eMedicine Specialties > Ophthalmology > Retina

Retinal Detachment, Rhegmatogenous

Author: Lihteh Wu, MD, Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Coauthor(s): Teodoro Evans, MD, Retina Fellow, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Contributor Information and Disclosures

Updated: Aug 2, 2007

Introduction

Background

Retinal detachment occurs when subretinal fluid accumulates in the potential space between the neurosensory retina and the underlying retinal pigment epithelium (RPE). Depending on the mechanism of subretinal fluid accumulation, retinal detachments traditionally have been classified into rhegmatogenous, tractional, and exudative.

The term rhegmatogenous is derived from the Greek word rhegma, which means a discontinuity or a break. A rhegmatogenous retinal detachment (RRD) occurs when a tear in the retina leads to fluid accumulation with a separation of the neurosensory retina from the underlying RPE; this is the most common type of retinal detachment.

Pathophysiology

Vitreoretinal traction is responsible for the occurrence of most RRD. As the vitreous becomes more syneretic (liquefied) with age, a posterior vitreous detachment (PVD) occurs. In most eyes, the vitreous gel separates from the retina without any sequelae. However, in certain eyes, strong vitreoretinal adhesions are present and the occurrence of a PVD can lead to a retinal tear formation; then, fluid from the liquefied vitreous can seep under the tear, leading to a retinal detachment.

A number of conditions exist that predispose to a PVD by prematurely accelerating the liquefaction of the vitreous gel. Myopia, aphakia or pseudophakia, familial conditions, and inflammation are among the common causes. In other cases, retinal necrosis with a retinal break formation occurs; then, fluid from the vitreous cavity can flow through the breaks and detach the retina without there being overt vitreoretinal traction present. This commonly occurs in acute retinal necrosis syndrome and in cytomegalovirus (CMV) retinitis in AIDS patients.

Frequency

United States

According to population-based studies in Iowa by Haimann et al and in Minnesota by Wilkes et al, the annual incidence of RRD is 12 cases per 100,000.1,2

International

Scandinavian studies by Laatikainen et al and Tornquist et al reveal an annual incidence of RRD of 7-10 cases per 100,000.3,4

A Japanese study by Sasaki et al reported an annual incidence of RRD of 10.4 cases per 100,000.5

A study from Singapore by Wong et al reported annual incidences of RRD of 11.6 cases per 100,000 in the Chinese population, 7 cases per 100,000 in the Malay population, and 3.9 cases per 100,000 in the Indian population.6

A study from Beijing, China, estimated the annual incidence of RRD to be 7.98 cases per 100,000.

Mortality/Morbidity

Visual results depend on the preoperative macular status. Most series report an anatomical success rate of 90-95%. Of the eyes that are successfully reattached, about 50% obtain a final visual acuity of 20/50 or better. In eyes where the macula was attached prior to surgery, as many as 10% have some vision loss despite successful surgery. In most cases, this decrease in vision is caused by cystoid macular edema and macular pucker.

Sex

RRD appears to be more common in males than in females.

Age

Most RRDs occur in persons aged 40-70 years. It is at this time that the syneretic vitreous undergoes separation from the retina.

Clinical

History

  • Specifically ask patients about risk factors that predispose to premature PVD.
    • Myopia
    • Prior intraocular surgery
    • Family history
    • RRD in the fellow eye
  • Symptoms
    • Photopsias refer to the perception of flashing lights by the patient. It probably arises from the mechanical stimulation of vitreoretinal traction on the retina. It may be induced by eye movements and appears to be more noticeable in dim illumination.
    • Visual field defect: Patients often describe a black curtain (visual field defect) once the subretinal fluid extends posterior to the equator.
    • Floaters
      • Floaters are opacities in the vitreous that cast a dark shadow according to their form and shape in the patient's visual field as they float in the vitreous cavity.
      • A ring-shaped floater is the Weiss ring or the remnant of the hyaloid that was attached to the edges of the optic disc.
      • Cobwebs are caused by condensation of the collagen fibers.
      • Small spots usually indicate fresh blood due to the rupture of a retinal vessel during an acute PVD.
    • Loss of central vision
      • When the macula becomes detached (ie, extension of subretinal fluid into the macula), the patient experiences a drop in visual acuity.
      • In other cases, a large bullous detachment may obstruct the macula, causing decreased visual acuity despite the fact that the macula is not detached.

Physical

  • Cell and flare may be seen in the anterior chamber of eyes with a RRD.
  • The intraocular pressure is usually lower in the eye with a RRD than in the fellow eye; this is usually reversed by retinal reattachment. In certain cases, the intraocular pressure may be higher than in the fellow eye.
  • Pigment in the anterior vitreous (tobacco dusting or a Shaffer sign) is usually present.
  • Once the retina becomes detached, it assumes a slightly opaque color secondary to intraretinal edema. It has a convex configuration, has a corrugated appearance, and undulates freely with eye movements unless severe proliferative vitreoretinopathy (PVR) is present.
  • A retinal break in the shape of a horseshoe or flap is often present. Of all RRDs, 50% have more than 1 break. Of all breaks, 60% are located in the upper temporal quadrant, and 15% are located in the upper nasal quadrant. Another 15% are in the lower temporal quadrant, and 10% are in the lower nasal quadrant.
  • Chronic RRD may present with retinal thinning, intraretinal cysts, subretinal fibrosis, and demarcation lines. These lines are usually at the junction of attached and detached retina. Even though they represent areas of increased retinal adhesion to the RPE, it is not uncommon for subretinal fluid to spread beyond the lines.

Causes

  • The main cause of a RRD is a PVD that leads to retinal tear formation. The following are risk factors that commonly share the premature liquefaction of the vitreous gel leading to an increased rate of PVD.
    • Abnormal vitreoretinal adhesions, which may be visible or invisible, are present in many eyes. Among the visible ones are enclosed oral bays, lattice degeneration, and cystic retinal tufts. When a PVD occurs and encounters such an area, a retinal tear may form.
    • Prior intraocular surgery, especially cataract extraction: It appears that an intact posterior capsule delays the onset of PVD. Other procedures, such as penetrating keratoplasty and pars plana vitrectomy (PPV), also may be complicated by a RRD.
    • Certain familial conditions, such as Stickler syndrome, Marfan syndrome, homocystinuria, and Ehlers-Danlos syndrome, are associated with RRD.
    • Inflammatory or infectious conditions, such as acute retinal necrosis syndrome, CMV retinitis in AIDS patients, ocular toxoplasmosis, and pars planitis
    • Axial myopia

More on Retinal Detachment, Rhegmatogenous

Overview: Retinal Detachment, Rhegmatogenous
Differential Diagnoses & Workup: Retinal Detachment, Rhegmatogenous
Treatment & Medication: Retinal Detachment, Rhegmatogenous
Follow-up: Retinal Detachment, Rhegmatogenous
Multimedia: Retinal Detachment, Rhegmatogenous
References
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Further Reading

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Keywords

rhegmatogenous retinal detachment, RRD, subretinal fluid accumulation, retinal tear, neurosensory retina, retinal pigment epithelium, RPE, vitreoretinal traction, posterior vitreous detachment, PVD, vitreoretinal adhesions

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Contributor Information and Disclosures

Author

Lihteh Wu, MD, Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Lihteh Wu, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Teodoro Evans, MD, Retina Fellow, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Disclosure: Nothing to disclose.

Medical Editor

Vytautas A Pakainis, MD, Chief of Ophthalmology, Dorn Veterans Administration Medical Center, Professor of Ophthalmology, Ophthalmology, University of South Carolina School of Medicine
Vytautas A Pakainis, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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