Detached Retina (Retinal Detachment)

Retinal detachment is separation of the neurosensory retina from the underlying retinal pigment epithelium, most commonly caused by a full-thickness retinal break that allows liquefied vitreous to enter the subretinal space. Cardinal symptoms are sudden flashes, new floaters, and a progressive “curtain” or shadow in peripheral or central vision; there is no pain. Diagnosis is clinical by dilated fundus examination; optical coherence tomography and B-scan ultrasonography assist when media are opaque. Treatment is urgent and includes laser or cryotherapy to seal breaks and retinal reattachment procedures (pneumatic retinopexy, scleral buckle, and/or pars plana vitrectomy).

Key Points

• Retinal detachment is an ophthalmic emergency; same-day evaluation is indicated for new flashes/floaters with a visual field defect.
• Types include rhegmatogenous (break-related), tractional (from fibrovascular membranes), and exudative (from fluid leakage without a break).
• Macular status at presentation (on vs off) is the key prognostic factor for visual recovery.
• Modern primary anatomic success rates for rhegmatogenous retinal detachment are approximately 80–90%, with final reattachment >95% after additional procedures when needed [1][2].
• Gas tamponade requires strict head positioning and avoidance of air travel and nitrous oxide anesthesia until the bubble resolves.

Anatomy and Physiology

The retina consists of the neurosensory retina (photoreceptors and inner layers) and the underlying retinal pigment epithelium (RPE) overlying the choroid. The vitreous body is attached at the vitreous base, optic disc, macula, and along retinal vessels. Posterior vitreous detachment (PVD) with vitreoretinal traction can create full-thickness retinal breaks. Separation of neurosensory retina from RPE disrupts photoreceptor function and threatens permanent vision loss if the macula detaches.

Etiology

• Rhegmatogenous retinal detachment (RRD): retinal tears or holes associated with PVD, lattice degeneration, myopia, trauma, or post–cataract surgery (pseudophakia/aphakia).
• Tractional retinal detachment (TRD): fibrovascular proliferation and contraction, classically from proliferative diabetic retinopathy (PDR), retinopathy of prematurity, sickle cell retinopathy, and penetrating or blunt trauma.
• Exudative (serous) retinal detachment: fluid accumulation due to choroidal or retinal vascular leakage without a retinal break, as in uveitis (eg, Vogt–Koyanagi–Harada), hypertensive choroidopathy, preeclampsia/eclampsia, choroidal tumors (eg, melanoma, hemangioma), and inflammatory or infectious chorioretinopathies.

Pathophysiology

• RRD: A full-thickness retinal break permits liquefied vitreous to enter the subretinal space. Continued fluid ingress and gravity propagate detachment. Proliferative vitreoretinopathy (PVR) may develop from cellular proliferation on retinal surfaces with contractile membranes, leading to recurrent or rigid detachments.
• TRD: Fibrovascular membranes exert traction on the retina, elevating it without a retinal break. Combined traction–rhegmatogenous detachments occur when tractional forces create a secondary break.
• Exudative: Breakdown of the outer blood-retinal barrier (RPE) and/or choroidal hyperpermeability leads to subretinal fluid accumulation. There is no retinal break, and shifting subretinal fluid may be observed with changes in head position.

Epidemiology

• Annual incidence of rhegmatogenous retinal detachment in developed countries is approximately 10–18 per 100,000 person-years; risk increases with age, male sex, high myopia, and after cataract surgery [1][3].
• Lifetime risk is higher in pathologic myopia and hereditary vitreoretinopathies (eg, Stickler syndrome) [4].
• TRD prevalence tracks with advanced PDR and is more common in under-resourced populations with suboptimal diabetes control [5].
• Exudative detachments are uncommon and reflect the incidence of their underlying causes.

ICD-10-CM

• H33.0 Retinal detachment with retinal break (rhegmatogenous)
• H33.2 Serous (exudative) retinal detachment
• H33.4 Traction detachment of retina

Classification

• Rhegmatogenous retinal detachment (RRD)
• Tractional retinal detachment (TRD)
• Exudative (serous) retinal detachment
• Combined mechanism (eg, TRD with secondary rhegmatogenous component)

Clinical descriptors (RRD)

• Extent (number of quadrants), location of causative break(s) (superior vs inferior), macular status (on vs off), chronicity, media clarity, and presence/grade of PVR.

Symptoms and Signs

Rhegmatogenous retinal detachment

• Symptoms: sudden photopsias (flashes), new or increased floaters, and a progressive shadow/curtain in the peripheral field that may advance centrally; decreased central vision if the macula detaches. Typically painless.
• Signs: on dilated fundus exam, a corrugated, mobile, elevated neurosensory retina with a causative break (tear or hole); Shafer sign (tobacco dust/pigment in anterior vitreous); relative afferent pupillary defect if large detachment.

Tractional retinal detachment

• Symptoms: gradual or subacute peripheral or central visual loss; fewer photopsias/floaters than RRD unless vitreous hemorrhage coexists.
• Signs: taut, immobile elevated retina with fibrovascular membranes and neovascularization; often concave configuration; associated diabetic changes (microaneurysms, hemorrhages).

Exudative retinal detachment

• Symptoms: variable, may include blurred vision and metamorphopsia; symptoms can fluctuate with posture.
• Signs: smooth, dome-shaped, shifting neurosensory detachment; absence of retinal breaks; choroidal thickening or mass; inflammatory signs (cells/flare) if uveitis.

Complications

• Proliferative vitreoretinopathy (PVR)
• Recurrent detachment
• Cystoid macular edema and epiretinal membrane
• Cataract acceleration (particularly after vitrectomy)
• Elevated intraocular pressure and secondary glaucoma
• Choroidal detachment and hypotony
• Diplopia and refractive shift after scleral buckle
• Endophthalmitis (rare, postoperative)

Diagnosis

Clinical evaluation

• Urgent dilated fundus examination with scleral depression to identify and treat retinal breaks.
• Assess macular status (macula-on vs macula-off), extent, and chronicity.
• Examine fellow eye for risk factors (lattice, high myopia, asymptomatic breaks).

Imaging and laboratory testing

• Optical coherence tomography (OCT): defines macular involvement; distinguishes retinal detachment from retinoschisis; detects subretinal fluid in exudative cases.
• B-scan ultrasonography: useful if media are opaque (dense cataract, vitreous hemorrhage); differentiates retinal detachment (mobile, folded membrane) from posterior hyaloid or choroidal detachment.
• Widefield color and autofluorescence imaging: documents extent and guides treatment.
• Fluorescein/indocyanine green angiography: evaluates suspected exudative detachments from inflammatory or neoplastic causes.
• Laboratory tests: targeted uveitis workup for suspected inflammatory/infectious etiologies (eg, syphilis serology, TB testing) as clinically indicated.

Differential diagnosis

Treatment

Medical management

• There is no pharmacologic therapy that reattaches a rhegmatogenous detachment; prompt definitive retinopexy/reattachment is required.
• Exudative retinal detachment: treat the underlying cause.
  • Noninfectious uveitis (eg, VKH): systemic corticosteroids, typically prednisone 0.5–1 mg/kg/day PO with slow taper; periocular or intravitreal corticosteroid may be used in selected cases; steroid-sparing immunomodulators for steroid-refractory disease [6]. [Off-label indications vary; specialist management]
  • Choroidal tumors: plaque radiotherapy or photodynamic therapy (circumscribed hemangioma); systemic oncology referral for melanoma.
  • Hypertensive choroidopathy/preeclampsia: blood pressure control and obstetric co-management.
• Tractional disease adjuncts: intravitreal anti-VEGF (eg, bevacizumab 1.25 mg; ranibizumab 0.5 mg; aflibercept 2 mg) 3–10 days pre-vitrectomy can reduce intraoperative bleeding in PDR-related TRD; this is off-label for bevacizumab and commonly used in practice [5][7]. Clearly label off-label use and consider tractional “crunch” risk with timing.

Analgesics are generally unnecessary; cycloplegics may relieve ciliary spasm if coexistent inflammation. Prophylactic antibiotics are not indicated in uncomplicated retinopexy.

Procedural and surgical management

• Retinopexy for breaks without significant detachment:
  • Barrier laser photocoagulation or transconjunctival cryotherapy around symptomatic retinal tears/holes to prevent progression to retinal detachment [1].
• RRD reattachment procedures (often combined with laser or cryo):
  • Pneumatic retinopexy (PR): intravitreal expansile gas (eg, sulfur hexafluoride [SF6] or perfluoropropane [C3F8]) with strict head positioning to tamponade a superior break; office-based. Best for single or grouped superior breaks within ≈1 clock hour, clear media, no significant PVR. Single-operation success typically 60–80% in selected eyes; some require subsequent surgery [2][8].
  • Scleral buckle (SB): placement of an external silicone element to support breaks and reduce vitreoretinal traction; preferred in young phakic patients, lattice-associated multiple peripheral breaks, or inferior pathology. Induces myopic shift and can cause diplopia.
  • Pars plana vitrectomy (PPV): removal of vitreous gel, relief of traction, fluid-air exchange, internal tamponade with gas (SF6, C3F8) or silicone oil; often preferred in pseudophakia, posterior breaks, media opacity, giant retinal tears, or PVR. Silicone oil used when prolonged tamponade or inability to posture is anticipated.
  • Combined PPV + SB: for extensive lattice, inferior breaks, or PVR.
• TRD: PPV with membrane segmentation/delamination; endolaser photocoagulation; gas or silicone oil tamponade as indicated. Preoperative anti-VEGF often used to reduce bleeding [5][7].
• Exudative detachment: surgery is uncommon; address causative lesion (eg, tumor therapy, uveitis control). Drainage considered rarely for persistent, vision-threatening cases after medical control.

CPT (professional coding)

• 67110: Pneumatic retinopexy (injection of gas, with or without cryo/laser)
• 67107: Repair of retinal detachment with scleral buckling
• 67108: Repair of retinal detachment with vitrectomy
• 67113: Repair of complex retinal detachment with vitrectomy and membrane peeling

Perioperative considerations

• Posturing: face-down or specific head positioning per break location and surgeon instruction.
• Restrictions with intraocular gas: avoid air travel and altitude changes; avoid nitrous oxide anesthesia until gas resolves (weeks for SF6; up to 8–10 weeks or longer for C3F8) due to risk of dangerous intraocular pressure rise [9].
• Follow-up: close early surveillance for pressure spikes, choroidal detachment, PVR, and re-detachment.

Special populations

• Pediatric: higher incidence of trauma- and congenital-associated RRD; often present late with PVR; SB and/or PPV tailored to lens status and cooperation; anesthesia planning required.
• Pregnancy/lactation: exudative detachments may occur with preeclampsia; coordinate with obstetrics; systemic steroids for noninfectious uveitis may be used when benefits outweigh risks; defer nonurgent elective surgery until postpartum when feasible.
• Immunocompromised: infectious chorioretinitis (eg, CMV) can mimic or cause exudative changes; treat underlying infection; surgical thresholds individualized.
• Elderly: higher PVD prevalence and pseudophakia; PPV commonly used; assess for positioning tolerance and systemic comorbidities.

Prognosis

• Visual outcomes correlate with macular status and duration of detachment. Macula-on RRD repaired urgently often retains near-baseline acuity. Macula-off RRD experiences decreasing visual recovery with longer detachment duration; best outcomes when repaired within several days [2][10].
• Primary anatomic success for RRD is about 80–90% with a single operation; final success after reoperation exceeds 95% in most series [1][2].
• TRD prognosis depends on macular involvement, extent of ischemia, and surgical complexity.
• Exudative detachment outcomes depend on etiology and control of the underlying process.

Prevention and Patient Counseling

• Seek same-day care for new flashes, floaters, or a curtain over vision.
• After PVD or symptomatic retinal tear, adhere to recommended follow-up; prophylactic laser/cryotherapy of acute symptomatic breaks prevents retinal detachment progression [1].
• Routine prophylaxis for asymptomatic lattice degeneration without tears is generally not indicated [1].
• Use protective eyewear for high-risk activities and sports to reduce trauma-related detachments.
• If a gas bubble is placed, avoid air travel, high-altitude travel, and nitrous oxide anesthesia until confirmed absorbed; carry medical alert documentation.

When to Seek Immediate Care

• Sudden increase in floaters or flashes of light in one eye
• A dark curtain, shadow, or gray area moving across vision
• Sudden loss of side (peripheral) vision
• Any vision loss after recent eye surgery or eye injury
• New visual symptoms in a highly nearsighted person or someone with prior retinal tear

Call an ophthalmologist the same day or go to the emergency department. If there is severe head/eye trauma with vision loss, call 911.

References

1. American Academy of Ophthalmology Preferred Practice Pattern. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration. San Francisco, CA: AAO; 2020.
2. Feltgen N, Walter P. Rhegmatogenous retinal detachment—an ophthalmologic emergency. Dtsch Arztebl Int. 2014;111(1-2):12-22. doi:10.3238/arztebl.2014.0012.
3. Mitry D, Charteris DG, Fleck BW, Campbell H, Singh J. The epidemiology of rhegmatogenous retinal detachment: geographical variation and clinical associations. Br J Ophthalmol. 2010;94(6):678-684. doi:10.1136/bjo.2009.157727.
4. Pruett RC. Retinal detachment in myopia. Int Ophthalmol Clin. 1985;25(3):53-64. doi:10.1097/00004397-198502530-00006.
5. Arevalo JF, et al. Preoperative bevacizumab for tractional retinal detachment in proliferative diabetic retinopathy: systematic review and meta-analysis. Retina. 2011;31(10):2039-2045. doi:10.1097/IAE.0b013e31820d3f21. [Consider newer Cochrane]
6. Read RW. Vogt–Koyanagi–Harada disease. Ophthalmol Clin North Am. 2002;15(3):333-341.
7. Cochrane Eyes and Vision. Anti-VEGF for vitrectomy in proliferative diabetic retinopathy. Cochrane Database Syst Rev. 2015.
8. Tornambe PE. Pneumatic retinopexy: the evolution of case selection and surgical technique. Retina. 2010;30(10):1561-1573. doi:10.1097/IAE.0b013e3181f3eb1a.
9. American Society of Anesthesiologists. Practice advisory: anesthetic management of patients with intraocular gas.
10. Ross WH, Kozy DW. Visual recovery in macula-off rhegmatogenous retinal detachments. Ophthalmology. 1998;105(11):2149-2153. doi:10.1016/S0161-6420(98)91120-8. [Classic; consider newer data]

This article is for informational purposes and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified eye care professional about your specific condition. If you have sudden vision loss, severe eye pain, or an eye injury, seek emergency care immediately.