Ophthalmology Supp · Supplementary · from Ophthalmology Supp

Case 3: Retinal Detachment

Patient Presentation

Demographics: 58-year-old male software engineer

Chief Complaint: "I've been seeing flashing lights in my left eye for two days, and today I noticed a dark shadow coming across my vision from the bottom."

History of Present Illness: The patient presents urgently to the ophthalmology clinic with a two-day history of photopsia (flashing lights) in his left eye, described as brief, arc-like white flashes in the temporal visual field, particularly noticeable in dim lighting and with eye movements. He also reports a sudden increase in floaters, describing them as "a shower of tiny black dots," beginning simultaneously with the flashing lights two days ago.

This morning, he noticed a dark curtain-like shadow progressing from the inferior visual field upward in his left eye. He estimates that approximately one-third of his lower visual field is now obscured. His central vision remains relatively intact. He denies eye pain, redness, or discharge.

He has a history of high myopia and underwent LASIK surgery on both eyes twelve years ago. He reports a remote history of blunt trauma to his left eye from a squash ball approximately five years ago, which was evaluated at the time and deemed to have no acute damage. He has not had a dilated eye examination in three years.

Past Medical History:

• High myopia (pre-LASIK refraction: -8.50 D OD, -9.25 D OS)
• Status post bilateral LASIK (12 years ago)
• Posterior vitreous detachment of the right eye (diagnosed 2 years ago, uncomplicated)
• Mild essential hypertension
• No history of diabetes

Medications:

• Amlodipine 5 mg daily
• Multivitamin daily
• Fish oil supplement

Social History:

• Non-smoker
• Social alcohol use (1-2 glasses of wine per week)
• Avid squash player (plays twice weekly)
• Works long hours at computer screens
• Married with two children

Family History:

• Father: retinal detachment repair at age 65
• Mother: glaucoma
• No family history of connective tissue disorders (Marfan, Stickler syndrome)

Physical Examination

• Vital Signs: BP 132/82 mmHg, HR 72 bpm, RR 14/min, Temp 36.6°C
• Right Eye:
• Visual acuity: 20/20 (post-LASIK)
• Anterior segment: clear cornea with LASIK flap scar, deep anterior chamber
• IOP: 15 mmHg
• Dilated fundus: Weiss ring noted (evidence of prior posterior vitreous detachment), no retinal breaks or detachment, lattice degeneration present at 10 o'clock position in the periphery, flat retina 360 degrees
• Left Eye:
• Visual acuity: 20/40 (decreased from baseline 20/20)
• Relative afferent pupillary defect: absent
• Anterior segment: clear, deep anterior chamber, trace anterior vitreous cells
• IOP: 10 mmHg (lower than fellow eye, suggestive of detachment)
• Dilated fundus examination:
• Tobacco dust (Shafer sign/pigmented cells) present in the anterior vitreous
• Vitreous: posterior vitreous detachment with collapse, mild vitreous hemorrhage
• Superior retina: horseshoe (flap) tear at 1 o'clock position, approximately 1.5 disc diameters in size, with a rolled posterior edge and a visible operculum
• Bullous retinal detachment extending from the superior tear, involving the superior and temporal quadrants, extending to just above the fovea
• Macula: attached but threatened (detachment border within 2 disc diameters of fovea)
• Subretinal fluid: moderate, shifting with positioning
• No proliferative vitreoretinopathy (PVR) noted
• Lattice degeneration at 9 o'clock with an atrophic hole (no associated subretinal fluid)

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• B-scan ultrasonography (left eye): Confirms superior bullous retinal detachment with the detached retina still tethered at the optic disc and ora serrata; no posterior vitreous mass or choroidal detachment; vitreous opacities consistent with mild hemorrhage and tobacco dust
• OCT macula (left eye): Fovea remains attached but shallow subretinal fluid is present within 500 μm of the foveal center, indicating imminent macula-off status
• Widefield fundus photography (left eye): Documents the extent of detachment involving approximately 40% of the retinal surface area (superior and supero-temporal quadrants)
• OCT macula (right eye): Normal foveal contour, no subretinal fluid, no epiretinal membrane

Clinical Image

Cross-sectional diagram illustrating a rhegmatogenous retinal detachment with a horseshoe tear, vitreous traction, and subretinal fluid accumulation. Source: Educational illustration.

Diagnosis

Rhegmatogenous Retinal Detachment, Left Eye — Macula-Threatening (Macula-On)

Key Diagnostic Criteria:

• Acute symptoms of photopsia, floaters, and progressive visual field loss
• Horseshoe retinal tear at 1 o'clock position (causative break)
• Bullous retinal detachment with subretinal fluid in the superior and temporal quadrants
• Shafer sign positive (tobacco dust in vitreous — pathognomonic for retinal break)
• Low IOP relative to fellow eye (10 vs 15 mmHg)
• Macula currently attached but imminently threatened
• Risk factors: high myopia, posterior vitreous detachment, lattice degeneration, family history, prior ocular trauma, age

Treatment Plan

1. Emergency surgical repair — this is a macula-on detachment with imminent macula-off threat; surgery should be performed within 24 hours to preserve central vision
2. Positioning: Patient positioned with head elevated and turned to the right (detachment is superior, so face-down/right positioning helps prevent macular involvement while awaiting surgery)
3. Surgical options (vitreoretinal surgeon decision):

• Primary pars plana vitrectomy (PPV) with endolaser to the retinal tear and gas tamponade (SF6 or C3F8): preferred approach for this bullous, superior detachment with a large horseshoe tear
• Alternative: Scleral buckle, which may be considered given patient's age and phakic status, though PPV is more commonly performed
• Combined PPV with scleral buckle if lattice degeneration with atrophic holes poses additional risk

1. Intraoperative treatment of lattice degeneration: Laser retinopexy to the lattice with atrophic hole at 9 o'clock and to the lattice in the fellow right eye at 10 o'clock
2. Postoperative care:

• Face-down positioning for 5-7 days if gas tamponade used
• Topical antibiotics and corticosteroids
• No air travel until gas tamponade resorbs (2-6 weeks depending on gas type)
• Activity restriction: no heavy lifting, straining, or racquet sports for 4-6 weeks

1. Prophylactic laser to the right eye: Barricade laser around the lattice degeneration at 10 o'clock to reduce risk of retinal detachment in the fellow eye
2. Long-term follow-up: Dilated fundus examination at 1, 3, 6, and 12 months post-surgery, then annually; counsel about symptoms of re-detachment

Key Learning Points

• The triad of new photopsia, floaters, and visual field loss should be considered a retinal detachment until proven otherwise and warrants urgent dilated fundus examination.
• Shafer sign (tobacco dust/pigmented cells in the anterior vitreous) is pathognomonic for a retinal break and should be specifically sought during slit-lamp examination.
• Macula-on retinal detachments are surgical emergencies (repair within 24 hours), as macular involvement dramatically worsens the visual prognosis; macula-off detachments are urgent but can typically be repaired within 24-72 hours.
• High myopia (>-6.00 D) is the most common risk factor for rhegmatogenous retinal detachment, increasing the risk 5-6 fold due to peripheral retinal thinning, lattice degeneration, and earlier posterior vitreous detachment.
• Fellow eye prophylaxis with laser retinopexy to lattice degeneration is important, as the lifetime risk of retinal detachment in the fellow eye of a myopic patient is 10-15%.

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