Retinal Detachment

Retinal detachment is a separation of the neurosensory retina from the retinal pigment epithelium.¹ It is relatively rare but poses a significant threat to vision when the macula is involved.¹ Retinal detachment is classified into three mechanisms. Rhegmatogenous retinal detachment (RRD), the most common form, occurs when fluid passes from the vitreous cavity into the subretinal space through one or more retinal breaks, holes, or tears.²¹ Tractional retinal detachment occurs from traction on the retina — classically from fibrovascular membranes in advanced proliferative diabetic retinopathy — without a primary retinal break.³ Exudative retinal detachment develops when inflammatory, infectious, infiltrative, neoplastic, vascular, or degenerative conditions cause blood-retinal barrier breakdown, allowing fluid to collect in the subretinal space without any mechanical break.⁵

Most RRDs are idiopathic, though traumatic RRDs can occur in hazardous sports and occupations.² Main risk factors for RRD include retinal tears, myopia, and previous cataract surgery.³ Myopic patients face increased risk of pseudophakic retinal detachment specifically, along with vitreous loss at the time of cataract surgery and Nd:YAG posterior capsulotomy as additional risk factors.⁴ Modern cataract techniques (extracapsular extraction, phacoemulsification) carry lower pseudophakic detachment risk than older intracapsular extraction.⁴ Posterior vitreous detachment is an important precursor to retinal tear formation, which can progress to detachment if untreated.³ In rhegmatogenous detachment, fluid passes through a retinal break into the subretinal space, separating the neurosensory retina from the RPE.² The subretinal space itself is the remnant of the embryonic optic vesicle — of minimal size in the developed eye but able to reopen when pathological conditions disrupt the blood-retinal barrier, as occurs in exudative detachment.⁵ Tractional detachment, by contrast, arises purely from mechanical pulling on an intact retinal surface rather than from a break or barrier breakdown.

Patients typically report flashes, floaters, or a visual field defect corresponding to the area of detachment; when the macula detaches, central vision is affected.¹ The interval between a retinal tear and progression to detachment is often long enough for prophylactic laser retinopexy, but public and non-ophthalmic provider awareness of these warning symptoms is limited — a major driver of delayed evaluation and the need for surgical rather than prophylactic treatment.² Most cases of pseudophakic retinal detachment present when the macula is already detached and central vision is affected.⁴

Key differentials for rhegmatogenous detachment include tractional retinal detachment, exudative retinal detachment, and retinoschisis.³ Exudative detachment may be associated with a spectrum of diseases seen in uveitis clinics — inflammatory, infectious, infiltrative, neoplastic, vascular, and degenerative conditions that disrupt the blood-retinal barrier.⁵ Distinguishing these entities is critical: rhegmatogenous detachment requires surgical intervention, while exudative detachment often requires treatment of the underlying cause instead.

For patients with symptoms of posterior vitreous detachment, indirect ophthalmoscopy under pupillary dilation is necessary to diagnose retinal tears or retinal detachment.³ Examination may reveal elevation of the neurosensory retina, visible retinal breaks or tears, and subretinal fluid; the extent and configuration of the detachment should be carefully documented, including whether the macula is involved.

In pseudophakic eyes, the fundus view is often impaired by anterior or posterior capsular opacification, IOL-related reflections, or poor mydriasis, complicating detection.⁴

Rhegmatogenous retinal detachment is an ophthalmologic emergency requiring immediate surgical treatment.³ Prevention is achieved by early accurate diagnosis of retinal tears and prophylactic outpatient retinopexy, which is easy and highly successful at sealing retinal breaks; traumatic RRD can also be avoided with protective eyewear in hazardous sports/occupations and timely examination.²

Once RRD has occurred, surgical options include scleral buckling, pneumatic retinopexy, and primary pars plana vitrectomy with or without combined scleral buckling.⁴ Anatomical success rates after vitreoretinal surgery are high, though a smaller proportion of patients recover good vision, particularly when the macula was detached preoperatively.²⁴ Vitrectomy specifically is associated with temporary visual loss and postoperative positioning restrictions with limited activity for 1-2 weeks, and phakic patients undergoing vitrectomy usually need cataract surgery within about 2 years.² Exudative detachment is managed by treating the underlying cause rather than by retinal surgery, and tractional detachment (e.g., from proliferative diabetic retinopathy) is managed with vitreoretinal surgery addressing the traction. Prompt diagnosis combined with patient education and appropriate intervention often can avert irrevocable visual impairment.¹

• Indirect ophthalmoscopy under pupillary dilation is necessary for patients with symptoms of posterior vitreous detachment to diagnose retinal tears or detachment³
• The interval between retinal tear and retinal detachment is often long enough for prophylactic laser retinopexy, which is highly successful and usually uncomplicated²
• Most cases of pseudophakic retinal detachment present when the macula is already detached⁴
• Phakic patients undergoing vitrectomy should be counseled that cataract surgery will likely be needed within about 2 years²
• New educational programs are needed to improve public and nonophthalmic provider awareness of retinal tear symptoms and the importance of prompt evaluation²
• Common pitfall: failing to perform indirect ophthalmoscopy under pupillary dilation in patients with posterior vitreous detachment symptoms, missing retinal tears or early detachment³
• Common pitfall: mistaking exudative or tractional retinal detachment for rhegmatogenous detachment, leading to inappropriate surgical intervention³
• Common pitfall: incomplete fundus examination in pseudophakic patients due to capsular opacification, IOL reflections, or poor mydriasis⁴