Ophthalmology/Eye Institute

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 Department of Ophthalmology Case Studies

 

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Diagnosis:
Rheumatogenous retinal detachment resulting from a peripheral retinal tear.

Discussion:
Retinal detachments (RD) can be classified into three categories, rheumatogenous, exudative, and tractional.

Rheumatogenous RD (RRD):
These detachments are caused by liquefied vitreous passing through a retinal break and in between the retinal pigment epithelium and the neurosensory retinal. This causes the retina to be lifted up and is seen as undulating bullae or folds on exam. A retinal break can be found in 90-97% of cases of RRD, and if not found, a break is presumed to be present.

Tractional RD:
Vitreous membranes that may be caused by penetrating injuries or proliferative retinopathies such as seen in diabetes can lead to retinal traction and pull the neurosensory retinal away from the retinal pigment epithelium without causing a retinal tear. The retina typically has a smooth surface with concave borders and is immobile, peaking to traction points. These detachments can develop breaks and become rheumatogenous.

Exudative RD:
May be caused by either retinal or choroidal disease in which fluid leaks into and accumulates underneath the neurosensory retinal. Most exudative detachments are small and are associated with choroidal neovascularization. Large detachments as seen in tractional and rheumatogenous types are rare but can occur. Large exudative RDs are normally due to neoplasia or inflammatory disease. These large exudative detachments often exhibit shifting fluid, are smooth and without folds. When sitting up the inferior retina will be detached, and when laying supine the posterior retinal will detach, including the macula (shifting fluid).

This particular patient has a rheumatogenous retinal detachment resulting from a peripheral retinal break. This retinal break is likely due to vitreous traction exhibited on the periphery, and may have been precipitated by the recent cataract surgery. Cataract surgery creates more space in the vitreous chamber and allows the vitreous jelly to shift (the intraocular lens is much thinner than the original lens). As the vitreous jelly moves to fill this new space it can tug on the retina and cause a retinal break. Other etiologies may include peripheral lattice, highly myopic eyes, posterior vitreous detachment, trauma, aphakia/pseudophakia, and sickle cell disease.

Rheumatogenous detachments are often treated surgically. Common procedures include scleral buckle or balloon to relieve vitreous traction and approximate the retina to the underlying choroid. Pneumatic retinopexy, and vitrectomy are also used to reattach the retina. Overall, the current surgical techniques have a 80-90% success rate of anatomical reattachment.

Postoperative visual acuity in patients with “mac on” retinal detachments results in 20/50 or better in 87% of cases. When the detachment involves the macula, only one third to one half of patients recover to a VA of 20/50 or better. If the macula off detachment is repaired within 1 week then 75% of patients will recover with a VA of 20/70 or better. This drops to 50% if repaired between 1 and 8 weeks.

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