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Summary Table

Feature	Detail
Risk Factors	High myopia, prior cataract surgery (aphakia/pseudophakia), trauma, family history, lattice degeneration, increasing age, diabetes (for tractional type)
Etiology	Separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE), caused by a retinal break (rhegmatogenous), vitreoretinal traction (tractional), or subretinal fluid accumulation (exudative)
Patient Presentation	Sudden, painless vision loss described as a "curtain" or "shadow" falling over the visual field, preceded by flashes of light (photopsia) and floaters
Classic Physical Exam	Loss of the red reflex on the affected side, elevated or billowing retina on fundoscopy, relative afferent pupillary defect (RAPD) if detachment is extensive
Key Diagnostic Results	Fundoscopic exam reveals a grey, elevated retina with folds; B-scan ultrasound confirms detachment when direct visualization is not possible
Management	Surgical: pneumatic retinopexy, scleral buckle, or pars plana vitrectomy depending on type and extent; laser photocoagulation or cryopexy for isolated retinal tears without detachment
Keywords	"Curtain coming down," "flashes and floaters," painless vision loss, loss of red reflex, tobacco dust (Shafer sign), high myopia

1. Pathophysiology

The retina is a multilayered neurosensory structure lining the posterior segment of the eye. Under normal conditions, the neurosensory retina is held in apposition to the retinal pigment epithelium (RPE) through a combination of metabolic pumping by the RPE, the pressure exerted by the vitreous body, and interphotoreceptor matrix adhesion. Retinal detachment occurs when this attachment is disrupted, allowing fluid to accumulate in the potential space between the neurosensory retina and the RPE.

In rhegmatogenous retinal detachment (the most common and most tested type), the process begins with posterior vitreous detachment (PVD). As the vitreous gel liquefies with age, it collapses and pulls away from the retina. If there is an area of abnormal vitreoretinal adhesion (such as lattice degeneration in myopic eyes), this traction can create a full-thickness retinal tear or hole. Once a break exists, liquefied vitreous fluid passes through the defect and dissects the neurosensory retina away from the RPE. This is why patients first experience photopsia (flashes of light from mechanical stimulation of photoreceptors by vitreous traction), followed by a sudden shower of floaters (from vitreous hemorrhage or pigment cells released into the vitreous cavity, known as Shafer sign or "tobacco dust"), and ultimately a progressive visual field defect described as a curtain or veil.

The retina has no pain fibers, so the entire process from tearing to detachment is painless. Pain in the setting of acute vision loss should redirect you toward other diagnoses such as acute angle-closure glaucoma or endophthalmitis.

In tractional retinal detachment, the retina is pulled inward by fibrovascular membranes that form on its surface. This is the hallmark of proliferative diabetic retinopathy, where neovascularization and subsequent fibrosis create contractile bands. There is no retinal break, which distinguishes it from rhegmatogenous detachment.

In exudative (serous) retinal detachment, fluid accumulates beneath the retina without a break or traction. This results from disruption of the blood-retinal barrier, seen in conditions like Vogt-Koyanagi-Harada disease, posterior scleritis, choroidal tumors (melanoma, metastases), or severe preeclampsia/eclampsia. The fluid is protein-rich and tends to shift with changes in patient position ("shifting fluid"), a feature that helps distinguish it clinically.

2. Classification and Clinical Manifestation

Type	Mechanism	Key Association	Clinical Features
Rhegmatogenous	Full-thickness retinal break allows liquefied vitreous to enter subretinal space	High myopia, PVD, aphakia, lattice degeneration, trauma	Flashes, floaters, progressive "curtain" visual field loss, tobacco dust in vitreous
Tractional	Fibrovascular proliferation on retinal surface exerts inward traction	Proliferative diabetic retinopathy, sickle cell retinopathy, retinopathy of prematurity	Gradual vision loss, no flashes (no acute break), concave retinal surface on exam
Exudative (Serous)	Subretinal fluid accumulation without break or traction	Choroidal tumors, Vogt-Koyanagi-Harada, preeclampsia, posterior scleritis	Shifting subretinal fluid with position change, smooth convex detachment, no retinal break seen

An additional clinical distinction worth noting: in rhegmatogenous detachment, macula status is the single most important prognostic factor. A "macula-on" detachment (where the fovea is still attached) is a true surgical emergency because outcomes are dramatically better if surgery is performed before the macula detaches. A "macula-off" detachment is still urgent but carries a worse visual prognosis regardless of intervention timing.

3. Diagnostic Workup

Test	Role	Key Findings
Dilated fundoscopy	Best initial test	Grey, corrugated, elevated retina; retinal break visible in rhegmatogenous type; loss of choroidal pattern beneath detachment
Indirect ophthalmoscopy with scleral depression	Gold standard clinical exam	Allows visualization of peripheral retina and identification of all retinal breaks, including small ones at the ora serrata
B-scan ultrasonography	Confirmatory when fundus is not visible	Bright, mobile membrane in the vitreous cavity; distinguishes retinal detachment from vitreous hemorrhage or choroidal detachment
Optical coherence tomography (OCT)	Adjunctive	Confirms subretinal fluid, assesses macular involvement, helpful for subtle or exudative detachments

The diagnostic approach to suspected retinal detachment begins with a thorough dilated fundoscopic examination. This is both the best initial test and usually sufficient for diagnosis. On direct visualization, the detached retina appears as a grey, opaque, billowing membrane that undulates with eye movement. In rhegmatogenous cases, identifying the retinal break (horseshoe tear, round hole, or giant retinal tear) is essential for surgical planning.

B-scan ultrasonography becomes critically important in two scenarios: when the fundus cannot be visualized (due to dense vitreous hemorrhage, cataract, or corneal opacity), and when you need to differentiate a retinal detachment from a posterior vitreous detachment or choroidal detachment. On ultrasound, a detached retina appears as a thin, highly reflective membrane that inserts at the optic disc posteriorly and the ora serrata anteriorly. A total detachment produces a characteristic "V-shape" or funnel configuration anchored at these two points.

For exudative detachments, identifying the underlying cause is crucial. This may require additional imaging with fluorescein angiography (to evaluate choroidal tumors or inflammatory causes), MRI of the orbits, or systemic workup depending on the clinical context.

A key exam trap: do not confuse posterior vitreous detachment (a benign and extremely common condition) with retinal detachment. Both present with flashes and floaters, but PVD alone does not cause visual field loss or a curtain defect. A patient with new-onset flashes and floaters must receive an urgent dilated exam to rule out a retinal tear before being reassured.

4. Management and Treatment

Scenario	Treatment	Details
Retinal tear or hole without detachment	Laser photocoagulation or cryopexy	Prophylactic barrier to prevent progression to full detachment; outpatient procedure
Rhegmatogenous (limited, superior, macula-on)	Pneumatic retinopexy	In-office injection of expansile gas (SF6 or C3F8) into vitreous cavity + laser/cryo to seal the break; patient must maintain head positioning
Rhegmatogenous (inferior, multiple breaks, complex)	Scleral buckle	Silicone band sutured around the globe to indent the scleral wall inward toward the detached retina; performed in the operating room
Rhegmatogenous (complex, recurrent, or with vitreous hemorrhage)	Pars plana vitrectomy (PPV)	Vitreous removal + endolaser + gas or silicone oil tamponade; most versatile surgical option
Tractional	Pars plana vitrectomy with membrane peeling	Surgical release of tractional membranes; indicated when detachment threatens or involves the macula
Exudative	Treat underlying cause	Corticosteroids for inflammatory causes, anti-VEGF or radiation for choroidal tumors, management of preeclampsia; surgery is not the primary intervention

Acute stabilization for a newly diagnosed rhegmatogenous detachment involves limiting patient activity (bed rest with limited eye movement) and correct head positioning. If the detachment is superior, the patient should be kept upright to prevent subretinal fluid from gravitating toward the macula. If the macula is still attached ("macula-on"), this is an emergency requiring surgery within 24 hours.

Pneumatic retinopexy is the least invasive surgical option. An expansile gas bubble (commonly $\text{SF}_6$ or $\text{C}_3\text{F}_8$) is injected into the vitreous cavity. The bubble rises and tamponades the retinal break, pushing the retina back against the RPE while cryopexy or laser creates a permanent adhesion around the break. The patient must maintain strict head positioning for 1 to 2 weeks to keep the bubble over the break. A critical contraindication: patients with gas tamponade must not undergo general anesthesia with nitrous oxide ($\text{N}_2\text{O}$), as it diffuses into the gas bubble and can cause dangerous intraocular pressure elevation. Air travel is also absolutely contraindicated until the gas resorbs (2 to 8 weeks depending on gas type).

Scleral buckle is a time-tested approach where a silicone band or sponge is secured to the external surface of the globe. This indents the scleral wall inward, bringing the RPE into contact with the detached retina. It is particularly effective for inferior detachments and in younger patients. A notable complication is induced myopia from the increased axial length of the globe.

Pars plana vitrectomy is the most versatile technique and is increasingly used as the primary approach. The vitreous is removed, subretinal fluid is drained, retinal breaks are treated with endolaser, and the vitreous cavity is filled with gas or silicone oil for tamponade. Silicone oil requires a second surgery for removal but is preferred in complex cases (proliferative vitreoretinopathy, giant retinal tears) and in patients who cannot maintain head positioning.

For tractional detachment in diabetic patients, surgery is indicated when the detachment involves or threatens the macula. Stable peripheral tractional detachments can be observed. The key is to not create iatrogenic retinal breaks during membrane peeling, which would convert a tractional detachment into a combined (rhegmatogenous + tractional) detachment.

5. Differential Diagnosis and Distractors

Differential	Why It Is Similar	Key Discriminator
Posterior vitreous detachment (PVD)	Also presents with flashes and floaters	No visual field defect or curtain; fundoscopy shows Weiss ring but no retinal break or detachment; benign unless complicated by a tear
Vitreous hemorrhage	Sudden painless vision loss with floaters	Vision loss is diffuse (not a curtain pattern); fundus view is obscured; no detached retina on B-scan ultrasound
Central retinal artery occlusion (CRAO)	Sudden painless monocular vision loss	Vision loss is immediate and complete (not progressive); fundoscopy shows pale retina with cherry-red spot at macula; no flashes or floaters
Central retinal vein occlusion (CRVO)	Sudden painless monocular vision loss	Fundoscopy shows "blood and thunder" appearance with diffuse hemorrhages, cotton-wool spots, and disc edema; no curtain or detached retina
Optic neuritis	Vision loss (though usually painful)	Typically painful with eye movement; associated with multiple sclerosis; RAPD present; fundus may show disc swelling but no retinal detachment
Choroidal detachment	Elevated structure seen on fundoscopy	Brown/dark dome-shaped elevations that do not extend to the ora serrata; often post-surgical or hypotonus; smooth, immobile compared to retinal detachment

6. Traps and High-Yield Pearls

The single most tested concept in retinal detachment is the symptom triad of photopsia, floaters, and progressive painless visual field loss. When you see "curtain coming down" or "shadow over the vision" in a vignette, the answer is retinal detachment until proven otherwise. The most common mistake students make is confusing an uncomplicated posterior vitreous detachment (which only causes flashes and floaters without visual field loss) with a true retinal detachment. Every patient with new flashes and floaters needs an urgent dilated fundoscopic exam, but the presence or absence of a visual field defect is what separates the two.

A second frequent trap involves the type of detachment. Test-writers will describe a diabetic patient with gradual vision loss and a concave retinal surface on exam to see if you recognize tractional detachment and select vitrectomy rather than pneumatic retinopexy or scleral buckle (which are for rhegmatogenous detachment only). Similarly, a pregnant patient with severe hypertension and bilateral serous detachments should trigger recognition of exudative detachment secondary to preeclampsia, where the correct management is delivery and blood pressure control rather than retinal surgery.

Finally, remember the nitrous oxide rule: any patient with an intraocular gas bubble who requires general anesthesia must have $\text{N}_2\text{O}$ avoided. This pharmacologic interaction question is a classic board-style distractor. The core competency being tested across all retinal detachment questions is your ability to integrate the clinical presentation with the correct subtype classification and match it to the appropriate intervention.

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