Retinal Detachment — Causes, Symptoms & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

Retinal detachment (RD) is a sight-threatening ocular emergency in which the neurosensory retina — the light-sensitive tissue lining the back of the eye — separates from the underlying retinal pigment epithelium (RPE), depriving it of its oxygen and nutrient supply. Without urgent surgical repair, photoreceptors degenerate irreversibly, leading to permanent vision loss. Three types exist: Rhegmatogenous RD (most common — caused by a full-thickness retinal tear/break allowing vitreous fluid to enter the subretinal space); Tractional RD (vitreoretinal traction pulls the retina away — common in proliferative diabetic retinopathy); Exudative/Secondary RD (subretinal fluid accumulation without a break — from choroidal tumour, vasculitis, or hypertension). Rhegmatogenous RD affects approximately 1 in 10,000 people per year. Surgical success rates exceed 90% for primary repair.

The most common precipitant of rhegmatogenous RD is posterior vitreous detachment (PVD) — the normal age-related separation of the vitreous gel from the retina, occurring in most people over 50. During PVD, vitreous traction can tear the peripheral retina, creating a break through which fluid enters the subretinal space, progressively detaching the retina. Risk factors for retinal detachment: high myopia (shortsightedness — thin, stretched retina predisposes to tears; 50% of RD occurs in myopic patients), previous retinal detachment (10% risk of RD in the fellow eye), family history, prior cataract surgery (pseudophakia — 0.5-1% risk), trauma (direct ocular injury), lattice degeneration (peripheral retinal thinning), and age (incidence peaks in the 6th and 7th decades). Diabetic retinopathy is the leading cause of tractional RD.

Prodromal symptoms of retinal tear (before detachment): Photopsia — sudden flashes of light (typically bright, white flashes in the peripheral visual field, most noticeable in dim lighting) caused by vitreous traction on the retina. New floaters — sudden increase in number and size of floaters (dark spots, strings, or cobwebs drifting across vision) representing vitreous haemorrhage or pigment cells from a retinal tear ('tobacco dust' or Schafer's sign on slit-lamp examination is highly specific for a retinal tear). Retinal detachment symptoms: peripheral visual field loss progressing centrally — patients often describe a 'dark curtain', 'shadow', or 'veil' encroaching from one side of the vision. Central visual acuity is preserved until the macula (fovea) is detached. Macula-off RD (detachment reached the central vision): sudden, severe central visual loss — prognosis for central vision recovery is significantly worse, particularly if macula has been detached for more than 24-48 hours.

Indirect ophthalmoscopy (examination of the retina with a bright headlight and condensing lens) by an ophthalmologist — detects the grey, billowing, detached retina and identifies the retinal break(s). Slit-lamp biomicroscopy: examines the anterior vitreous for tobacco dust (Schafer's sign) — pigmented cells released from the RPE through a retinal tear, indicating high-risk for RD. B-scan ocular ultrasonography: when media opacity (dense vitreous haemorrhage or cataract) prevents fundal view — detects RD as an elevated echogenic membrane. Optical coherence tomography (OCT): assesses macular involvement and degree of subretinal fluid. Fundus photography documents the extent and location of detachment. History and examination determine RD type (rhegmatogenous vs. tractional vs. exudative) to guide treatment. Scleral depression examination is performed by the vitreoretinal surgeon to examine the full peripheral retina.

Retinal tear (without detachment): Laser photocoagulation or cryotherapy creates a scar barrier around the tear to prevent fluid entry and progression to detachment — highly effective when performed within 24-72 hours of tear detection. Rhegmatogenous RD surgical repair: Pneumatic Retinopexy — injection of an expanding gas bubble (SF6 or C3F8) into the vitreous cavity (office procedure); patient maintains specific head position for several days to tamponade the break; cryotherapy or laser applied to the tear. Suitable for superior breaks, phakic patients, single break. Success rate 70-80% with single procedure. Scleral Buckling — an encircling silicone band is sutured to the outside of the eye to indent the sclera, closing the retinal break; vitreous fluid is drained externally. Preferred for young patients and inferior breaks. Vitrectomy (Pars Plana Vitrectomy — PPV) — removal of the vitreous gel, laser to retinal breaks, tamponade with gas (C3F8, SF6) or silicone oil; standard for complex, posterior, or recurrent RD. Macula-threatening RD (approaching or involving the macula): surgical emergency — operation within 24 hours significantly improves visual outcome. Tractional RD from proliferative diabetic retinopathy: PPV to relieve traction.

Permanent central vision loss is the most devastating complication of macula-off retinal detachment — even after successful anatomical reattachment, photoreceptors damaged by prolonged detachment may not fully recover; best-corrected visual acuity is often permanently reduced and metamorphopsia (image distortion) frequently persists, particularly if the macula has been detached for more than 24-48 hours. Proliferative vitreoretinopathy (PVR) — the most common cause of primary surgical failure — occurs in 5-10% of retinal detachment repairs: retinal pigment epithelium cells proliferate on the retinal surface forming contractile membranes that cause re-detachment; requires complex repeat vitrectomy with silicone oil tamponade and carries a poor visual prognosis. Fellow eye risk: 10-15% lifetime risk of retinal detachment in the contralateral eye, requiring prophylactic laser retinopexy to identified retinal tears. Persistent visual field defect (typically inferior arc corresponding to the repaired superior detachment) commonly remains after successful surgical reattachment. End-stage complications of chronic untreated or irreparable detachment include neovascular glaucoma, hypotony, and phthisis bulbi (atrophic, shrunken eye).

Regular dilated retinal examination in high-risk individuals: highly myopic patients (above -6 dioptres), those with a history of retinal detachment in one eye (10% risk to fellow eye), family history of RD, and pseudophakic patients. Prophylactic laser retinopexy to symptomatic retinal tears (tears associated with new floaters/flashes, horseshoe tears, or tears with sub-retinal fluid) prevents progression to RD. Asymptomatic round holes may be monitored rather than treated. High myopes should undergo dilated retinal examination annually and promptly report any new floaters, flashes, or visual field loss. Protective eyewear during contact sports or work with eye injury risk (projectile hazards). Tight glucose and blood pressure control in diabetic patients reduces proliferative diabetic retinopathy and subsequent tractional RD.

Seek emergency same-day ophthalmology assessment for: a sudden shower of new floaters (especially with flashes), a dark curtain or shadow encroaching on your visual field from any direction, sudden deterioration of central vision, or any painless loss of peripheral vision. These are classic warning signs of retinal tear or detachment — time is critical. A retinal tear treated with laser within 24-48 hours can almost always prevent progression to detachment. A detachment reaching or threatening the macula requires surgery within 24 hours to preserve central vision. Never delay seeking ophthalmic review for these symptoms, even at night or on weekends — most large ophthalmology units provide 24/7 emergency eye services.