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Evaluation and Management of Suspected Retinal Detachment

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Evaluation and Management of Suspected Retinal Detachment Evaluation and Management of Sus- pected Retinal Detachment RAY F. GARIANO, M.D., PH.D., Stanford University School of Medicine, Stanford, California CHANG-HEE KIM, M.D., Naval Medical Center, San Diego, California Retinal detachment often is a preventable cause of vision loss. There are three types of retinal detachments: exudative, tractional, and rhegmatogenous. The most common type is rhegmatogenous, which results from retinal breaks caused by vitreoretinal traction. Risk factors for retinal detachment include advancing age, previous cataract surgery, myopia, and trauma. Patients typically will present with symptoms such as light flashes, floaters, peripheral visual field loss, and blurred vision. Early interven- tion facilitates prevention of retinal detachment after formation of retinal breaks and improves visual outcomes of retinal detachment surgery. Patients with acute onset of flashes or floaters should be referred to an ophthalmologist. (Am Fam Physician 2004;69:1691-8. Copyright© 2004 American Academy of Family Physicians.) See page 1591 for defi- etinal detachment is relatively separates from the underlying retinal pigment nitions of strength-of- uncommon, affecting only epithelium (Figure 1, lower right). Retinal recommendation labels. one in 10,000 people per year, detachments are classified into three patho- or approximately one in 300 genetic types (Table 1). A patient may present patients in the course of a with one or more of these types. Rlifetime.1 Retinal detachment often is repaired Exudative (or serous) retinal detachment with little or no vision loss; therefore, it is results from the accumulation of serous and/ a much less significant cause of irreversible or hemorrhagic fluid in the subretinal space blindness than other retinal diseases, such as because of hydrostatic factors (e.g., severe acute diabetic retinopathy and macular degenera- hypertension), or inflammation (e.g., sarcoid tion.2 Retinal detachment should be consid- uveitis), or neoplastic effusions. Exudative reti- ered in the differential diagnosis of vision nal detachment generally resolves with success- loss, however, because it is more prevalent ful treatment of the underlying disease, and in defined subpopulations and may require visual recovery is often excellent. urgent surgical repair. The second type of detachment, tractional retinal detachment, occurs via centripetal Pathogenesis of Retinal Detachment mechanical forces on the retina, usually medi- The retina is a neurosensory tissue that lines ated by fibrotic tissue resulting from previ- the interior posterior two thirds of the eye ous hemorrhage, injury, surgery, infection, or (Figure 1, left). The central retina, or macula, inflammation. Correction of tractional retinal and the centermost macula, or fovea, exhibit detachment requires disengaging scar tissue structural and cellular specializations for fine from the retinal surface. In patients with trac- central acuity. tional retinal detachment, vision outcomes Retinal detachment results when physi- are often poor. ologic and anatomic mechanisms of reti- The third and most common type is rheg- nal attachment are overcome and the retina matogenous retinal detachment. The key pathogenetic steps of rhegmatogenous retinal detachment are illustrated in Figure 2. The vit- reous humor is a hydrated gel whose structure Retinal detachment often is repaired with little or no is maintained by a collagenous and mucopoly- vision loss. saccharide matrix (Figure 2a). As persons age, this macromolecular network begins to liquefy Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2004 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. and collapse, the vitreous shrinks, and vitreoret- Cornea inal traction develops.3 Eventually, the vitreous partly separates from the retinal surface, which Iris Ciliary body is known as posterior vitreous detachment Conjunctiva Lens (Figure 2b). Approximately one in four per- sons develops a posterior vitreous detachment Zonules between 61 and 70 years of age, and nearly two Vitreous thirds have posterior vitreous detachment after 70 years of age.4 Posterior vitreous detachment is harmless by itself, though bothersome float- Vitreous Sclera ers (blood or retinal pigment epithelium cells) may develop and persist. However, in 10 to 15 Vessel percent of patients with symptomatic posterior Choroid Retina vitreous detachment, a retinal flap tear or hole Photoreceptor forms as the vitreous pulls away from the retina, Retina Plane of cells especially in the periphery where the retina is separation 5 Optic nerve Retinal pigment thinner (Figure 2c). epithelium Retinal tears may occur without symptoms, Choroid but often photopsia (luminous rays or light Sclera Vessel flashes in vision) is noted. Photopsia results from mechanical stimulation of the retina ILLUSTRATION BY MARCIA ILLUSTRATION HARTSOCK FIGURE 1. (Left) Schematic diagram indicating several ocular structures. by vitreoretinal traction. When the retina (Lower right) Cross-section through the posterior eye wall shows the tears, blood and retinal pigment epithelium retina in contact with the vitreous at its inner aspect. Photoreceptor cells may enter the vitreous cavity and are cells in the outermost retina adhere to the retinal pigment epithelium, perceived as floaters (Figure 2c). Patients with which appears as a darkly pigmented cellular monolayer above the symptomatic retinal tears are at high risk of vascular choroid. The sclera is the white outer coat of the eye that invests the optic nerve and is continuous with the dura. The plane of progression to retinal detachment. separation in retinal detachment is between the retina and the retinal Rhegmatogenous detachment occurs when pigment epithelium. Vision is lost because photoreceptor cells require liquid vitreous enters the subretinal space contact with the retinal pigment epithelium and choroid for metabolic through a retinal break and creates a plane of and vascular support. dissection between the retina and retinal pig- ment epithelium (Figure 2d). Over time, the TABLE 1 area of detachment increases as more fluid Classification and Management of Retinal Detachment passes through the retinal break. Symptoms depend on the location and extent of the Type Etiology Management detachment. For example, a small detachment in the inferior retina results in a small supe- Exudative (serous) Inflammation (sarcoid uveitis), Treat underlying disease. rior visual field defect, while a large temporal severe acute hypertension, detachment causes extensive nasal field loss. neoplastic tumors Tractional Fibrosis* Surgical excision of fibrosis When the macula detaches, central acuity is Rhegmatogenous Retinal tears† Surgery lost. If untreated, nearly all rhegmatogenous retinal detachments progress to involve the *—Caused by previous retinal detachment, surgery, trauma, or proliferative macula. retinopathy. †—See Figure 2. Epidemiology of Retinal Detachment The role of the vitreous in the pathogenesis of retinal breaks and detachments clarifies the 1692-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004 Retinal Detachment TABLE 2 Risk Factors for Retinal Detachment Approximately one in four persons develops a posterior vitreous detachment between 61 and 70 years of age, and Common Less Common nearly two thirds have posterior vitreous detachment after Aging Congenital eye diseases Cataract surgery Diabetic retinopathy 70 years of age. Focal retinal Family history of detachment atrophy* Hereditary vitreoretinopathy Myopia (axial) Prematurity Trauma Uveitis Vitreous gel *—Atrophic retinal lesions are designated by descrip- tive terms such as “lattice” degeneration. A Retina risk factors for retinal detachment (Table 2). Detachment is more likely with advancing age because molecular breakdown and shrinkage B Fluid-filled space of the vitreous humor increases over time.4,6 Previous cataract surgery commonly is associ- Retina ated with retinal detachment.7 The detach- ment occurs because following the surgical removal of the lens during cataract surgery, Retinal break vitreous hyaluronic acid may pass into the C anterior chamber and escape through the trabecular meshwork. Shrinkage and detach- Fluid-filled space ment of the vitreous are accelerated, and increase the risk of development to retinal tears. Retinal detachment occurs in approxi- mately 1 percent of patients in the weeks to D years following cataract surgery.8 Myopia, or nearsightedness, is another lead- 9 ing risk factor for retinal detachment. In most Retinal detachment patients with moderate or severe myopia, the axial (anteroposterior) length of the eye is greater, resulting in an egg-shaped globe. As a consequence, centripetal vitreoretinal traction FIGURE 2. Pathogenesis of rhegmatogenous retinal detachment. (A) increases and posterior vitreous detachment The vitreous gel evenly fills the vitreous cavity and is adherent to the retinal surface. (B) With aging and other factors, the gel shrinks, may occur at a younger age than in persons exerts a centripetal traction force on the retina (arrows), and eventu- 4 without myopia. Also, in myopic eyes, the ally separates from the retina, a condition known as posterior vitreous retina is thinner and more prone to tear or detachment; a fluid-filled space enlarges between the retracting
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