1. Retinal detachment
A Self Directed Learning package for medical students.

2. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
2
Introduction
 Although relatively rare, retinal detachment is an important
eye condition which leads to blindness if untreated.
 This self directed E-learning package will help you in your
understanding and identification of the condition, and
introduce you to some of the treatment options available.
 To use this package, open the PowerPoint presentation as
a slide show and click to move on to the next slide.
 Clicking on the contents bar to the left of the page will allow
you to jump directly to that slide
 Clicking on blue underlined words will take you to a glossary
for more information
 Answering the questions (by clicking on the options provided)
will help to consolidate what you have learnt

3. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
3
Learning outcomes
At the end of this SDL you should:
 Be able to describe the epidemiology of
retinal detachment, including the risk
factors
 Understand the pathophysiology of retinal
detachment, and be able to describe the
three main types
 Be able to describe the symptoms
associated with retinal detachment, and
the investigations used in diagnosis
 Be aware of the treatment options and the
associated prognosis

4. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
4
Epidemiology
 Rare
 1 in 10,000 per year
 Lifetime risk of 1 in 300
 Incidence increases with age with a peak at 50-60 years
 An increased risk is seen in:
 Severe myopia (> 6 diopters)
 Lifetime risk increases to 1 in 20, and tends to affect younger patients
 Approximately 50% of retinal detachments occur in myopic
individuals.
 Following cataract surgery
 Overall risk increases to around 1% but depends on a variety of
patient characteristics such as previous myopia or eye trauma
 Trauma
 Family history
 Retinal pathology such as lattice degeneration
 Vitreous humour pathology such as posterior vitreous detachment
 There is a 10-15% risk of developing a retinal detachment after a
posterior retinal detachment
 Previous retinal detachment
 There is a 15% chance of developing a detachment in the other eye.

5. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
5
Anatomy of the eye
Light passes through the cornea
and aqueous humour and
enters the pupil aperture where
it is focused by the lens onto
the most sensitive part of the
retina – the fovea.
Ora serrata
Copyright free image obtained from http://commons.wikimedia.org/wiki/File:Schematic_diagram_of_the_human_eye_en.svg

6. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
6
Anatomy of the retina
 The retina is responsible for
converting focused light images
into nerve impulses for
conduction to the occipital lobes
of the brain.
 It consists of two parts,
separated by the subretinal
space:
1. Neurosensory retina – a thin,
transparent layer of connecting
neural cells transmitting impulses to
the optic nerve:
 Photoreceptors
 Bipolar cells
 Ganglion cells
2. Retinal pigment epithelium (RPE)
– a single layer of pigmented cells
which maintain photoreceptor
physiology by synthesising and
storing metabolites and vitamins.

7. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
7
Pathogensis
Sclera
Choroid
RPE
Neurosensory retina
Subretinal space
A retinal detachment
(RD) is a separation of
these two retinal layers.
There are three types:
1. Rhegmatogenous
2. Exudative
3. Tractional

8. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
8
Sclera
Choroid
RPE
Neurosensory retina
Subretinal space
Vitreous humour
Rhegmatogenous RD
 This is the most common form of retinal detachment.
 A tear or hole in the neurosensory retina (called a retinal
break) allows vitreous fluid to enter the subretinal space.
 It is often preceded by a posterior vitreous detachment
(PVD), whereby the gel-like vitreous humour liquefies with
age and contracts, peeling away from the retina to cause a
break. This condition is commoner is severe myopes (due
to the elongated shape of the globe) and following eye
trauma.
 An underlying weakness of the retina (such as lattice
degeneration) also increases the likelihood of a break
forming.

9. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
9
Sclera
Choroid
RPE
Neurosensory retina
Subretinal space Vitreous
humour
Tractional RD
 This is distinguished from rhegmatogenous retinal detachment by
the fact that the retina does not break.
 Instead, traction produced by contractile membranes on the
surface of the neurosensory retina causes the retina to be pulled
apart.
 This is often associated with proliferative diabetic retinopathy, as
the abnormal blood vessel growth across the surface of the retina
can act as a traction point.
 Fibrous tissue deposited after trauma can also be responsible.
 The traction can eventually result in a retinal tear, giving rise to a
combined rheumatogneous and tractional retinal detachment.

10. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
10
Exudative RD
 This type, also known as serous retinal detachment,
results from an excess of fluid in the subretinal space, and
does not involve a retinal break.
 It is the least common form of retinal detachment
 The fluid can be due to:
 Abnormal choroidal circulation, e.g. due to intraocular
tumours such as malignant melanoma of the choroid
 Inflammatory processes such as scleritis or posterior uveitis ,
although this is rare.
 Central serous retinopathy
Choroid
RPE
Neurosensory retina
Sclera
Vitreous humour
Subretinal space

11. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
11
Quiz
1. The 2 layers of the retina are called the
neural layer and the choroid
2. Retinal detachment caused by a tear in the
neural retina is called rhegmatogenous.
3. Exudative retinal detachment is associated
with diabetic retinopathy
4. Posterior vitreous detachment can occur
as part of the normal ageing process
T F
T F
T F
T F
Answer the following true or false
questions:

12. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
12
Symptoms
Easy to remember as the 4 Fs:
1. Flashing lights (Photopsia) – caused by traction on the retina and
usually seen in the periphery.
2. Floaters – caused by condensations in the vitreous
humour causing shadows to be cast onto the retina. These
are described by patients as spots or strands moving with
eye movements. They can also occur due to small bleeds
into the vitreous humour during a retinal tear. As floaters
are common in myopic patients, it is a sudden onset or an
increased number which are important.
3. Visual Field defect – often manifesting as a dark shadow or curtain coming
across the eye from the periphery.
4. Falling acuity - Loss of central vision or visual blurring occurs when the
detachment directly involves the fovea, or if the usual light pathway is obscured by
a detachment elsewhere.
PVD can present with photopsia and floaters, but field loss is an indication
of a retinal tear. However, as PVD can develop into retinal detachment,
any of the above symptoms merit further investigation.
Artist impression of
floaters against a blue
sky *
* Copyright free image from http://www.cynical-c.com/archives/bloggraphics/Floaters.png

13. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
13
 Clinical examination of the symptoms, i.e. confirmed visual field loss
and falling acuity
 Relative afferent pupillary defect – in severe rheumatogenous retinal
detachment
 Intraocular pressure (measured using a tonometer) may be
decreased
 On dilated fundoscopy:
 Loss of red reflex – the area of retina
detached determined the degree of loss.
 Grey retina which “balloons” forwards if there
is marked fluid accumulation in the subretinal
space. This detached portion will
move in an undulating as the eye moves, and
may have corrugated folds.
 Retinal tears appear reddish/pink due to underlying
choroidal blood vessels.
Signs and investigations
* Image obtained, with permission, from stlukeseye.com
*

14. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
14
 Further tests to confirm the diagnosis include:
 Using a slit lamp (which uses high-power lenses) to
obtain a more detailed view of the retina.
 The Goldmann triple mirror test, which uses a slit lamp
and a contact lens surrounded by three mirrors on an
anaesthetised cornea to examine the peripheral retina.
 Ultrasonography of the eye showing the detached retina
as a highly reflective signal.
 CT or MRI if a tumour or foreign body is suspected.
Signs and investigations (continued)
Slit lamp*
*Image obtained copyright free from: www.gettyimages.co.uk

15. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
15
 Surgery is the only treatment and patients
should be referred to an ophthalmologist
immediately.
 There are four main aims of surgery:
1. Relief of vitreo-retinal traction
2. Closure of retinal break (if present)
3. Drainage of subretinal fluid
4. Reattachment of neurosensory retina to RPE
 There are two main surgical approaches
which meet these aims: external and
internal.
Treatment

16. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
16
1. Relief of vitreo-retinal traction
 Using a scleral buckle - a silicone
sponge which pushes on the retina
from the outside. This creates an
inward indentation which decreases
traction, and also helps to close any
retinal tears present.
2. Closure of retinal break
 The break is further secured using cryotherapy or lasers. This technique
can also be used for the prophylactic closure of retinal breaks which have
not yet led to a detachment.
3. Drainage of subretinal fluid
 Using a needle through the sclera and choroid (sclerostomy)
4. Reattachment of neurosensory retina to RPE
 The scleral buckle helps to hold them in place, while the cryotherapy or
laser treatments create local inflammation which strengthens the
attachment.
External approach
Retinal break
Silicone
sponge
Sutures
This approach is more commonly
used in this country and all
procedures are done without
entering the globe of the eye.

17. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
17
Internal approach
1. Relief of vitreo-retinal traction
 By vitrectomy – some or all of the vitreous is removed using instruments inserted
into the vitreous cavity through the pars plana
2. Closure of retinal break
 Inert gas or silicone oil is injected to form a
bubble which pushes against the tear from
the inside (Pneumatic retinopexy).
Any subretinal fluid will be resorbed, and the
bubble itself is gradually absorbed over months.
To ensure that the bubble stays in the correct
position, the patient may have to maintain a
specific head posture for a few days, and this
surgery is only practical for breaks in the superior retina.
 This method is used in conjunction with laser or cryotherapy to aid break closure.
3. Drainage of subretinal fluid
 Fluid can be drained from inside, through the retinal break itself.
4. Reattachment of neurosensory retina to RPE
 The tamponade helps to hold them in place, while the cryotherapy or laser
treatments create local inflammation which strengthens the attachment.
This approach (also called vitreoretinal
surgery) is sometimes used for larger
retinal tears and instruments are inserted
into the globe itself.
Retinal
break
Oil or gas
bubble

18. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
18
Prognosis
 The amount of recovery depends on the
degree and duration of detachment, and
whether or not the fovea was involved initially
 Prompt surgery is usually successful at
restoring vision, although detachments
involving the fovea may have residual visual
acuity loss
 Complications of surgery include the formation
of fibrotic areas in the vitreous which can
cause retinal traction (proliferative
vitreoretinopathy) and lead to further
detachment.

19. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
19
Quiz – read the following clinical case and answer the true or false
question which follow
On examination you expect to find:
5. Loss of red reflex
6. Increased intraocular pressure
7. A ballooning retina with undulating folds
Clinical case: A 67 yr old man who has recently
recovered from a cataract operation presents to
A & E with a 2 day history of floaters and flashing
lights and now reports a “dark curtain” obscuring
his vision.
T F
T F
T F

20. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
20
Quiz
8. Removal of the vitreous is carried out at the
junction of the photosensitive and non-
photosensitive retina.
9. Vitreoretinal surgery involves the use of a
silicone sponge.
10. The prognosis for this man’s vision after
the operation is good.
After slit lamp examination, the man is
diagnosed as having a large rhegmatogenous
retinal detachment and undergoes emergency
vitreoretinal surgery.
T F
T F
T F

21. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
21
References and further reading
 Batterbury, M., Bowling, B. Ophthalmology – an illustrated colour text. London:
Churchill Livingston, 1999
 James, B., Chew, C., Bron,. Lecture notes: Ophthalmology. Oxford: Blackwell
Publishing, 2007 (10th edition)
 Friedman, N. J., Kaiser, P.K. Essentials of ophthalmogy. Saunders Elsevier, 2007
 Galloway, N. R., Amoaku, W. M. K., Galloway, P. H., Browning A. C. Common eye
diseases and their management. London: Springer, 2006 (3rd edition)
 Ivanisević, M., Bojić, L., Eterović, D. Epidemiological study of nontraumatic phakic
rhegmatogenous retinal detachment. Ophthalmic Res. 2000; 32:5, 237–9.
 Tuft, S.J.,Minassian, D., Sullivan, P. Risk Factors for Retinal
Detachment after Cataract Surgery: A Case–Control Study. Ophthalmology 2006;
113:4, 650-656.
 All images are either drawn by the author or obtained from copyright free sources
and referenced on the slides.

22. •Introduction
•Learning
outcomes
•Epidemiology
•Anatomy of the
eye
•Anatomy of the
retina
•Pathogenesis
- Rhegmatogenous
-Tractional
- Exudative
•Quiz
•Symptoms
•Signs and
investigations
•Treatment
-External
- Internal
•Prognosis
•Quiz
•References
•Glossary
22
Glossary
 Central serous retinopathy – an idiopathic condition in which small breaks in the RPE allow
choroidal fluid to leak into the subretinal space. It is usually unilateral and self-limiting ,and tends to
affect young males.
 Choroid – layer of blood vessels, connective tissue and pigment cells between the retina and the
sclera, providing oxygen and nutrients to the retina.
 Lattice degeneration – condition of unknown aetiology whereby the peripheral retina becomes
atrophic. It is an important cause of retinal detachment (present in 40% of cases), especially in young
myopic patients. The condition is also seen in patients with Marfan and Ehlers Danlos syndromes.
 Myopia – Also known as short sightedness. Distant images are brought to a focus in front of the
retina instead of on it. This is often due to an elongated eye, and affected patients are unable to see
distant objects clearly.
 Pars plana – The area at the posterior part of the cilliary body, at the junction where the transition
from non-photosensitive retina to photosensitive retina occurs (known as the ora serrata)
 Posterior uveitis – inflammation of the choroid often associated with systemic diseases such as
connective tissue diseases as well as infectious disease such as syphilis.
 Retinal break – a full thickness fissure in the neurosensory retina which can either be a tear (caused
by vitreous traction ) or a hole (caused by chronic atrophy of the retina).
 Scleritis – inflammation of the sclera often associated with connective tissue diseases such as
rheumatoid arthritis.
 Vitreous humour – a viscous gel-like substance filling the posterior part of the eye between the lens
and the retina. Its purpose is to provide support to the globe of the eye. With age, the vitreous humour
becomes more liquid (syneresis) as the collagen network breaks down. This can lead to vitreous
detachment.
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