Retinal Detachment — Symptoms, Causes & Treatment | MyMedicPlus

Retinal detachment is an ophthalmic emergency where the neurosensory retina — the light-sensitive tissue lining the inner surface of the eye — separates from the underlying retinal pigment epithelium (RPE), disrupting the blood supply and causing progressive, irreversible vision loss if not surgically repaired. There are three main types: rhegmatogenous retinal detachment (RRD — the most common, accounting for 90% of cases) results from a retinal tear or hole allowing liquefied vitreous to enter the subretinal space; tractional retinal detachment occurs when fibrous scar tissue pulls the retina away from the RPE — most commonly from proliferative diabetic retinopathy, sickle cell retinopathy, or retinopathy of prematurity; and exudative (secondary) retinal detachment results from fluid accumulation without a tear, caused by tumours, severe uveitis, or choroidal disease. RRD has an incidence of approximately 12 per 100,000 per year in the general population and is significantly higher in people with high myopia, aphakia (absence of the natural lens), or previous vitreoretinal surgery. Prompt surgical repair — ideally within 24 hours for macula-on detachments — is essential to preserve central vision.

Posterior vitreous detachment (PVD) is the most common precursor event for rhegmatogenous retinal detachment. As the vitreous gel liquefies with age (syneresis), it separates from the retina. In most cases PVD is uncomplicated; however, in approximately 10-15% of cases it tears the retina — allowing fluid to enter the subretinal space and detach the retina. Key risk factors for RRD: high myopia (above -6 dioptres — elongated axial length causes peripheral retinal thinning, lattice degeneration, and atrophic holes; risk is approximately 6 times higher than non-myopic individuals); prior cataract surgery (aphakia or pseudophakia — posterior capsulotomy with Nd:YAG laser further increases risk); blunt or penetrating eye trauma (the second most common cause in young men); lattice degeneration (peripheral retinal thinning with atrophic holes present in 8% of the population — predisposes to traction tears); family history of retinal detachment; previous retinal detachment in the fellow eye (10-15% lifetime risk of fellow eye detachment); Marfan syndrome and Stickler syndrome (connective tissue disorders with vitreoretinal degeneration); and premature birth. Tractional RD: caused by proliferative diabetic retinopathy (the most common cause globally), sickle cell retinopathy, and retinopathy of prematurity.

Retinal detachment produces a characteristic symptom triad that should be recognised immediately as an ophthalmic emergency. Photopsia (flashing lights): sudden onset of flashing lights in the peripheral visual field, typically in one eye — caused by mechanical traction on the retina by the detaching vitreous stimulating photoreceptors; most prominent in dark environments. Floaters: a sudden shower or dramatic increase in floaters (dark specks, threads, or cobwebs drifting in the visual field) — caused by vitreous haemorrhage or 'tobacco dust' (pigment cells from the torn RPE entering the vitreous cavity); a sudden large floater or ring (Weiss ring — formed when PVD occurs) is common with PVD and may precede a tear. Visual field defect: a dark shadow, curtain, or veil advancing across the peripheral visual field — corresponding to the area of detached retina; spreads progressively as detachment extends; is not painful. Macula involvement: when the detachment reaches the macula (the central 5mm of the retina responsible for detailed central vision), visual acuity drops dramatically — patients describe sudden blurring of central vision. Critical distinction: a macula-on detachment (central vision preserved) is a surgical emergency requiring repair within 24 hours to preserve vision; a macula-off detachment (central vision lost) still requires urgent surgery but visual prognosis is worse.

Urgent dilated fundus examination is the essential diagnostic investigation. Slit-lamp biomicroscopy (with 78D or 90D lens): allows detailed examination of the posterior pole including the macula and posterior vitreous. Indirect ophthalmoscopy with scleral depression (pressing on the eye wall while examining): the gold standard technique for identifying the full extent of the detachment, peripheral retinal breaks, and tears — requires a dilated pupil and expert vitreoretinal examination technique. Key findings: grey or bullous elevation of the retina with loss of the underlying choroidal pattern, retinal tear (usually a U-shaped or horseshoe tear at the site of vitreoretinal traction), and 'tobacco dust' cells (Shafer's sign — pathognomonic pigment cells in the anterior vitreous indicating a retinal break). B-scan ultrasound (ocular ultrasound): used when the fundal view is obscured by vitreous haemorrhage, dense cataract, or media opacity — shows the detached retina as a highly reflective membrane. Optical coherence tomography (OCT): high-resolution imaging of the macula — assesses whether the macula is on or off (prognostic significance), identifies subtle subretinal fluid, and helps plan surgery. Careful mapping of all breaks is essential for surgical planning.

All rhegmatogenous retinal detachments require surgical repair. The choice of procedure depends on the location and number of breaks, extent of detachment, presence of proliferative vitreoretinopathy (PVR), and surgeon expertise. Pneumatic retinopexy: an office-based procedure in which an intravitreal gas bubble (perfluoropropane — C3F8, or sulfur hexafluoride — SF6) is injected to tamponade the retinal break, combined with cryotherapy or laser photocoagulation to seal the tear; requires strict head positioning postoperatively; best suited for superior detachments with a single break without significant PVR; anatomic success approximately 70-85% with a single procedure. Scleral buckle: a silicone band or sponge is sutured externally around the globe to indent the sclera, closing the retinal break and relieving vitreoretinal traction; appropriate for inferior detachments, young myopic patients, and aphakic detachments; avoids entry into the eye; overall anatomic success 85-90%. Pars plana vitrectomy (PPV): removal of the vitreous gel followed by retinal flattening with perfluorocarbon liquid, laser or cryo to the break, and gas or silicone oil tamponade; the preferred technique for complex detachments with large tears, posterior breaks, PVR, vitreous haemorrhage, or after failed pneumatic retinopexy; anatomic success above 90% for primary RRD; silicone oil may be used for cases at high risk of re-detachment and requires a second procedure for removal. Prophylactic laser photocoagulation: for symptomatic retinal tears without detachment — seals the break with surrounding laser burns, preventing progression to full detachment in over 95% of cases.

Permanent visual loss is the primary complication of retinal detachment, particularly when the macula is involved. Even after successful anatomic reattachment, patients with macula-off detachments often have residual distortion (metamorphopsia), reduced visual acuity (below 20/40 in 30-40%), and contrast sensitivity deficits — worsening with each additional day the macula is detached before surgery. Proliferative vitreoretinopathy (PVR): the most common cause of surgical failure — occurring in 5-10% of operated cases. Retinal pigment epithelial cells proliferate on the retinal surface, forming contractile membranes that cause re-detachment resistant to repeat surgery; requires repeated vitrectomy with silicone oil. Re-detachment: occurs in 10-15% of cases, most commonly from missed breaks or new breaks. Cataract development: vitrectomy with gas or oil tamponade accelerates nuclear sclerotic cataract formation — typically requiring cataract surgery within 1-3 years. Elevated intraocular pressure: from silicone oil or gas, requiring topical pressure-lowering drops. Cystoid macular oedema (CMO): oedema of the macula post-surgery reducing visual recovery. Diplopia: from scleral buckle surgery or large intraocular gas bubble. Fellow eye detachment: 10-15% lifetime risk of RRD in the fellow eye — all patients require a dilated examination of the fellow eye.

Retinal detachment is a medical emergency requiring same-day emergency ophthalmology assessment. Seek emergency eye care immediately (do not wait until the next day) for: sudden onset of multiple new floaters or a shower of floaters, flashing lights (photopsia — especially in one eye), a shadow, curtain, or dark area appearing in the peripheral visual field, or sudden deterioration of vision in one eye. These symptoms may indicate either a retinal tear (which can be treated preventatively with laser before detachment occurs) or an established retinal detachment. If a curtain or shadow is spreading towards your central vision, this is an extreme emergency — every hour of delay increases the extent of detachment and risk of permanent visual loss. Call your nearest ophthalmology emergency department, eye casualty, or A&E immediately. Do not eat or drink if you may need surgery. Lie flat while waiting if the shadow is in the lower visual field (to prevent inferior extension of detachment). After treatment for retinal detachment, report any recurrence of symptoms immediately — the fellow eye should also have examination and prophylactic treatment if predisposing peripheral retinal lesions are found.

Annual dilated eye examinations for high-risk individuals (high myopia above -6 dioptres, family history of retinal detachment, post-cataract surgery, history of significant eye trauma, connective tissue disorders such as Marfan or Stickler syndrome, prior retinal detachment in the fellow eye, and lattice degeneration). Prophylactic laser photocoagulation for symptomatic retinal tears (horseshoe tears with associated symptoms of floaters or photopsia) — prevents progression to detachment in over 95% of cases by creating scar tissue that seals the break. Asymptomatic small atrophic holes in lattice degeneration typically do not require treatment. Protect eyes from blunt trauma (sports eye protection, workplace goggles). Patients with a history of retinal detachment should be educated to report immediately any new floaters, photopsia, or visual field change — indicating a possible new retinal tear in the same or fellow eye. Patients with intraocular gas (C3F8 or SF6) must avoid air travel and high altitude until the gas bubble has completely reabsorbed — rapid altitude change causes gas expansion and dangerous intraocular pressure spikes. After successful retinal detachment surgery, avoid contact sports and heavy lifting for 4-6 weeks during recovery. Long-term follow-up with an ophthalmologist every 6-12 months is recommended for all patients who have had a retinal detachment.