Retinal Detachment: Symptoms and Causes
Symptoms
Patients with retinal detachment typically present with light flashes (photopsias), floaters (myodesopias), peripheral visual field loss described as a "dark curtain," and blurred vision. 1, 2, 3
Key Symptomatic Features:
- Light flashes are most noticeable in the dark and result from vitreous traction on the retina as the vitreous separates from the posterior retina 1
- Floaters may be due to blood from a torn or avulsed retinal vessel, condensations of vitreous collagen, or epipapillary glial tissue (Weiss ring) torn from the optic nerve head 1
- Progressive peripheral visual field loss occurs as the detachment extends, often described as a curtain or shadow moving across the vision 2, 3
- Decreased central vision develops if the macula becomes involved 3
Critical Clinical Pitfall:
Patients presenting with acute onset of flashes or floaters require urgent same-day ophthalmologic evaluation by an ophthalmologist skilled in binocular indirect ophthalmoscopy, as these symptoms indicate possible posterior vitreous detachment with retinal breaks that can progress to full detachment 1, 3
Causes and Pathophysiology
The essential mechanism of retinal detachment involves full-thickness retinal breaks that permit fluid passage from the vitreous cavity into the subretinal space, separating the neurosensory retina from the underlying retinal pigment epithelium, most commonly triggered by posterior vitreous detachment. 4, 5
Primary Causative Mechanism:
- Posterior vitreous detachment (PVD) is the primary precipitating event that induces horseshoe tears through vitreoretinal traction at sites of significant vitreoretinal adhesion 1, 4
- PVD typically occurs between ages 45-65 in the general population, though it occurs earlier in myopia and trauma 1, 4
- Vitreous traction at the vitreous base and in areas of lattice degeneration is responsible for most symptomatic retinal breaks leading to rhegmatogenous retinal detachment 1
Major Risk Factors
Myopia (Most Significant):
- More than half of all nontraumatic retinal detachments occur in myopic eyes, with low myopia carrying a fourfold increased risk and proportionately higher risks as axial length increases 4
- The elongated globe creates increased vitreoretinal traction during PVD 4
Lattice Degeneration:
- Present in 6-8% of the general population but found in 20-30% of patients with retinal detachment 4
- Perivascular or radial lattice patterns carry higher risk than circumferential patterns 1, 4
- Detachment occurs either from atrophic round holes or when PVD induces horseshoe tears in lattice areas 4
Cataract Surgery:
- Overall risk of retinal detachment after cataract surgery is approximately 1%, with 34% of all retinal detachments having prior cataract surgery 4
- PVD develops at a median of 7 months postoperatively and represents the major risk factor for subsequent detachment 4
- Specific risk factors include axial myopia, pre-existing vitreoretinal disease, male gender, younger age, vitreous prolapse, vitreous loss, and spontaneous capsulotomy extension 4
- Nd:YAG laser capsulotomy increases risk fourfold, especially in myopic patients 4
- The critical factor is absence of pre-existing PVD at time of surgery in high-risk eyes 4
Ocular Trauma:
- Accounts for 10% of all retinal detachments 4, 6
- Retinal dialysis (crescentic peripheral retinal break at the ora serrata) is pathognomonic for trauma 6
- Blunt or penetrating injuries that alter vitreous or retinal structure increase risk 6
- Trauma can induce PVD at younger ages than typical age-related PVD 6
Genetic and Familial Factors:
- Genetic disorders such as Stickler syndrome, characterized by perivascular lattice, increase risk 4
- Family history of retinal detachment in first-degree relatives increases risk 4
- History of retinal detachment in the fellow eye increases risk 4
Epidemiology
- Annual incidence is 10-18 per 100,000 persons, with peak incidence of 53 per 100,000 between ages 55-59 years 4
- Distribution of causes: 20-40% post-cataract surgery, 10% trauma-related 4
- Persons in the sixth and seventh decades of life are most commonly affected 3
Types of Retinal Detachment
While rhegmatogenous retinal detachment (caused by retinal breaks) is the most common type, two other forms exist 2, 5:
- Tractional retinal detachment: Preretinal, intraretinal, or subretinal membranes contract and exert tangential forces that elevate the retina 5
- Exudative (serous) retinal detachment: Underlying inflammatory condition, vascular abnormality, or tumor causes exudative fluid to accumulate in the subretinal space, exceeding the osmotic pump function of the RPE 5
High-Risk Patient Education
Patients at high risk should be educated about symptoms of PVD and retinal detachment as well as the need for periodic follow-up examinations. 1 Patients with retinal or vitreous hemorrhage have an increased risk of multiple retinal tears 1