Neuroscience · Year 2 · from Neuroscience
Case 1: Retinal Detachment
Patient Presentation
Demographics: 58-year-old male
Chief Complaint: Sudden visual disturbance in right eye for 2 days
History of Present Illness: A 58-year-old myopic man (wears -8.00 diopter glasses) presents with visual changes in his right eye that began 2 days ago. He first noticed new floaters "like a swarm of gnats" and flashing lights in his peripheral vision. Yesterday, he developed a "curtain" or "shadow" coming down from the top of his vision in the right eye. He has progressive loss of vision in the affected eye. He denies eye pain, redness, or trauma. He had cataract surgery on the right eye 6 months ago.
Physical Examination:
- Vital signs: Normal
- Visual acuity: Right eye 20/200, Left eye 20/25 with correction
- Pupillary examination: Right relative afferent pupillary defect (RAPD)
- Intraocular pressure: Right 10 mmHg, Left 16 mmHg
- Slit lamp examination: Anterior segment unremarkable; pseudophakia (intraocular lens) in right eye
- Dilated fundoscopic examination:
- Right eye: Elevated, corrugated retina in superior and temporal quadrants with multiple horseshoe tears; macula still attached; vitreous hemorrhage
- Left eye: Peripheral lattice degeneration but flat retina
Workup:
- B-scan ultrasonography: Confirms rhegmatogenous retinal detachment in right eye with attached macula
- Optical coherence tomography (OCT): Macula attached but subretinal fluid approaching fovea
Diagnosis: Rhegmatogenous retinal detachment of the right eye (macula-on)
Treatment:
- Urgent ophthalmology/retina surgery consultation
- Pars plana vitrectomy with membrane peeling, endolaser photocoagulation, and silicone oil tamponade performed within 24 hours
- Positioning (face-down) post-operatively
- Silicone oil removal at 3 months
- Final visual acuity 20/40 in right eye
- Prophylactic laser photocoagulation to lattice degeneration in left eye
Clinical Pearl: Retinal detachment results from separation of the neurosensory retina from the underlying retinal pigment epithelium (RPE). In rhegmatogenous detachment, liquefied vitreous passes through a retinal tear into the subretinal space. High myopia is a major risk factor due to globe elongation and vitreous degeneration. The photoreceptors receive oxygen and nutrients from the RPE; prolonged detachment causes photoreceptor death. Macula-on detachments are surgical emergencies because macular detachment dramatically worsens visual prognosis. The classic symptom progression is floaters and photopsias (from vitreous traction and tear formation) followed by a progressive visual field defect (the "curtain" of detached retina).