detachment (5).

Answer 6

1. Peripheral Visual Fields : Reduced.
2. Central Visual Acuity : Reduced to Hand Movements (if Macula is Detached).
3. Swinging Light Test - RAPD (if Optic Nerve is involved).
4. Fundoscopy : Loss of Red Reflex.
5. Fundoscopy : Retinal Folds appear Pale, Opaque or Wrinkled.

Question 7

Management of Retinal Tear.

• Aim.
• Method (2).

Answer 7

Aim : Create adhesions between Retina and Choroid to prevent detachment.

Method : Laser Therapy or Cryotherapy.

Question 8

Management of Retinal Detachment :

• Aim.
• Methods (3).

Answer 8

Aim : Reattach retina and reduce any traction or pressure that may cause it to detach (e.g. tears).

Method 1 : Vitrectomy (removal of relevant parts of vitreous body and replacing it with oil/gas).

Method 2 : Scleral Bulking (silicone ‘buckle’ used to put pressure on the sclera so that the outer eye indents to bring the choroid inwards and into contact with detached retina).

Method 3 : Pneumatic Retinopexy (inject gas bubble into vitreous body and positioning patient so the gas bubble creates pressure to flatten retina against choroid and close detachment).

Question 9

Epidemiology of Posterior Vitreous Detachment (2).

Answer 9

1. Common - occurs in over 75% of people above the age of 65 and commoner in females.
2. Risk Factor : High Myopia (Near-Sightedness) due to longer axial length.

Question 10

Posterior Vitreous Detachment Pathophysiology (2).

Answer 10

1. The vitreous body keeps the retina pressed on the choroid - it is made up of Collagen and Water.
2. As people age, the vitreous fluid in the eye becomes less viscous and so is not as sturdy to hold its shape as well so it pulls the vitreous membrane away from the retina towards the centre of the eye.

Question 11

Clinical Presentation of Posterior Vitreous Detachment (5).

Answer 11

1. No Pain or Loss of Vision.
2. Sudden Appearance of Floaters (occasionally Weiss Ring - temporal to central vision (ring of floaters)).
3. Flashes of Light (Photopsia) in Peripheral Vision.
4. Blurred Vision.
5. Cobwebs Across Vision.

Question 12

Investigation of Posterior Vitreous Detachment.

Answer 12

Any patient suspected with Vitreous Detachment needs examination by an Ophthalmologist within 24 hours to rule out retinal tears/detachment.

Question 13

Management of Posterior Vitreous Detachment.

Answer 13

Symptoms gradually improve over a period of around 6 months - no treatment is necessary (unless associated retinal tear/detachment).