What are the causes of retinal detachment?

Causes of Retinal Detachment

Retinal detachment occurs through three primary mechanisms: rhegmatogenous (caused by retinal breaks allowing fluid passage), tractional (from membrane contraction pulling the retina), and exudative (from fluid accumulation without breaks). 1, 2

Rhegmatogenous Retinal Detachment (RRD) - Most Common Type

RRD develops when full-thickness retinal breaks allow vitreous fluid to pass into the subretinal space, separating the neurosensory retina from the retinal pigment epithelium. 1, 2

Primary Causative Mechanisms for Retinal Breaks:

Posterior Vitreous Detachment (PVD):

• Age-related vitreous liquefaction causes acute separation of the posterior vitreous cortex from the retina 1
• Vitreoretinal adhesions during PVD create traction that tears the retina, producing horseshoe tears or flap tears 1
• At least 50% of untreated symptomatic horseshoe tears with persistent vitreoretinal traction progress to clinical retinal detachment 1
• PVD-induced tears typically occur at sites of firm vitreoretinal adhesion or at margins of lattice degeneration 1

Lattice Degeneration:

• Peripheral vitreoretinal lesions characterized by retinal thinning, overlying vitreous liquefaction, and firm vitreoretinal adhesions at margins 1
• Present in 6-8% of the general population but found in 20-30% of patients with RRD 1
• Round atrophic holes develop within lattice lesions unassociated with PVD 1
• Horseshoe tears form at lattice margins when PVD occurs 1
• Perivascular or radial lattice carries higher risk for tear formation 1

Major Risk Factors:

Myopia:

• More than half of nontraumatic RRD occurs in myopic eyes 1
• Low myopia (1-3 diopters) confers a fourfold increased risk 1
• Risk increases proportionately with axial length 1

Cataract Surgery:

• Overall RRD risk approximately 1% after cataract surgery 1
• 20-40% of all RRD cases have prior cataract surgery history 1
• Risk factors include: axial myopia, pre-existing vitreoretinal disease, male gender, younger age, vitreous prolapse, vitreous loss (ruptured posterior capsule/zonules), and spontaneous capsulotomy extension 1
• Postoperative PVD development (median 7 months after surgery) is the major risk factor, not lattice presence 1
• Nd:YAG laser capsulotomy associated with fourfold increased RRD risk, especially in myopic patients 1

Ocular Trauma:

• Accounts for 10% of all RRD cases 1
• Blunt trauma causes retinal dialysis (crescentic peripheral breaks at ora serrata) 1
• Shockwave propagation produces high retinal strain leading to breaks, while negative pressure and inertial motion pull retina from supporting tissue 3
• Penetrating injuries alter vitreous and retinal structure 1
• Traumatic changes may manifest immediately or years later 1

Fellow Eye History:

• 10% increased risk if nontraumatic RRD occurred in the other eye due to bilateral pathologic vitreoretinal changes 1
• Phakic fellow eyes in patients with pseudophakic RRD have 7% risk 1

Genetic Disorders:

• Stickler syndrome is the most common inherited vitreoretinal disorder associated with RRD 1
• Features include high myopia, retrolental/transvitreal/epiretinal membranes, lattice degeneration with perivascular component, autosomal dominant inheritance (COL2A1 gene defect) 1
• Family history of RRD in first-degree relatives increases risk 1

Other Risk Factors:

• Retinopathy of prematurity 1
• Prior intraocular surgery beyond cataract extraction 1

Specific Retinal Break Types:

• Horseshoe tears: Caused by vitreoretinal traction with flap remaining attached to detached vitreous 1
• Operculated tears: Circular/oval tissue pulled free; usually eliminates traction if occurring during PVD 1
• Round atrophic holes: Unassociated with traction, occur within lattice or normal-appearing retina 1
• Retinal dialysis: Traumatic crescentic breaks at ora serrata 1

Tractional Retinal Detachment

Preretinal, intraretinal, or subretinal membranes contract and exert tangential forces that elevate the retina from the RPE. 2

• Occurs in proliferative diabetic retinopathy, proliferative vitreoretinopathy, and other fibrovascular conditions 2
• Myopic traction maculopathy affects 9-34% of highly myopic eyes, presenting as retinoschisis, foveal RD, lamellar or full-thickness macular holes 4

Exudative (Serous) Retinal Detachment

Inflammatory, infectious, infiltrative, neoplastic, vascular, or degenerative conditions disrupt the blood-retinal barrier, causing fluid accumulation in the subretinal space that exceeds RPE osmotic pump function. 2, 5

Common Causes:

• Vogt-Koyanagi-Harada disease: Most common cause of uveitic serous RD (48.7% of cases) 6
• Infectious uveitis: Toxoplasmic retinochoroiditis (10.3%), presumed tuberculosis (3.8%) 6
• Inflammatory conditions: Sarcoidosis (6.4%), posterior scleritis (2.6%) 6
• Neoplastic: Intraocular lymphoma (5.1%) 6
• Vascular abnormalities: Coats' disease, central serous chorioretinopathy 7, 5
• Dome-shaped macula in high myopia: SRD occurs in 8-50% of cases when dome height exceeds specific thresholds 8

Clinical Pitfall:

Approximately 19% of uveitic serous RD cases remain idiopathic despite thorough evaluation 6. Always exclude inflammatory, infectious, and neoplastic etiologies before labeling as idiopathic.

Pediatric-Specific Causes

Only 3-7% of RRD occurs in children, with distinct predisposing factors 7:

• Trauma (most frequent) 7
• Hereditary vitreoretinopathies (most common inherited cause) 7
• Retinopathy of prematurity 7
• Congenital malformations 7
• Coats' disease 7

Important Note: Functional and anatomical outcomes in pediatric RRD are less successful than in adults, requiring etiology-specific treatment strategies 7.