Retinal Detachment 

Next to central retinal artery occlusion and chemical burns to the eye, retinal detachment is one of the most time-critical eye emergencies encountered in the ED. Retinal detachment (RD) was first recognized in the early 1700s by de Saint-Yves, but clinical diagnosis remained elusive until Helmholtz invented the ophthalmoscope in 1851.

Tragically, retinal detachments were uniformly blinding until the 1920s when Jules Gonin, MD, pioneered the first repair of retinal detachments in Lausanne, Switzerland. Today, with the advent of scleral buckling, intravitreal gas, microscopic, laser, and cryotherapy techniques, rapid ED diagnosis and treatment of a retinal detachment truly can be a vision-saving opportunity.

For more information, see Medscape's AMD and Retinal Disease Resource Center.

Eye anatomy is shown in the image below.

Retinal detachment refers to separation of the inner layers of the retina from the underlying retinal pigment epithelium (RPE, choroid). The choroid is a vascular membrane containing large branched pigment cells sandwiched between the retina and sclera. Separation of the sensory retina from the underlying RPE occurs by the following 3 basic mechanisms:

• A hole, tear, or break in the neuronal layer allowing fluid from the vitreous cavity to seep in between and separate sensory and RPE layers (ie, rhegmatogenous RD)
• Traction from inflammatory or vascular fibrous membranes on the surface of the retina, which tether to the vitreous
• Exudation of material into the subretinal space from retinal vessels such as in hypertension, central retinal venous occlusion, vasculitis, or papilledema

Retinal detachments may be associated with congenital malformations, metabolic disorders, trauma (including previous ocular surgery), vascular disease, choroidal tumors, high myopia or vitreous disease, or degeneration.

Of the 3 types of retinal detachment, rhegmatogenous RD is the most common, deriving its name from rhegma, meaning rent or break. Vitreous fluid enters the break and separates the sensory retina from the underlying RPE, resulting in detachment.

Exudative or serous detachments occur when subretinal fluid accumulates and causes detachment without any corresponding break in the retina. The etiologic factors are often tumor growth or inflammation.

Tractional retinal detachment occurs as a result of adhesions between the vitreous gel and the retina. Centripetal mechanical forces cause the separation of the retina from the RPE without a retinal break. Advanced adhesion may result in the development of a tear or break. The most common causes of tractional retinal detachment are proliferative diabetic retinopathy, sickle cell disease, advanced retinopathy of prematurity, and penetrating trauma. Vitreoretinal traction increases with age, as the vitreous gel shrinks and collapses over time, frequently causing posterior vitreous detachments in approximately two thirds of persons older than 70 years.

Retinal detachments are shown in the images below.

Frequency

United States

Although 6% of the general population have retinal breaks, most of these are benign atrophic holes, which are without accompanying pathology and do not lead to retinal detachment. Incidence of retinal detachment is 1 in 15,000 population, with a prevalence of 0.3% in the US. The annual incidence is approximately one in 10,000 or about 1 in 300 over a lifetime.^[1] Other sources suggest that the age-adjusted incidence of idiopathic retinal detachments is approximately 12.5 cases per 100,000 per year, or about 28,000 cases per year in the US.^[2]

Certain groups have higher prevalence than others. Patients with high myopia (>6 diopters), a condition that is more common in males than in females have a 5% risk; individuals with aphakia (ie, cataract removal without lens implant) have a 2% risk. Cataract extraction complicated by vitreous loss during surgery has an increased detachment rate to 10%.

International

The most common worldwide etiologic factors associated with retinal detachment are myopia (ie, nearsightedness), aphakia, pseudophakia (ie, cataract removal with lens implant), and trauma. Approximately 40-50% of all patients with detachments have myopia, 30-40% have undergone cataract removal, and 10-20% have encountered direct ocular trauma. Traumatic detachments are more common in young persons, and myopic detachment occurs most commonly in persons aged 25-45 years. Although no studies are available to estimate incidence of retinal detachment related to contact sports, specific sports (eg, boxing and bungee jumping) have an increased risk of retinal detachment.

Mortality/Morbidity

Estimates reveal that 15% of people with retinal detachments in one eye develop detachment in the other eye. Risk of bilateral detachment is increased (25-30%) in patients who have had bilateral cataract extraction.

Race

Incidence of retinal detachment is relatively frequent in people of Jewish ethnicity and relatively low in black persons.

Sex

• No predilection exists; overall, incidence is unchanged even when corrections for the higher rate of ocular trauma in men is considered.
• Of those younger than 45 years who have retinal detachment, 60% are male and 40% are female.

Age

As the population ages, retinal detachments (RDs) are becoming more common. Retinal detachment usually occurs in persons aged 40-70 years. However, paintball injuries in young children and teens are becoming increasingly common causes of eye injuries, including traumatic retinal detachments.