A 35-year-old male presented with a chief complaint of blurry vision at distance and near with his current glasses. His past Ocular and systemic health were unremarkable and he was on no medications. His first and only eye examination was 2 years ago and according to the patient, that exam did not include pupil dilation. Nothing was mentioned about his ocular health at that time.

On examination today

VA with current glasses:
OD -0.25-2.00X032  VA: 20/30
OS -0.25-2.00X141  VA: 20/30

Pupils: PERRLA OU no APD

EOM: Full OU

Confrontation visual field:
OD: Full
OS: Full, yet hesitant superiorly

Subjective Refraction:
OD: PL- 4.00X042  VA 20/20
OS: PL- 4.00X132  VA 20/20

Slit lamp evaluation was unremarkable, IOP 13/12.

See fundus photos below:

At first glance, these retinas are normal. Wait, what’s going between the lashes inferiorly in the left eye?? It looks wide, there are horizontal lines and a dark retinal vessel over the affected area. (Note: Retinal vessels turn dark on Optos when the area is elevated) Oh my, I believe we are looking at a retinal detachment! This is quite surprising knowing that the patient was totally asymptomatic and had no history of trauma. On the other hand, this justifies the hesitant responses on confrontation visual field OS. See further imaging below. As you can see the inferior retina shows scattered pigmentary changes (which is indicative of chronicity) and most importantly a demarcation line with pigmentary changes as well at the superior edge of the detachment which is “protective” against further detachment. Two retinal holes were found in the far inferior periphery.

Image is fundus autofluorescence.

 

Question for you, do you think this detachment is shallow or high?

The answer is shallow, but what allows you to make this affirmation? Look at the detached area, can you still see the choroidal vasculature through the retina? That tells you the detachment is shallow.

Discussion

The literature on chronic retinal detachment (RD) is limited. One reason is there is a varied definition of the duration of chronicity. Largely, the length of RD ranging from 2 weeks to 3 months is classified as chronic. The variation in chronicity is highly significant as a prognostic factor because studies showed that the duration of detachment greater than 30 days led to decreased reattachment rates. Additionally, RD with detachment greater than 3 months only had a 57% anatomical success rate. Despite these reports of high risk of failure, some chronic RD are still repaired to preserve vision and prevent long-term complications such as hypotony, uveitis, cataract formation, strabismus, proliferative vitreoretinopathy (PVR), and phthisis bulbi (depending on the extent of the RD).

Based on literature review, chronic RD can be subdivided into two groups given their different clinical features and their different outcomes. We describe these two groups as ones without a posterior vitreous detachment (PVD) or with a PVD. More favorable outcomes are noted in the “no PVD” chronic RD that is more often seen in young patients. These patients can have a demarcation line, and often lack any symptoms. In asymptomatic cases, Brod et al. demonstrated that this risk of progression was lower than the risks associated with repair and thus could be monitored. PVD-type chronic RRD is less studied, however, and outcomes tend to be worse. The exact risk and benefit with undergoing surgical repair of these chronic cases remains unclear.

Back to our patient. This 35-year-old male presented without any symptoms and findings were incidental. On examination the detached area was almost immobile, most likely secondary to sub retinal fibrosis, a sign of chronicity. The detached area also shows a demarcation line and pigmentary changes which are also signs of chronicity and is protective against further detachment. The situation is not an emergency. The patient was seen a few days later by our retinal specialist who decided to observe it indefinitely as long as the condition remains stable and intervene surgically only if the retina detaches further.

I hope you enjoyed this case. I’ll see you next month!

 

References

1. Steel D. Retinal detachment. BMJ Clin Evid. 2014;2014:710.

2. Rowe JA, Erie JC, Baratz KH, et al. Retinal detachment in Olmsted County, Minnesota, 1976 through 1995. Ophthalmology. 1999;106:154–159. doi: 10.1016/S0161-6420(99)90018-0.

3. Sayman Muslubas I, Hocaoglu M, et al. Choroidal thickness in chronic rhegmatogenous retinal detachment before and after surgery, and comparison with acute cases. Int Ophthalmol. 2018;38:1035–1042. doi: 10.1007/s10792-017-0556-9.

4. Sahanne S, Tuuminen R, Haukka J, et al. A retrospective study comparing outcomes of primary rhegmatogenous retinal detachment repair by scleral buckling and pars plana vitrectomy in Finland. Clin Ophthalmol. 2017;11:503–509. doi: 10.2147/OPTH.S128746.

 

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Interesting Retinal Cases: Differentiating Retinal Detachment, Pigment Epithelial Detachment & Retinoschisis