Retinal Detachment Clinical Presentation

  • Author: Gregory L Larkin, MD, MS, MSPH, FACEP; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Sep 8, 2010
 

History

  • Initial symptoms commonly include the sensation of a flashing light (photopsia) related to retinal traction and often accompanied by a shower of floaters (RPE) and vision loss.
  • Over time, the patient may report a shadow in the peripheral visual field, which, if ignored, may spread rapidly to involve the entire visual field in a matter of days. Vision loss may be filmy, cloudy, irregular, or curtainlike.
  • Retinal tissue is stimulated by light but also responds to mechanical disturbances. Flashing lights usually are caused by separation of the posterior vitreous. As the vitreous gel separates from the retina, it stimulates the retinal tissue mechanically, resulting in the release of phosphenes and the sensation of light.
  • Pathologic stimulation of the retina and production of phosphenes cause photopsia.
  • Patients often may note decreased visual acuity and a wavy distortion of objects (metamorphopsia). If a RD involves the macula, acuity is severely reduced.
  • Posterior vitreous detachment is usually a benign process; however, 12% of symptomatic detachments reveal a peripheral tear in the retina. The location of the light sensation in the patient's visual field has no correlation to the location of a retinal tear.
  • Floaters are a very common visual symptom in the population; thus, distinguishing their etiology requires eliciting a detailed history.
    • The sudden onset of one large floater in the center of the visual axis indicates posterior vitreous detachment (PVD). The patient observes a circular floater when the vitreous detaches from its annular ring surrounding the optic nerve.
    • Numerous curvilinear opacities indicate vitreous degeneration, which is considered a normal aspect of a mature eye. More ominous and concerning is the description of hundreds of tiny black specks appearing before the eye. This is pathognomonic for vitreous hemorrhage, resulting from disruption of a retinal vessel caused by a retinal tear or mechanical traction of a vitreoretinal adhesion.
    • A few hours after the initial shower of black spots, the patient can note cobwebs that result from blood forming irregular clots.
    • Generally, the new onset of floaters associated with flashing lights indicates a retinal tear until proven otherwise.
  • Visual field defects are a late symptom of retinal detachment.
  • While symptoms of photopsia and floaters are not helpful in locating the position of the retinal tear or detachment, the visual field defect is very specific for locating the detachment.
  • Detachments anterior to the equator of the eye cannot be detected with visual field testing.
  • Detachment posterior to the equator can be isolated with visual field testing, but the patient usually is unaware of a defect until it involves the posterior pole and macula.
  • Patients are less aware of a superior field defect (indicating an inferior detachment) than an inferior field defect (indicating a superior retinal detachment).
  • Inferior retinal detachment can be a long-standing condition that progresses without symptoms until the detachment reaches the fovea.
  • Bullous (ie, large ballooning) detachments produce dense visual field defects (ie, blackness), and flat detachments produce relative field defects (ie, grayness).
  • When a patient has an extensive detachment, inquiring about the initial symptoms of the visual field loss is helpful to assist in localization of the tear.
  • Onset of decreased visual acuity dates the duration of fovea involvement of the detachment, which correlates with the prognosis for recovery of the central vision.
  • Metamorphopsia is a macular fluid-based distortion of a visual image and is commonly described by patients as waviness.
  • Inquire about history of trauma, including whether it occurred several months before the symptoms or coincided with the onset of symptoms. Documentation of head or ocular trauma may be subject to legal investigation, especially in children.
  • Note previous surgery, including cataract extraction, intraocular foreign body removal, and retinal procedures.
  • Question the patient about previous conditions, such as uveitis, vitreous hemorrhage, amblyopia, glaucoma, and diabetic retinopathy. Query about family history of eye disease because, although RDs usually are sporadic events, certain pedigrees may be prone to detachment. Systemic diseases associated with retinal detachment include the following:
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Physical

  • Check visual acuity, correcting for refractive error.
  • Conduct an external examination for signs of trauma, checking the visual field (usually a confrontation field examination is adequate). Visual fields can help isolate the location of the retinal detachment.
  • Check pupil reaction (a fixed dilated pupil may indicate previous trauma; a positive Marcus-Gunn pupil can occur with any disturbance of the afferent pupillomotor pathway, including retinal detachment).
  • Administer slit-lamp biomicroscopy (the anterior segment is usually normal).
  • Examine the vitreous for signs of pigment or tobacco dust (ie, Shafer sign), which is pathognomonic for a retinal tear in 70% of cases with no previous eye disease or surgery.
  • Check intraocular pressure measurement in both eyes (hypotony of >4-5 mm Hg less than the fellow eye is common).
  • Conduct a fundus examination with ophthalmoscopy (pupils must be dilated or a panoptic may be used).
    • Indirect ophthalmoscopy is the definitive means of diagnosing retinal detachment with the use of scleral depression in order to see the anterior retina and definitively identify the location of the tear or hole.
    • Direct funduscopy may detect vitreous hemorrhage and large detachment of the posterior pole, but it is inadequate for complete examination because of the lower magnification and illumination, lack of stereopsis, and limited view of the peripheral retina.
    • A 3-mirror contact lens examination with a slit-lamp may accomplish adequate examination without scleral depression.
    • Obvious detachment is observed as marked elevation of the retina, which appears gray with dark blood vessels that may lie in folds.
    • The detached retina may undulate and appear out of focus. Shallow detachments are much more difficult to detect; thus, comparing the suspected area with an adjacent normal quadrant is helpful to detect any change in retinal transparency. Binocular vision is needed to do this well.
    • A pigmented or nonpigmented line may demarcate the limit of a detachment, and the retinal surface may have an orange-peel appearance.
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Contributor Information and Disclosures
Author

Gregory L Larkin, MD, MS, MSPH, FACEP  Professor of Surgery, Associate Director of Emergency Medicine, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine

Gregory L Larkin, MD, MS, MSPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Society for Bioethics and Humanities, Association for the Advancement of Automotive Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph A Salomone III, MD  Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Douglas Lavenburg, MD  Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

  1. Haimann MH, Burton TC, Brown CK. Epidemiology of retinal detachment. Arch Ophthalmol. Feb 1982;100(2):289-92. [Medline].

  2. Subramanian ML, Topping TM. Controversies in the management of primary retinal detachments. Int Ophthalmol Clin. 2004;44(4):103-14. [Medline].

  3. Shinar Z, Chan L, Orlinsky M. Use of Ocular Ultrasound for the Evaluation of Retinal Detachment. J Emerg Med. Jul 20 2009;[Medline].

  4. Day S, Grossman DS, Mruthyunjaya P, Sloan FA, Lee PP. One-year outcomes after retinal detachment surgery among medicare beneficiaries. Am J Ophthalmol. Sep 2010;150(3):338-45. [Medline]. [Full Text].

  5. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. Aug 2002;9(8):791-9. [Medline].

  6. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 3rd ed. WB Saunders; 1998.

  7. Rosen P, Baker FJ, Barkin RM. Emergency Medicine: Concepts and Clinical Practice. Vol 1. Mosby-Year Book; 1988:1033-49.

  8. Rosen P, Barkin RM, Sternbach GL. Essentials of Emergency Medicine. Mosby-Year Book; 1991:553-66.

  9. Tintinalli JE, Krome RL, Ruiz E. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill; 1992:833-40.

  10. Wilkes SR, Beard CM, Kurland LT, et al. The incidence of retinal detachment in Rochester, Minnesota, 1970-1978. Am J Ophthalmol. Nov 1982;94(5):670-3. [Medline].

 
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Anatomy of the eye.
Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Retinal detachment. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
 
 
 
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