AKT · Ophthalmology/Retina & vitreous

Retinal detachment

Separation of the neurosensory retina from the RPE (rhegmatogenous via a retinal tear)

Overview

Separation of the neurosensory retina from the underlying retinal pigment epithelium, most often rhegmatogenous (a retinal tear lets fluid track underneath). Presents with new flashes, a shower of floaters and a progressing 'curtain' over the visual field. A surgical emergency if the macula is still attached ('macula-on'). Risk factors: myopia, prior cataract surgery, trauma, posterior vitreous detachment.

Recognise

New-onset FLASHES (photopsia) and FLOATERS, then a dark CURTAIN/shadow advancing across the field
Painless visual-field loss; reduced acuity once the macula detaches ('macula-off')
Risk factors: high myopia, aphakia/pseudophakia, trauma, lattice degeneration, PVD, family history

Red flags

Field loss, reduced acuity, or fundoscopic detachment/vitreous haemorrhage → same-day retinal-surgery referral
'Macula-on' detachment is a true emergency — repair before the macula detaches to preserve central vision

Differentials & how to tell them apart

Posterior vitreous detachmentflashes/floaters but NO field loss or detachment — must be examined to exclude an associated tear

Vitreous haemorrhagesudden floaters/haze with loss of the red reflex; often diabetic

Migraine aurabilateral homonymous zig-zag scintillations lasting ~20 min, then resolving

Retinal vein/artery occlusionsudden painless loss without flashes/curtain

Rhegmatogenous retinal detachment — elevated detached retina
Amaris5 / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Dilated indirect ophthalmoscopy (the retina is elevated/grey with a tear); B-scan ultrasound if no fundal view. Slit-lamp for Shafer sign (pigment 'tobacco dust').

Management

Emergency retinal-surgery referral (vitrectomy / scleral buckle / pneumatic retinopexy)

1New flashes/floaters with field loss, reduced acuity or a visible detachment → IMMEDIATE same-day referral to a retinal surgeon. No field loss and a normal exam → urgent (within 24 h) slit-lamp/indirect ophthalmoscopy to exclude a tear.Gate: Macula-ON detachment must be repaired urgently before the macula detaches — once 'macula-off', central vision is often permanently reduced even after successful reattachment
2Retinal tear without detachment → laser retinopexy/cryotherapy. Detachment → vitrectomy, scleral buckle, or pneumatic retinopexy.

None medical — management is surgical/laser

Key points

Flashes + floaters + an advancing curtain = retinal detachment. The macula-on vs macula-off distinction sets the urgency and the visual prognosis.

Monitor & prognosis

Post-op review; the fellow eye is also at risk.

Good if repaired macula-on; reduced central vision once macula-off.

Source: NICE CKS Retinal detachment; RCOphth