Traumatic Retinal Detachment

Separation of the neurosensory retina from the retinal pigment epithelium after ocular trauma. It accounts for about 10 to 20 percent of rhegmatogenous detachments, often in young males.

• Mechanisms: retinal dialysis (disinsertion at the ora serrata, most often inferotemporal, caused by vitreous base avulsion after blunt force), giant retinal tear (more than 90 degrees), tears from vitreous traction, macular hole, penetrating injury with retinal incarceration or foreign body, and tractional detachment due to vitreous incarceration or proliferative vitreoretinopathy.
• Delayed onset is characteristic: dialysis detachments are slow progressing and may present months or years (up to 5 years) later; about 50 percent appear within 8 months and 80 percent within 1 year.
• Risk factors: high myopia, previous cataract surgery, vitreoretinal degenerations, and severe trauma with vitreous haemorrhage.
• Complications: proliferative vitreoretinopathy, macular detachment with poor vision, and cystoid macular oedema.

• Painless flashes (photopsia), floaters, curtain like peripheral field loss progressing centrally, reduced central vision when the macula detaches.
• In children and young adults, symptoms may be absent in peripheral dialysis, and detachment is often noticed late or incidentally.
• Relative afferent pupillary defect (extensive detachment), lowered intraocular pressure.
• Fundus: grey elevated retina with undulating folds, retinal break (dialysis at ora, horseshoe tear, giant tear), pigmented demarcation line (chronic), vitreous haemorrhage, pigment in the vitreous (tobacco dust), and signs of other injuries (commotio retinae, choroidal rupture, hyphaema).
• Chronic detachment: retinal cysts, tide marks, fixed retinal folds.

• Dilated indirect ophthalmoscopy with scleral depression (360 degrees), supported by slit lamp biomicroscopy with a contact or non-contact lens; careful search for all breaks.
• B-scan ultrasound when the view is obscured (vitreous haemorrhage, cataract), without pressure when globe injury is possible.
• Optical coherence tomography of the macula for macular involvement; widefield imaging.
• Serial examination at 1 to 2 weeks, 4 to 6 weeks, and 3 months after significant blunt injury, even in asymptomatic patients, because of delayed detachment.

• Urgent referral to a vitreoretinal surgeon. Macula on detachments need prompt surgery (within 24 hours); macula off within 3 to 7 days.
• Retinal tears and small dialysis without detachment: laser retinopexy or cryopexy to create adhesion around the break (laser 3 to 4 rows of burns, 200 to 500 micrometre spot, 0.1 s, 150 to 300 mW; cryotherapy until retinal whitening).
• Repair of retinal detachment:
  • Scleral buckle (segmental or encircling) with cryopexy and subretinal fluid drainage when needed: preferred for young phakic patients with dialysis, no posterior vitreous detachment, and anterior breaks.
  • Pars plana vitrectomy with membrane peeling, internal drainage, endolaser, and tamponade with gas (sulphur hexafluoride 20 percent or perfluoropropane 14 percent) or silicone oil (1000 or 5000 centistokes), for giant tears, posterior breaks, vitreous haemorrhage, proliferative vitreoretinopathy, and pseudophakic or lens damaged eyes.
  • Pneumatic retinopexy for superior single breaks in selected patients (intravitreal gas 0.3 mL of 100 percent sulphur hexafluoride or 0.3 mL of perfluoropropane, cryopexy, positioning).
• Giant retinal tear: vitrectomy with perfluorocarbon liquid, laser, and silicone oil tamponade.
• Postoperative care: topical prednisolone acetate 1 percent four times daily, antibiotics for 1 week, atropine 1 percent, positioning as instructed, no air travel or nitrous oxide with gas, intraocular pressure monitoring; silicone oil removal after 3 to 6 months once the retina is stable.
• Prevent proliferative vitreoretinopathy where indicated with intravitreal methotrexate (400 micrograms in 0.1 mL, repeated up to 8 times in selected patients) or oral steroids.
• Prognosis: anatomical success 85 to 90 percent, functional results depend on macular status, duration and proliferative vitreoretinopathy; fellow eye examination is advised.