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Floaters: Retinal Detachment, Posterior Vitreous Detachment, or Vitreous Hemorrhage?

It may be challenging to differentiate a retinal from vitreous detachment depending on the angle of visualization. The retina will always remain attached at the optic disc because the retina is continuous with the optic sheath, whereas the vitreous body is not. In a partial detachment, the operator will see a “V” shape in the posterior segment, representing the retina attached to the optic disc posteriorly and the ora serrata anteriorly. Notably, to differentiate between a retinal and a vitreous detachment, the optic nerve must be visualized. The retina may or may not remain attached to its anterior attachment site at the ora serrata.

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  Intern Ultrasound of the Month: Retinal Detachment

POCUS findings: hyperechoic linear membrane within the vitreous body attached posteriorly near the optic nerve on the medial side of the globe; moves with kinetic exam but remains tethered (is not free floating) —> suggestive of (medial) retinal detachment

 Eye spy a detached retina

You can brace yourself by resting your pinky finger on the cheek or bridge of the nose to prevent sliding or applying pressure to the eye. Initially, you will want normal gain settings to look at the retina, optic nerve sheath and vitreous in both transverse and longitudinal planes. Make sure there is enough depth to visualize the optic nerve sheath posterior to the globe. Once you have done this, turn your gain settings up significantly to look at the vitreous body; this will highlight subtle findings, such as vitreous detachment or vitreous hemorrhage.

 Ultrasound for Retinal Detachment

Have patient close eye. Place Tegaderm over the high-frequency linear transducer. Use lots of ultrasound gel to avoid significant contact and pressure to the eye. Probe to the patient’s right side. Adjust depth to place the entire eye within view. Scan the retina in both planes. The normal retina is continuous with other structures of the posterior eye. It is thus not visibly distinct. With retinal detachment, fluid enters into the space beneath the retinal epithelium. This “detaches” the retina from the posterior structures of the eye. The retina appears as a thick and hyperechoic “wiggly line.”

Articles of Interest

Retinal Detachment

Bedside ocular ultrasound revealed a serpentine, hyperechoic membrane that appeared tethered to the optic disc posteriorly with hyperechoic material underneath. These findings are consistent with retinal detachment (RD) and associated retinal hemorrhage.

Ultrasound for Acute Retinal Detachment

Already in use for decades by ophthalmologists, ocular ultrasound is a relatively recent addition to emergency ultrasonography. Since 2002, a number of studies have demonstrated that emergency physicians using general-purpose, high-frequency transducers can accurately identify a ­variety of ocular pathologies, including retinal detachment. Bedside ultrasound is an indispensable tool for evaluating this potentially vision-threatening condition.

Acute Visual Loss in the Emergency Department: Pearls and Pitfalls

Retinal detachment can occur in the setting of trauma but is often not associated with an instigating event. Three mechanisms exist: rhegmatogenous (most common), exudative, and tractional. Sudden onset of new floaters, black dots, and flashes of light are common symptoms. Early stages may present with visual field loss, but if the macula or central retina becomes involved, visual acuity is severely affected. This is not painful. Afferent pupillary defect may be present, but no signs of red eye will be present. US will be the key to diagnosis, which will demonstrate a highly reflective, mobile undulating membrane. Treatment requires emergent ophthalmology consultation and evaluation.

Emergency management: retinal detachment

Retinal detachment is treated using surgery. The aim of surgery is to close the retinal break. This stops fluid from leaking under the retina and allows it to re-attach. This can be done either by removing the vitreous (using vitrectomy) and filling the eye with a bubble of gas that holds the retina in place, or by stitching a piece of plastic to the sclera (a scleral buckle).

Management of retinal detachment: a guide for non-ophthalmologists

Patients with retinal detachment often present to their general practitioner, emergency department, or optometrist after central vision has been compromised. This delay is unfortunate because early repair results in little or no visual loss. Once the detachment extends across the fovea (the central macula), permanent visual impairment is almost inevitable.

Minimally invasive retinal detachment treatment has better outcomes, clinical trial finds

A minimally invasive treatment for retinal detachment gives patients sharper vision, less distortion and reduced side-effects, according to the findings of a recent trial.

Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, Vitreous Detachment...

Ocular POCUS is a useful diagnostic modality for Retinal Detachment, Vitreous Detachment and Vitreous Hemorrhage. Ultrasound is the most sensitive in detecting retinal detachment, which is an ophthalmologic emergency.

Retinal Detachment

You can have flashes and floaters without retinal detachment, but you cannot have retinal detachment without flashes and floaters. Prompt ophthalmologic evaluation is therefore important to differentiate benign from pathologic. So next time you see a patient with floaters and flashes of light, be sure to ask about timing and any changes, especially in the context of vision loss. Any new flashes and floaters with vision changes should be alarming.

Retinal Detachment: From One Medical Student to Another)

In the case of rhegmatogenous retinal detachment, you may see a large bullous separation of the retina. There will always be an associated tear or hole. These are often more peripheral and may be visualized better using an indirect ophthalmoscope.

The Problem: Unilateral, painless vision changes and floaters

Ocular ultrasound is a short and sweet procedure that could change your practice and greatly benefit your patients. It can actually be used to diagnose retinal detachment, which in the past required a referral to an ophthalmologist and often led to delayed therapy.

Urgency of retinal detachment repair: is it time to re-think our priorities?

Traditionally, the timing of rhegmatogenous retinal detachment (RRD) repair has been dependent on a binary assessment—whether the macula is detached or not. The rationale for this was based on the opinion that permanent functional damage occurred once the macula had detached, and therefore surgery should be performed within 24 h for a macula-on detachment.