Clinical features

Symptoms of vitreous detachment are usual in tractional detachment and may precede retinal detachment by minutes or years. They include:

• photopsia -
  • flashes of light without retinal stimulation
  • can occur anywhere but usually seen in the temporal peripheral field
  • produced by traction on the retina as the vitreous pulls away (1)
• vitreous opacities / floaters -
  • from vitreous haemorrhage or collapse (2)
  • patients describes them as fine dots, veils, cobwebs, clouds, or strings (3)

Visual field defects caused by retinal detachment are usually noticed as a dark "shadow" or "curtain" spreading across the field of vision. As the detachment extends the symptom moves from the periphery to the centre of the visual axis over hours, days, or even weeks (1). Since the retina is devoid of any pain receptors detachment of the retina is painless (2)

Central visual acuity is lost as the macular area is affected (2) and in the case of slowly developing detachments, this may be the first symptom. The patient may complain of distortion of images (1). Blindness may develop in severe cases.

On examination, the detached retina is grey or translucent and the normal choroidal pattern absent. It bulges forwards into the vitreous and may be thrown into folds that shift with movements of the eye. In the area of the detachment, the retinal vessels are dark red and tortuous. Visual field defects correspond to the area of detachment.

Other possible signs:

• retinal tears - may be seen as holes with the bright red choroid shining through. Peripheral tears are often horseshoe shaped and due to vitreous traction.
• lattice degeneration - elongated troughs in the peripheral retina with glistening white particles on the surface of the lines and the adjacent vitreous. These indicate areas of retinal weakness and are an aetiologic agent in one-third of rhegmatogenous retinal detachment.
• retinal dialysis - separation of the sensory retina at ora serrata, the ragged anterior edge of the sensory retina beyond which the pigment epithelium continues to relate to the posterior surface of the ciliary process and the iris. This is more common in younger patients.
• in some cases, examination may be possible only with ultrasound because of severe vitreous haemorrhage

Reference:

• (1) Kang HK, Luff AJ. Management of retinal detachment: a guide for non-ophthalmologists. BMJ. 2008;336(7655):1235-40
• (2) American Optometric association. Care of patient with retinal detachment and related peripheral vitreoretinal disease
• (3) Gariano RF, Kim CH. Evaluation and management of suspected retinal detachment. Am Fam Physician. 2004;69(7):1691-8