Ophthalmology
Question 178 of 180
A 54 year old woman presents to the Emergency Department complaining of visual loss in her right eye. She describes seeing flashes of light and a haze before losing her "upper vision" like a curtain coming down. What is the most likely diagnosis?
Answer:
Retinal detachment presents with the 4Fs:- Floaters (perception of mobile dots, lines, or haze due to blood and pigment cells entering the vitreous cavity casting shadows on the retina)
- Flashes (perception of light often seen as recurrent, brief flashes, caused by traction on the retina as the vitreous pulls away)
- Field loss (may be described as a dark curtain or shadow, which starts in the periphery and progresses towards the centre as the detachment extends)
- Fall in visual acuity (if the macula detaches, central visual acuity may be severely reduced)
Retinal Detachment
Ophthalmology
Last Updated: 12th February 2021
Retinal detachment refers to the separation of the inner neurosensory retina from the underlying retinal pigment epithelium, which allows fluid to accumulate in the subretinal space.
Retinal detachment is a preventable cause of vision loss, as prompt recognition and referral may allow early surgical repair before the macula is detached, which reduces the risk of permanent visual impairment. If left untreated, symptomatic retinal detachment invariably results in permanent loss of vision.
Causes
There are three main types of retinal detachment (in addition to trauma):
- Rhegmatogenous (most common) - as the vitreous shrinks and partly separates from the retinal surface, a retinal tear or break may develop
- Exudative - caused by leakage of fluid into the subretinal space, often due to inflammation or malignancy
- Tractional - most commonly seen in people with proliferative diabetic retinopathy, where abnormal vasculature causes contraction of the vitreous which then pulls on the underlying retina
Risk factors
- Myopia (increases risk of posterior vitreous detachment)
- Family history or previous history of retinal break or detachment
- Eye trauma (especially blunt trauma e.g. boxing, paintball injury)
- Previous cataract surgery
- Proliferative diabetic retinopathy
- Inflammatory conditions e.g. uveitis, scleritis
- Malignancy e.g. choroidal melanoma or ocular metastasis
- Congenital eye disease e.g. glaucoma, cataract or retinopathy of prematurity
Clinical features
Retinal detachment presents with the 4Fs:
- Floaters (perception of mobile dots, lines, or haze due to blood and pigment cells entering the vitreous cavity casting shadows on the retina)
- Flashes (perception of light often seen as recurrent, brief flashes, caused by traction on the retina as the vitreous pulls away)
- Field loss (may be described as a dark curtain or shadow, which starts in the periphery and progresses towards the centre as the detachment extends)
- Fall in visual acuity (if the macula detaches, central visual acuity may be severely reduced)
Fundoscopy findings
- Loss of red reflex
- Vitreous opacities
- Detached retinal folds (appear pale, opaque and wrinkled in larger detachments)
Management
- Urgent ophthalmology referral
- Specialist treatment
- Retinal tears or breaks are treated by laser therapy or cryotherapy (creates a scar adhesion between the retina and retinal pigment epithelium which seals the hole and prevents fluid access into the subretinal space, preventing progression to retinal detachment)
- Retinal detachment may be treated with a variety of surgical techniques (which aim to close any retinal tears/holes, reduce vitreous traction and reattach the retina):
- Vitrectomy
- Scleral buckling
- Pneumatic retinopexy
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
