PassFinals
Eyes & Vision

Retinal detachment

Retinal detachment separates the neurosensory retina from its support tissues and can cause permanent sight loss; new flashes, floaters, a curtain or sudden visual loss need urgent retinal assessment, especially before the macula detaches.

In a nutshell

New flashes, floaters, a curtain or sudden painless visual loss may represent retinal tear or detachment. Urgent dilated retinal examination determines whether the macula is attached. Retinal tears are sealed with laser or cryotherapy; detachment requires vitreoretinal repair, followed by gas-bubble safety advice and planned review.

Classic presentation

A short-sighted patient develops sudden flashes and a shower of new floaters, then a painless dark curtain spreading through the peripheral field. Central acuity may be preserved if the macula remains attached.

Key points

  • Posterior vitreous detachment can be benign, but new or increasing flashes and floaters must be examined for a retinal break.
  • A curtain, shadow or field defect is a retinal emergency; do not wait for pain or major acuity loss.
  • Macula-on versus macula-off is the key prognostic distinction, but both need urgent vitreoretinal assessment.
  • Laser or cryotherapy treats a retinal break; a detached retina needs a mechanical reattachment procedure.
  • Vitrectomy, scleral buckle and pneumatic retinopexy are selected by retinal anatomy, lens status and postoperative positioning feasibility.
  • Gas requires no flying or high altitude and no nitrous oxide; tell every anaesthetist and emergency clinician.
  • New symptoms after a reassuring examination or after surgery require repeat assessment, and the fellow eye also needs review.

First-line investigation

Urgent dilated retinal examination with visual acuity, fields and assessment of retinal breaks and macular status; use B-scan if the fundal view is obscured.

Management

Refer new flashes, floaters or a curtain urgently

  • Arrange urgent eye-service assessment for new or increasing flashes/floaters, a curtain, field loss or sudden blur; macula-on detachment should be assessed within 24 hours.1,2,4,6

Examine the retina and locate the break

  • Use dilated indirect ophthalmoscopy, peripheral examination and visual assessment; use B-scan when haemorrhage or media opacity prevents a view.1,3,6

Seal the break or reattach the retina

  • Use laser/cryotherapy for an appropriate isolated break and vitreoretinal repair with vitrectomy, buckle or pneumatic retinopexy for detachment.2,3,1

Follow surgical positioning and gas precautions

  • Follow the instructed posture, avoid flying/high altitude with gas, and tell every anaesthetist or emergency clinician because nitrous oxide can expand the bubble.2,3,7

Assess the fellow eye and associated vitreoretinal risks

  • Examine the fellow eye and give specific repeat-referral advice for new symptoms, particularly after a previous tear, detachment, trauma or surgery.4,5,2

Safety-net postoperative and recurrent symptoms

  • Use prescribed drops and attend retinal follow-up; return urgently for worsening pain, redness, blur, flashes, floaters, shadow or sudden visual loss.2,3

Exam traps

  • Retinal detachment is usually painless; pain points to another or additional ocular emergency.
  • New flashes and floaters are not automatically benign posterior vitreous detachment until the retina has been examined.
  • Macula-on detachment is time-critical because central vision is still potentially preservable; macula-off detachment remains urgent.
  • Laser retinopexy seals an isolated break but does not reattach a detached retina.
  • Nitrous oxide must be avoided while intraocular gas remains, even if the operation was weeks earlier.

Illustrations

Rhegmatogenous retinal detachment mechanismDiagram showing vitreous traction causing a retinal tear, with fluid tracking behind the retina to separate it from the retinal pigment epithelium.PassFinals · original
Visual field curtain progressing across visionIllustration of a patient's visual field showing a dark shadow encroaching from the periphery toward central vision.PassFinals · original
Fundoscopic appearance of a detached retinaFundus photograph showing an elevated, folded, pale area of detached retina with a visible retinal tear.Amaris5, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE CKS: Retinal detachment (Recognition, urgent referral, examination, retinal-tear management and follow-up; access may require NHS/OpenAthens authentication)
  2. NHS: Detached retina (retinal detachment) (Symptoms, urgent advice, surgery options, postoperative positioning, flying and safety-netting)
  3. Moorfields Eye Hospital: Vitreoretinal emergency clinic and retinal-detachment aftercare (Emergency referral, surgical options, posturing, gas-bubble restrictions and postoperative red flags)
  4. NHS: Floaters and flashes in the eyes (Urgent symptom triage and distinction between common posterior vitreous detachment symptoms and sight-threatening retinal disease)
  5. Guy's and St Thomas' NHS Foundation Trust: Posterior vitreous detachment (PVD presentation, retinal-tear warning symptoms and repeat eye-casualty advice)
  6. Royal College of Ophthalmologists: Quality Standard for Vitreoretinal Services (Macula-on rhegmatogenous retinal-detachment assessment within 24 hours, timely surgery, competent vitreoretinal service and posturing standards)Published 1 Dec 2021
  7. Royal College of Ophthalmologists: Do not use nitrous oxide when there is gas in an operated eye (Patient-safety alert on gas expansion and nitrous oxide after retinal surgery)Published 1 Dec 2018

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.