Retinal Detachment Management
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Direct answer
Retinal detachment separates the neurosensory retina from the retinal pigment epithelium, and the mechanism decides management. Rhegmatogenous detachment — vitreous fluid entering a hole or tear, classically after posterior vitreous detachment in a high myope — announces itself with flashes (photopsia), a sudden shower of floaters (the Weiss ring) and a progressive curtain in peripheral vision; it is a surgical emergency treated by sealing the breaks with cryotherapy or laser and supporting them (scleral buckling) or by vitrectomy with gas or silicone oil tamponade. Tractional detachment, from fibrovascular membranes in proliferative diabetic retinopathy or after penetrating trauma, requires vitrectomy to relieve traction; exudative detachment, from a choroidal tumour or Vogt-Koyanagi-Harada disease, is managed by treating the underlying cause.
What you must remember
- Three mechanisms: rhegmatogenous (a break), tractional (membranes pulling) and exudative (fluid leaking beneath an attached retina); surgery is aimed at the mechanism.
- Posterior vitreous detachment heralds trouble: sudden unilateral floaters and photopsias demand a dilated peripheral examination with scleral indentation the same week, looking for horseshoe tears; prophylactic laser or cryo barricades symptomatic breaks before detachment.
- High-risk eyes for rhegmatogenous detachment: axial myopia, lattice degeneration, previous cataract surgery, trauma, fellow-eye detachment and a family history.
- Scleral buckling: a silicone sponge or band sutured to the sclera over the break, combined with cryotherapy and drainage of subretinal fluid where needed; the classic repair in young phakic eyes with anterior breaks.
- Pneumatic retinopexy: intravitreal gas bubble plus cryotherapy or laser for superior breaks, needing disciplined posturing; the bubble expands against the break and tamponades it.
- Pars plana vitrectomy: removes traction and media opacity, allows endolaser and tamponade; preferred for giant tears, posterior breaks, proliferative vitreoretinopathy and tractional detachment.
- Tamponade durations: air days, sulphur hexafluoride about two weeks, perfluoropropane about two months, silicone oil indefinitely until removed; a gas-filled patient must not fly or receive nitrous oxide anaesthesia.
- Proliferative vitreoretinopathy — membrane formation on both retinal surfaces — is the commonest cause of redetachment and the main reason buckle-only surgery fails in complex cases.
- Exudative detachment shows shifting subretinal fluid that gravitates with posture and a smooth bullous retina without a break; find the cause — choroidal melanoma, Vogt-Koyanagi-Harada disease, central serous chorioretinopathy, toxaemia of pregnancy.
From flash to buckle: one evening in casualty
A 52-year-old myope reports two days of flashing lights at the temporal edge, then a "cobweb" drifting, and this morning a grey curtain rising from below in the right eye. Vision is 6/12; the anterior segment is quiet. Dilated examination with indentation finds a horseshoe tear at 11 o'clock in the retinal periphery and a shallow superior detachment creeping toward the macula — a rhegmatogenous detachment, urgent because the fovea is hours to days from lifting. Options are weighed like a surgeon weighing them: a single superior break in a phakic eye suits scleral buckling with cryotherapy; posterior or multiple breaks, media opacity or early proliferative vitreoretinopathy swing the choice to vitrectomy with endolaser and gas. Postoperatively he postures so the bubble presses the break, avoids air travel while gas remains, and returns immediately if the fellow eye flashes. Had this been a diabetic with a concave, immobile detachment and no tear, the plan flips entirely — vitrectomy and membrane peeling for traction, with silicone oil if the retina is stiff; and a painless, shifting, bullous detachment in a quiet eye would have sent the search to the choroid beneath.
Where students slip
The missed opportunity students should never repeat is waving off new floaters and flashes as "ageing vitreous" without a dilated peripheral exam — the preventable tear is found exactly then. Mechanism-matching errors follow: laser or buckle for an exudative detachment (the disease is under the retina), or observation of a tractional diabetic detachment crossing the macula. The exam also tests tamponade arithmetic — which gas lasts two weeks (sulphur hexafluoride) — and the air-travel prohibition with an intraocular gas bubble.
Frequently asked questions
What are the three types of retinal detachment with a cause each?
Rhegmatogenous (a retinal break, after posterior vitreous detachment or trauma), tractional (fibrovascular membranes in proliferative diabetic retinopathy) and exudative (choroidal tumour or inflammation such as Vogt-Koyanagi-Harada disease).
What symptom triad suggests rhegmatogenous detachment?
Photopsia (flashes), a sudden shower or cobweb of floaters with posterior vitreous detachment, and a progressive peripheral shadow or curtain — each warrants same-week dilated examination.
What does scleral buckling achieve?
It indents the sclera beneath the break, apposing retina to pigment epithelium while cryotherapy seals the edges; subretinal fluid drains or resorbs, and the buckle supports the vitreous base.
Which tamponade agents last how long?
Air for days, sulphur hexafluoride around two weeks, perfluoropropane up to about two months, and silicone oil indefinitely until surgically removed.
What is proliferative vitreoretinopathy?
Proliferation of glial and pigment-epithelial membranes on retinal surfaces after detachment, stiffening and re-detaching the retina; it is the commonest cause of failed primary repair and pushes surgery toward vitrectomy.
What is shifting fluid and what does it indicate?
Subretinal fluid that relocates with head position over minutes, indicating an exudative detachment — the search then moves to the choroid and systemic cause rather than a break.