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Emergency And Acute Medicine – Retinal Detachment
Retinal detachment occurs when the sensory retina separates from the underlying retinal pigment epithelium, disrupting photoreceptor function and threatening permanent vision loss. There are three main types with a common final pathway of retinal separation: rhegmatogenous, tractional, and exudative. Rhegmatogenous retinal detachment (RRD) is the most common and results from a retinal break or tear that allows vitreous fluid to enter the subretinal space. It is typically an acute event and often associated with flashes of light from traction on retinal nerve fibers and floaters from associated vitreous hemorrhage. Tractional retinal detachment (TRD) occurs when fibrous vitreous bands contract and pull the retina away, usually as a chronic, progressive process related to prior pathology. Exudative retinal detachment (ERD) results from accumulation of subretinal fluid without a retinal tear and is often secondary to systemic or inflammatory disease; it usually does not require surgical repair.
Risk factors for RRD include myopia, prior cataract surgery, trauma, connective tissue disorders such as Marfan syndrome, and degenerative changes in the vitreous or retina. TRD is commonly associated with proliferative diabetic retinopathy, vasculopathies, penetrating trauma, retinopathy of prematurity, sickle cell disease, and chronic inflammatory processes. ERD is often caused by malignant hypertension, preeclampsia, intraocular tumors such as melanoma or retinoblastoma, and inflammatory conditions including posterior scleritis or Harada disease.
Patients typically present with painless visual disturbances. Common symptoms include flashes of light (photopsias), new floaters, and a progressive “curtain” or “veil” descending across the visual field. Visual loss often begins peripherally and advances centrally if untreated. Visual acuity may initially remain normal if the macula is spared. History should focus on onset, progression, prior eye disease, surgery, trauma, and systemic conditions.
Physical examination begins with assessment of visual acuity and visual fields before dilation. A field defect usually corresponds to the opposite side of the detachment. An afferent pupillary defect may be present in extensive detachments. Loss of the red reflex may be noted. Fundoscopic examination may reveal a pale, elevated, wrinkled retina; however, fundoscopy alone is insufficient to rule out detachment. Slit-lamp examination may reveal anterior vitreous pigment granules, known as “tobacco dust,” which strongly suggests a retinal tear. Intraocular pressure is often lower in the affected eye. Ocular ultrasound performed by trained emergency physicians is highly sensitive and can confirm the diagnosis when visualization is limited.
The differential diagnosis includes central retinal artery occlusion, central retinal vein occlusion, vitreous hemorrhage, migraine with aura, choroidal detachment, toxic exposures such as methanol poisoning, and other retinal or central nervous system pathology. A thorough neurologic examination is important to exclude cerebrovascular events when symptoms are atypical.
Management in the emergency setting includes placing the patient at bed rest and positioning with the side of the detachment dependent, which may help limit progression. Emergent ophthalmology consultation is required. Detachments involving the macula require surgical repair within 24 hours to optimize visual outcomes. Chronic detachments may be repaired on a less urgent timeline based on ophthalmologic assessment. Exudative detachments are treated by addressing the underlying systemic condition.
Early recognition of retinal tears allows prophylactic intervention and may prevent progression to full detachment. The presence of “tobacco dust” carries a high risk of retinal tear. Clinicians must also avoid missing central retinal artery occlusion, which carries an increased risk of stroke in patients with carotid or cardioembolic disease. Prompt diagnosis and referral are essential to preserve vision.
Retinal detachment occurs when the sensory retina separates from the underlying retinal pigment epithelium, disrupting photoreceptor function and threatening permanent vision loss. There are three main types with a common final pathway of retinal separation: rhegmatogenous, tractional, and exudative. Rhegmatogenous retinal detachment (RRD) is the most common and results from a retinal break or tear that allows vitreous fluid to enter the subretinal space. It is typically an acute event and often associated with flashes of light from traction on retinal nerve fibers and floaters from associated vitreous hemorrhage. Tractional retinal detachment (TRD) occurs when fibrous vitreous bands contract and pull the retina away, usually as a chronic, progressive process related to prior pathology. Exudative retinal detachment (ERD) results from accumulation of subretinal fluid without a retinal tear and is often secondary to systemic or inflammatory disease; it usually does not require surgical repair.
Risk factors for RRD include myopia, prior cataract surgery, trauma, connective tissue disorders such as Marfan syndrome, and degenerative changes in the vitreous or retina. TRD is commonly associated with proliferative diabetic retinopathy, vasculopathies, penetrating trauma, retinopathy of prematurity, sickle cell disease, and chronic inflammatory processes. ERD is often caused by malignant hypertension, preeclampsia, intraocular tumors such as melanoma or retinoblastoma, and inflammatory conditions including posterior scleritis or Harada disease.
Patients typically present with painless visual disturbances. Common symptoms include flashes of light (photopsias), new floaters, and a progressive “curtain” or “veil” descending across the visual field. Visual loss often begins peripherally and advances centrally if untreated. Visual acuity may initially remain normal if the macula is spared. History should focus on onset, progression, prior eye disease, surgery, trauma, and systemic conditions.
Physical examination begins with assessment of visual acuity and visual fields before dilation. A field defect usually corresponds to the opposite side of the detachment. An afferent pupillary defect may be present in extensive detachments. Loss of the red reflex may be noted. Fundoscopic examination may reveal a pale, elevated, wrinkled retina; however, fundoscopy alone is insufficient to rule out detachment. Slit-lamp examination may reveal anterior vitreous pigment granules, known as “tobacco dust,” which strongly suggests a retinal tear. Intraocular pressure is often lower in the affected eye. Ocular ultrasound performed by trained emergency physicians is highly sensitive and can confirm the diagnosis when visualization is limited.
The differential diagnosis includes central retinal artery occlusion, central retinal vein occlusion, vitreous hemorrhage, migraine with aura, choroidal detachment, toxic exposures such as methanol poisoning, and other retinal or central nervous system pathology. A thorough neurologic examination is important to exclude cerebrovascular events when symptoms are atypical.
Management in the emergency setting includes placing the patient at bed rest and positioning with the side of the detachment dependent, which may help limit progression. Emergent ophthalmology consultation is required. Detachments involving the macula require surgical repair within 24 hours to optimize visual outcomes. Chronic detachments may be repaired on a less urgent timeline based on ophthalmologic assessment. Exudative detachments are treated by addressing the underlying systemic condition.
Early recognition of retinal tears allows prophylactic intervention and may prevent progression to full detachment. The presence of “tobacco dust” carries a high risk of retinal tear. Clinicians must also avoid missing central retinal artery occlusion, which carries an increased risk of stroke in patients with carotid or cardioembolic disease. Prompt diagnosis and referral are essential to preserve vision.
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