What Does a Retinal Detachment Look Like?
A rhegmatogenous retinal detachment (RRD) appears as a separation of the neurosensory retina from the underlying retinal pigment epithelium, visible on examination as an elevated, gray-white, undulating retinal surface with loss of the normal red reflex in the affected area 1.
Clinical Appearance on Examination
Fundoscopic Findings
The detached retina appears:
- Elevated and gray-white with a corrugated or undulating surface that moves with eye movements
- Loss of normal red reflex in the detached area
- Retinal breaks (full-thickness defects) are often visible as:
- Horseshoe tears: U-shaped flaps with the apex pointing toward the ora serrata, caused by vitreoretinal traction 1
- Round holes: Circular defects, often within areas of lattice degeneration
- Operculated tears: Circular defects with a free-floating piece of retinal tissue (operculum)
Associated Findings
The examination typically reveals 1:
- Vitreous hemorrhage (blood in the vitreous cavity) - present in 8-22% of acute cases
- Pigmented cells in the vitreous ("tobacco dust" or Shafer's sign)
- Weiss ring - a circular opacity representing torn glial tissue from the optic nerve head, indicating posterior vitreous detachment
- Subretinal fluid accumulation causing the retinal elevation
- Demarcation lines in chronic cases (pigmented lines marking previous extent of detachment)
Types of Retinal Detachment Appearance
Rhegmatogenous (Most Common)
Caused by retinal breaks allowing fluid passage into the subretinal space 1, 2. The detachment typically:
- Extends from a visible retinal tear
- Has a convex, bullous configuration
- Shows corrugated folds in the detached retina
Tractional
Caused by preretinal membranes pulling the retina away 2. Appears:
- Concave configuration
- Taut, immobile retinal surface
- No retinal breaks visible
Exudative (Serous)
Fluid accumulation without breaks 2. Shows:
- Smooth, dome-shaped elevation
- Shifting fluid with position changes
- No retinal tears
Key Diagnostic Features
The critical examination findings that distinguish RRD include 1:
- Visible retinal break(s) - the defining feature
- Mobile, corrugated retinal surface that shifts with eye movement
- Demarcation between attached and detached retina
- Vitreous pigment or hemorrhage indicating recent tear formation
Clinical Context
Patients typically present with the "4 Fs" 3:
- Flashes (photopsias) - most noticeable in darkness
- Floaters (myodesopsias) - from blood, vitreous condensation, or Weiss ring
- Field defects - described as a "dark curtain" or shadow
- Failing vision - especially if macula is involved
The detachment progresses from peripheral to central, and early diagnosis before macular involvement is critical for preserving visual acuity 1, 4.
Examination Technique Considerations
Adequate visualization requires:
- Dilated fundoscopic examination with indirect ophthalmoscopy
- Scleral depression to visualize peripheral retinal breaks near the ora serrata
- B-scan ultrasonography when media opacity (cataract, vitreous hemorrhage) prevents direct visualization 5
Common pitfall: The anterior border of horseshoe tears near the ora serrata is most easily missed due to difficult visualization - this is the most common cause of treatment failure 1.