History. Differential Diagnoses

History

Initial symptoms of retinal detachment commonly include the sensation of a flashing light (photopsia) related to retinal traction and often accompanied by a shower of floaters and vision loss.

Over time, the patient may report a shadow in the peripheral visual field, which, if ignored, may spread to involve the entire visual field in a matter of days. Vision loss may be described as cloudy, irregular, or curtainlike.

Retinal tissue is stimulated by light but also responds to mechanical disturbances. Flashing lights usually are caused by separation of the posterior vitreous. As the vitreous gel separates from the retina, it stimulates the retinal tissue mechanically, resulting in the release of phosphenes and the sensation of light.

Pathologic stimulation of the retina and production of phosphenes cause photopsia. If a retinal detachment involves the macula, acuity may be severely reduced.

The location of the light sensation in the patient's visual field has no correlation to the location of a retinal tear.

Floaters are a very common visual symptom in the population; thus, distinguishing their etiology requires eliciting a detailed history. The sudden onset of large floaters in the center of the visual axis may indicate posterior vitreous detachment (PVD). The patient observes a circular floater when the vitreous detaches from its annular ring surrounding the optic nerve (referred to as Weiss ring). More ominous and concerning is the description of hundreds of tiny black specks appearing before the eye, as this maybe be indicative of a vitreous hemorrhage, resulting from disruption of a retinal vessel caused by a retinal tear or mechanical traction of a vitreoretinal adhesion. A few hours after the initial shower of black spots, the patient can note cobwebs that result from blood forming irregular clots. Generally, the new onset of floaters associated with flashing lights is highly suggestive of a retinal tear.

While symptoms of photopsia and floaters are not helpful in locating the position of the retinal tear or detachment, the visual field defect can be helpful in locating the detachment.

Bullous (ie, large ballooning) detachments produce dense visual field defects (ie, blackness), and flat detachments produce relative field defects (ie, grayness).

Inquire about history of trauma, including whether it occurred several months before the symptoms or coincided with the onset of symptoms. Documentation of head or ocular trauma may be subject to legal investigation, especially in children.

Note previous surgery, including cataract extraction, intraocular foreign body removal, and retinal procedures.

Question the patient about previous conditions, such as uveitis, vitreous hemorrhage, amblyopia, glaucoma, and diabetic retinopathy. Query about family history of eye disease because, although RDs usually are sporadic events, certain pedigrees may be prone to detachment.

Determine length of time there has been visual symptoms and visual loss. This can help determine the appropriate timing of treatment

Physical

Check visual acuity at near and distance, correcting for refractive error.

Conduct an external examination for signs of trauma, checking the visual field (usually a confrontation field examination is adequate). Visual fields can help isolate the location of the retinal detachment.

Check pupil reaction (a fixed dilated pupil may indicate previous trauma; a positive Marcus-Gunn pupil can occur with any disturbance of the afferent pupillomotor pathway, including retinal detachment).

Check intraocular pressure measurement in both eyes (relative hypotony of > 4-5 mm Hg less than the fellow eye is common).

Administer slit-lamp biomicroscopy

Examine the vitreous for signs of pigment or tobacco dust (ie, Shafer sign), which is suggestive for a retinal tear in 70% of cases with no previous eye disease or surgery.

Conduct a dilated fundus examination with ophthalmoscopy (panoptic ophthalmoscope may be used). Indirect ophthalmoscopy is the definitive means of diagnosing retinal detachment. Direct funduscopy may detect vitreous hemorrhage and large detachment of the posterior pole, but it is inadequate for complete examination because of the lower magnification and illumination, lack of stereopsis, and limited view of the peripheral retina. Obvious detachment is observed as marked elevation of the retina, which appears gray with dark blood vessels that may lie in folds. The detached retina may undulate and appear out of focus. Shallow detachments are much more difficult to detect; thus, comparing the suspected area with an adjacent normal quadrant is helpful to detect any change in retinal transparency. A pigmented or nonpigmented line may demarcate the limit of a detachment.

Complications

Loss of vision to hand motion or light perception is a frequent complication of retinal detachments that involve the macula.

DDx

Differential Diagnoses

Migraine with or without aura Posterior uveitis

Posterior vitreous detachment

Retinal Artery Occlusion (RAO) Retinal artery occlusion

Retinal vein occlusion Vitreous Hemorrhage Vitreous syneresis

Workup

Workup

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