116 I: Principles

Figure 5–24. Severe subretinal fibrosis with tight peripapillary colarette.

NONRHEGMATOGENOUS RETINAL DETACHMENT

Rhegmatogenous retinal detachments must be differentiated from exudative and tractional detachments. The diagnostic features of all three types of retinal detachment are summarized in Table 5–4. More than 90% of all clinical detachments are of the rhegmatogenous type. Rhegmatogenous detachments are termed primary detachments, while exudative and tractional detachments are called secondary or nonrhegmatogenous detachments. The terms serous detachment and exudative detachment are used interchangeably.

The differential diagnosis of nonrhegmatogenous retinal detachment is summarized in Table 5–5.

DISTINGUISHING SEROUS FROM RHEGMATOGENOUS DETACHMENT

If no retinal break can be found to account for the detachment, the possibility of a serous (or tractional) detachment should be entertained. However, in about 10% of rhegmatogenous detachments, no retinal break can be found. Therefore, lack of a visible tear alone does not rule out rhegmatogenous detachment.

Pigmented vitreous cells will usually, but not always, be present with a rhegmatogenous detachment. These cells are seen best with the slit lamp on high intensity, looking posterior to the lens using no auxillary lens. Recent detachments caused by small retinal breaks may not have these cells initially. Absence of pigmented cells may be part of a collection of features that leads to a suspicion of serous rather than rhegmatogenous detachment.

When serous detachment is suspected, the patient is evaluated for shifting fluid, and the presence of an underlying cause of serous detachment is sought in history, with retinal examination, and potentially with laboratory evaluation. Ultrasound may be helpful.

Serous subretinal fluid usually shifts with changes in position of the head. “Shifting fluid” is defined as a changing of the detachment borders in response

118 I: Principles

Table 5–5. Differential Diagnosis of Nonrhegmatogenous Retinal Detachment

Exudative

Primary tumors

Malignant melanoma of choroid

Hemangioma of choroid

Retinoblastoma

Metastic tumors to choroid

Breast or lung cancer most common

Inflammation

Scleritis

Choroiditis (e.g., Harada’s syndrome)

Retinitis (e.g., toxoplasmosis)

Vascular disease

Angiomatosis of retina (von Hippel’s disease)

Telangiectasia retinae (juvenile and adult Coats’ disease)

Eale’s disease

Retinal vein occlusion

Optic nerve disease

Pit or coloboma of optic nerve head with serous detachment of macula Nerve head drusen with serosanguineous detachment of adjacent retina

Congenital disease

Nanophthalmos

Familial exudative vitreoretinopathy (FEVR)

Macular disease

Central serous chorioretinopathy (rarely can extend to ora serrata)

Age-related macular degeneration

Other causes of disciform detachment

Ocular histoplasmosis, angioid streaks, high myopia

Systemic disease

Toxemia

Uremia

Lupus erythematosus

Leukemia

Tractional

Proliferative diabetic retinopathy

Retinopathy of prematurity

Sickle cell retinopathy

Posttraumatic vitreous membranes

Retinal vein occlusion

to changes in head position; it does not mean movement of the fluid within stable detachment borders. Shifting fluid is common in exudative detachments, and in rare instances is also seen in old rhegmatogenous detachments.

Rhegmatogenous retinal detachment usually has a characteristic undulation or “tobacco-paper wrinkle.” Usually there is a visible distinction between the

120 I: Principles

A

B

Figure 5–26. Vogt-Koyanagi-Harada syndrome with serous retinal detachment.

Figure 5–27. Capillary hemangioma with dilated, tortuous feeder vessel in von Hippel’s disease.

An inflammatory detachment is characterized by a transparent retina with an unusually clear view of the underlying choroid. Signs of inflammation with flare and cells are seen during slit-lamp examination of the vitreous; inflammatory lesions of the choroid can usually be seen with indirect ophthalmoscopy. Retinitis is manifested by a fluffy white retinal lesion with turbidity of the vitreous.

Figure 5–28. Optic pit with serous retinal detachment.

Vascular lesions with serous detachment

Vascular lesions capable of causing serous detachment include Coats’ disease, Eale’s disease, and retinal vein occlusion. Choroidal hemangiomas and retinal angiomatosis as seen in von Hippel’s disease (Figure 5–27) are vascular tumors that can cause serous detachment.

Congenital causes of serous detachment

Nanophthalmos is a congenital condition that can cause uveal effusion and serous retinal detachment. Familial exudative vitreoretinopathy causes exudative and tractional detachment. Congenital optic nerve pits and optic nerve colobomas may also cause serous macular detachments (Figure 5–28).

Macular lesions with serous detachment

Age-related macular detachment with choroidal neovascularization is a common vascular lesion of the macula that occasionally causes extensive exudation and serous detachment. This process can also occur in the periphery with peripheral disciform scarring and exudation. Extensive subretinal hemorrhagic retinal detachment may also occur.

Central serous chorioretinopathy typically involves serous detachment of the macula. Occasionally, serous subretinal fluid will also settle inferiorly into the peripheral fundus.

DISTINGUISHING TRACTIONAL FROM

RHEGMATOGENOUS DETACHMENT

Fibrous proliferation on or under the retina may cause retinal detachment in the absence of retinal breaks. The causative fibrous or fibrovascular proliferation is generally clinically evident, but vitreoretinal traction can be subtle. Tractional detachments typically have a concave contour rather than the convex contour of