Changes

August 2024 — reviewed. A literature search was conducted in July 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has undergone minor restructuring, and the recommendations on the diagnosis, assessment and management of suspected retinal detachment have been updated to align with current evidence.

Update

Goals

To support primary healthcare professionals to:

• Recognize suspected retinal detachment at the earliest opportunity.
• Immediately refer people with suspected sight-threatening retinal detachment and visual loss to an ophthalmologist for specialist assessment and treatment if necessary.
• Urgently refer people with suspected retinal detachment and no visual loss or change in vision to a practitioner competent in slit lamp examination and indirect ophthalmoscopy.
• Provide advice and information on driving safety, the early warning signs of possible future retinal tear or detachment, and use of eye protection for at-risk sports.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Retinal detachment refers to the separation of the inner neurosensory retina from the underlying retinal pigment epithelium, which allows liquified vitreous fluid to accumulate in the subretinal space [Lin, 2024; BMJ Best Practice, 2024].
  • The separation results in progressive loss of vision leading to permanent visual loss in the affected eye if the detachment extends across the macula [Sultan, 2020].
• Retinal tears or breaks often precede full retinal detachment and may form due to vitreoretinal traction, causing a small, localized defect in the neurosensory retina without an extensive amount of subretinal fluid [Sharma, 2015].
  • About 50% of people with untreated symptomatic retinal breaks will progress to retinal detachment [RCOphth, 2010].
• Posterior vitreous detachment may lead to retinal detachment by causing one or more retinal tears [RCOphth, 2010]. This is when the vitreous fluid shrinks and separates from the retina as part of the normal ageing process.
  • By 80 years of age, up to 86% of people develop a partial or complete posterior vitreous detachment, compared with 10% of people less than 60 years of age [D'Amico, 2008].
  • People with symptomatic posterior vitreous detachment have a 10–15% risk of developing retinal breaks [D'Amico, 2008; Kang, 2008].
• There are three types of retinal detachment [Sultan, 2020; BMJ Best Practice, 2024; Lin, 2024]:
  • Rhegmatogenous (the commonest form) — as the vitreous shrinks and partly separates from the retinal surface, a retinal tear or break may develop. Continuing traction by the vitreous on the retinal surface allows fluid to enter the subretinal space, causing retinal detachment.
  • Exudative — this is caused by leakage of fluid into the subretinal space, often due to inflammatory conditions such as uveitis, or malignant conditions such as choroidal melanoma. Treatment of the underlying disease often results in resolution of the retinal detachment, without the need for surgery.
  • Tractional — this is most commonly seen in people with proliferative diabetic retinopathy, where abnormal vasculature causes contraction of the vitreous, which then pulls on the underlying retina. Unlike a rhegmatogenous detachment, there is no retinal break.
    • Combined rhegmatogenous and tractional detachment can develop when tractional forces cause a break in the retina.

How common is it?

Retinal detachment is one of the most common eye emergencies in the UK [Shah, 2014].

• It has an annual incidence of about 10–15 per 100,000 people [RCOphth, 2010]. This equates to an estimated 7,300 new cases in the UK each year [Mitry, 2010].
  • A study of UK hospital admission rates for retinal detachment found the annual person-based admission rate increased from 13.4 in 1999 to 15.4 in 2011, with the increase attributed to an increase in the prevalence of diabetes [Shah, 2014].
  • Rhegmatogenous retinal detachment appears to be the most common, with the incidence estimated at 1 per 10,000 people [Lin, 2024].
• The incidence of retinal detachment increases with advancing age [Haimann, 1982].
  • The lifetime risk of retinal detachment is estimated to be 3% at 85 years of age [Kang, 2008].
  • The average age of presentation is 60 years of age [Haimann, 1982].
  • Retinal detachment is unusual in younger people. The annual incidence is 2.9 per 100,000 people aged 10–19 years [Rosner, 1987].
• Men appear to be affected more often than women, with an estimated male-to-female ratio of 1.3:1 [BMJ Best Practice, 2024]. Men also men present more commonly with retinal detachment secondary to trauma [Haimann, 1982].
• Approximately 1 in 8 people with retinal detachment develop subsequent detachment in the contralateral eye [Sultan, 2020].

What are the risk factors?

Risk factors for retinal detachment vary depending on the underlying type and site of detachment and include:

• Myopia (short-sightedness) — this increases the risk of posterior vitreous detachment, and the peripheral retina may be thinned and more likely to tear.
  • Estimates have indicated up to a 10-fold increase in the risk of retinal detachment in people with myopia over three dioptres. 
• Family history of retinal break or detachment — there may be a tendency towards inherited myopia or degenerative retinal lesions.
• Previous history of retinal break or detachment in this eye or the other eye — about 1 in 8 people with retinal detachment develop subsequent detachment in the contralateral eye.
• Eye trauma (especially blunt trauma, for example, due to boxing) — there may be a latent period of several months to years before retinal detachment is detected. In older children, most cases of retinal detachment are secondary to a history of trauma.
• Previous cataract surgery — this accelerates posterior vitreous detachment.
  • Retinal detachment occurs in about 1% of people in the weeks to years after cataract surgery, almost nine times higher than expected.
  • Detachment is thought to occur as a result of post-surgical anatomical and biochemical alterations in the vitreous and most typically occurs 1.5 to 2.3 years after surgery.
  • Male sex, age <60 years and axial eye length ≥ 25 mm have been identified as the three main risk factors for retinal detachment post-cataract surgery. In a population-based cohort study, 9.46% of men younger than 60 years of age with an axial length ≥25 mm experienced retinal detachment within the follow-up period (mean 4.7 years).
  • Previous complicated cataract surgery substantially increases the risk of subsequent retinal detachment.
  • See the CKS topic on Cataracts for more information.
• Proliferative diabetic retinopathy — due to chronic traction from scars on the retinal surface.
  • See the CKS topics on Diabetes - type 1 and Diabetes - type 2 for more information.
• Inflammatory conditions (for example, uveitis and scleritis) — these may predispose to exudative retinal detachment.
  • See the CKS topic on Uveitis for more information.
• Malignancy (for example, choroidal melanoma or ocular metastasis) — predisposes to exudative retinal detachment.
• Congenital eye diseases, such as glaucoma, cataracts, or retinopathy of prematurity.
  • See the CKS topics on Glaucoma and Cataracts for more information.
• Genetic disorders such as Stickler and Marfan syndrome — characterized by defective collagen production with ophthalmologic manifestations including cataract, glaucoma, vitreous abnormalities, myopia and retinal detachment.
• Increasing age — structural changes of the vitreous gel occurs as age increases making the retina prone to traction forces which can promote retinal breaks.
• Ethnicity — Caucasian and Asian populations appear to be at higher risk.

 [Go, 2005; Bhagat, 2007]  [RCOphth, 2010; Gelston, 2013; Khan, 2013; Shah, 2014; Sultan, 2020; Thylefors, 2022; GeneReviews, 2023]

What is the prognosis?

Retinal detachment is a preventable cause of permanent visual loss, as prompt recognition and management may allow early surgical repair before the macula is detached [Sultan, 2020].

• The outcome of surgery for retinal detachment depends on the type, duration, and site of detachment — the greater the degree of macular involvement and the longer the duration of detachment, the worse the prognosis [D'Amico, 2008; Gelston, 2013].
  • It is estimated that the first surgical treatment will be successful in about 75-80% of cases of rhegmatogenous retinal detachment. The first operation also has the highest chance of success, while increased risks of post-surgical posterior vitreous detachment are associated with subsequent operations [BMJ Best Practice, 2024].
• Children tend to have a poorer prognosis in visual outcomes compared with adults. This is due to the increased risk of late detection as children are less likely to report reduced vision or visual disturbance, and different underlying disease processes [Bhagat, 2007].
• If left untreated, symptomatic retinal detachment may lead to permanent visual loss in the affected eye [BMJ Best Practice, 2024].

What are the complications?

Retinal detachment is a preventable cause of permanent vision loss.

• There is a high risk of visual impairment or complete vision loss, as retinal detachment quickly leads to degeneration of photoreceptors due to ischaemia [Pokhrel, 2007].
  • Visual loss depends on the type of retinal detachment and how quickly it is recognized and treated [BMJ Best Practice, 2024].
  • Once the detachment extends across the macula, permanent visual loss is almost inevitable, even with successful reattachment of the retina [Kang, 2008; Sultan, 2020].
  • It is likely that the prognosis worsens every day that the macula remains detached [Sultan, 2020].
• Recurrent retinal detachment may occur due to unsuccessful closure of a retinal break, the occurrence of a new break, or development of proliferative vitreoretinopathy (a scarring reaction characterized by the development of membranes on and beneath the retinal surface) [D'Amico, 2008].
• Other complications which can develop include [BMJ Best Practice, 2024]:
  • Post-operative complications of retinal detachment including endophthalmitis, proliferative vitreoretinopathy, myopia, cataract and surgical treatment failure.
  • Fellow eye detachment — about 1 in 8 people with retinal detachment develop subsequent detachment in the contralateral eye. Risk to the fellow-eye appears highest during the early postoperative period and declines thereafter [Sultan, 2020].
  • Photoreceptor damage — retinal exposure to exudate or serous fluid can be tolerated for long periods of time, however, contact with blood can inflict early and permanent damage.
  • Sympathetic ophthalmia — uveitis which develops in the fellow eye after ocular injury or surgery.

When should I suspect retinal detachment?

Suspect a diagnosis of retinal detachment if the person has:

• New onset of floaters.
  • These describe the perception of mobile dots, lines, or haze of varying translucency caused by blood, pigment cells, and inflammatory debris entering the vitreous cavity and casting shadows on the retina.
• New onset of flashes.
  • These describe the perception of light often seen as recurrent, brief flashes, caused by traction on the retina as the vitreous pulls away.
• Sudden-onset painless and usually progressive visual field loss.
  • This may be described as a dark curtain or shadow, which usually starts in the periphery and progresses towards the centre over hours, days, or weeks as the detachment extends.
  • If the macula detaches, central visual acuity may be severely reduced.
• A reduction in visual acuity, blurred or distorted vision, causing persistent and progressive visual loss.
  • Loss of central vision may suggest a major vitreous haemorrhage or macular detachment.

How should I assess a person with suspected retinal detachment?

If a person has suspected retinal detachment:

• Ask about:
  • The characteristics, duration, and laterality of any flashes or floaters — flashes may be more noticeable in dim light and are typically seen in the temporal visual field.
  • The size, shape, and distribution of any floaters — floaters may be more noticeable against a bright, uniform background, such as a computer screen or white paper.
  • The onset, nature, and duration of any change in vision — a loss of peripheral visual field may be less commonly noticed than central visual acuity deterioration. Where noticed, a loss of peripheral visual field may be described as a dark veil, cloud, or curtain that suddenly impairs vision.
  • Any personal or family history of retinal break or retinal detachment.
  • Any other risk factors for retinal detachment, including co-morbidities (such as diabetes, previous cataract or any other eye surgery, intraocular tumour or age-related macular degeneration) and any history of eye trauma.
• Examine for:
  • Reduced visual acuity using a Snellen chart — vision may be reduced to finger counting or hand movements if the macula is detached.
  • Peripheral visual field loss by performing confrontational field testing.
  • A relative afferent pupillary defect if there is extensive detachment — using the swinging flashlight test, the pupil dilates rather than constricts or stays the same size when light is shone on it, suggesting optic nerve disease.
  • Fundoscopic findings of an asymmetric red reflex, vitreous opacities, or detached retinal folds, which appear pale, opaque, and wrinkled in larger detachments. Note that no fundoscopic abnormality may be seen if the detachment is small.
  • Note: Given the high risk of retinal detachment in the other eye, both eyes should be evaluated to determine whether visual defects are present in both or just one eye.

What else might it be?

• Alternative causes of flashes include:
  • Posterior vitreous detachment (a simple collapse of the vitreous gel, which increases the risk of developing retinal tears; may be part of the normal ageing process).
  • Migraine (visual aura may precede the headache; typically bright zigzag lines or spots with associated flashing coloured light sensations, occurring in the visual field of one or both eyes simultaneously and persisting for minutes or hours at a time). See the CKS topic on Migraine for more information.
  • Postural hypotension (typically presents with dizziness, lightheadedness, and blurred vision). See the CKS topic on Blackouts for more information.
  • Optic nerve pathology, such as optic neuritis (may present with gradual visual loss, often starting in the periphery, associated with flashes).
  • Transient ischaemic attack (amaurosis fugax presenting as transient visual loss like a curtain falling across the vision, and usually resolving within seconds to minutes). See the CKS topic on Stroke and TIA for more information.
  • Choroidal tumours (rare; may cause spots of light travelling across the visual field and floaters).
  • Drugs such as chloroquine.
• Alternative causes of floaters include:
  • Posterior vitreous detachment (a simple collapse of the vitreous gel, which increases the risk of developing retinal tears; may be part of the normal ageing process).
  • Myopia (short-sightedness).
  • Vitreous haemorrhage (describes the leakage of blood or blood products from a retinal vessel around and into the vitreous gel, for example, due to diabetic retinopathy or trauma).
  • Uveitis (especially posterior; typically causes visual loss, photophobia, and floaters). See the CKS topic on Uveitis for more information.

Scenario: Management of suspected retinal detachment

From age 10 years onwards.

Search strategy

Scope of search

A literature search was conducted for guideline and systematic reviews on primary care management of retinal detachment.

Search dates

July 2019 - July 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 24th July 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S4    S1 OR S2 OR S3 
S3    AB ( (flash* AND floater* ) OR TI ( (flash* AND floater* ) 
S2    AB retina* N2 detach* OR TI retina* N2 detach* 
S1    (MH "Retinal Detachment") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
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• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
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  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
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Competing interests declared for this topic:

None.