Retinal Detachment
Types, Pathogenesis, Symptoms and Clinical Signs
Understand the three principal types of retinal detachment, then follow the clinical pathway from posterior vitreous detachment and retinal tear to rhegmatogenous retinal detachment.
Retinal Detachment
This companion note follows the lecture’s clinical sequence while refining selected terminology and examination points.
What Is Retinal Detachment?
The retina is traditionally described as having ten histological layers. The outermost layer is the retinal pigment epithelium (RPE), while the inner nine layers together form the neurosensory retina.
These layers normally remain closely apposed, but a potential space exists between the photoreceptor outer segments and the RPE. Retinal detachment occurs when the neurosensory retina separates from the underlying RPE and fluid accumulates in this subretinal space. [1]
Three Types of Retinal Detachment
Retinal detachment is classified according to the mechanism by which the neurosensory retina separates from the retinal pigment epithelium. [1]
| Type | Basic mechanism | Common clinical settings |
|---|---|---|
| Rhegmatogenous | Liquefied vitreous passes through a full-thickness retinal break and enters the subretinal space. | Posterior vitreous detachment, myopia, pseudophakia and ocular trauma. |
| Tractional | Contracting fibrous or fibrovascular tissue mechanically pulls the retina away from the RPE. | Proliferative diabetic retinopathy and sickle-cell retinopathy. |
| Exudative or serous | Subretinal fluid accumulates without a retinal break or significant traction. | Inflammatory disease, choroidal tumours and severe hypertensive choroidopathy. [6] |
Rhegmatogenous
- Basic mechanism
- Liquefied vitreous passes through a full-thickness retinal break and enters the subretinal space.
- Common clinical settings
- Posterior vitreous detachment, myopia, pseudophakia and ocular trauma.
Tractional
- Basic mechanism
- Contracting fibrous or fibrovascular tissue mechanically pulls the retina away from the RPE.
- Common clinical settings
- Proliferative diabetic retinopathy and sickle-cell retinopathy.
Exudative or serous
- Basic mechanism
- Subretinal fluid accumulates without a retinal break or significant traction.
- Common clinical settings
- Inflammatory disease, choroidal tumours and severe hypertensive choroidopathy. [6]
Rhegmatogenous Retinal Detachment
The word rhegmatogenous is derived from rhegma, meaning a break or rent.
A rhegmatogenous retinal detachment (RRD) develops when liquefied vitreous passes through a full-thickness retinal break and enters the subretinal space, separating the neurosensory retina from the retinal pigment epithelium. [1] [3]
A full-thickness retinal break
The break creates a pathway between the vitreous cavity and the potential subretinal space.
Liquefied vitreous
Fluid vitreous must be able to reach and pass through the retinal break.
Loss of retinal–RPE apposition
Vitreoretinal traction and fluid movement allow subretinal fluid to accumulate and extend beneath the retina.
The defining feature of RRD is a full-thickness retinal break. Without a break, the detachment is not primarily rhegmatogenous.
Retinal Breaks Associated with RRD
A retinal break may result from acute vitreoretinal traction or from local retinal thinning. The risk of progression to retinal detachment differs according to the type of break. [2] [7]
Horseshoe or flap tear
- Mechanism: posterior vitreous pulls on persistent vitreoretinal adhesion.
- Shape: U-shaped or horseshoe-shaped retinal flap.
- Key point: the apex remains attached to the vitreous, so traction may continue.
- Clinical significance: a fresh symptomatic horseshoe tear is an important precursor of rhegmatogenous retinal detachment.
Operculated retinal hole
- Mechanism: a piece of avulsed retina separates from the break margin.
- Operculum: the avulsed retinal tissue remains attached to the vitreous.
- Clinical significance: once traction has been released, the risk of detachment is generally lower than with a horseshoe tear.
Atrophic round hole
- Mechanism: develops because of local retinal thinning rather than acute vitreoretinal traction.
- Association: may occur within lattice degeneration.
- Clinical significance: most atrophic holes do not cause retinal detachment, although slowly progressive RRD may occur in selected eyes.
Giant retinal tear
- Definition: a full-thickness circumferential retinal break.
- Extent: extends through at least 90°, or three clock hours, of the retina.
Retinal dialysis
- Definition: circumferential separation of the retina at the ora serrata.
- Association: particularly associated with blunt ocular trauma, although spontaneous cases also occur.
Risk Factors for Rhegmatogenous Retinal Detachment
Conditions that promote vitreous liquefaction, posterior vitreous detachment, firm vitreoretinal adhesion or peripheral retinal weakness increase the risk of RRD. [1] [2] [7]
Vitreous and Age-Related Factors
earlier or acute PVD- Increasing age: vitreous liquefaction and posterior vitreous separation become more common.
- Acute posterior vitreous detachment: traction at persistent vitreoretinal adhesions may produce a retinal tear.
- Vitreous degeneration: liquefied vitreous can pass through a full-thickness retinal break.
Ocular Risk Factors
retinal weakness- Axial myopia: associated with peripheral retinal thinning, earlier vitreous liquefaction and earlier PVD.
- Lattice degeneration: may contain retinal holes and areas of abnormal vitreoretinal adhesion.
- Aphakia or pseudophakia: associated with an increased long-term risk of retinal tear and RRD.
- Previous intraocular surgery: may alter vitreous structure and accelerate posterior vitreous separation.
- Previous retinal tear or detachment: indicates an eye already predisposed to vitreoretinal pathology.
- Retinal detachment in the fellow eye: increases concern for similar predisposing changes in the other eye.
Mechanical and Inherited Factors
traction or structural risk- Ocular trauma: may produce horseshoe tears, giant retinal tears or retinal dialysis.
- Family history: may indicate a shared anatomical or inherited predisposition.
- Inherited vitreoretinal disorders: abnormal vitreous and peripheral retinal development can markedly increase detachment risk.
From Vitreous Degeneration
to RRD
Age-related vitreous change creates the conditions for posterior vitreous separation. A retinal tear develops when the separating vitreous remains firmly attached to a focal area of retina. [3]
SYNCHYSIS
Liquefaction of the vitreous gel, producing enlarging pockets of fluid vitreous.
SYNERESIS
Collapse and condensation of the remaining vitreous gel.
VITREOUS LIQUEFACTION
Small pockets of fluid vitreous enlarge and merge within the vitreous gel.
POSTERIOR VITREOUS SEPARATION
The collapsing posterior vitreous cortex begins separating from the retinal surface.
PERSISTENT VITREORETINAL ADHESION
Separation is resisted where the vitreous remains firmly attached to the retina.
FOCAL VITREORETINAL TRACTION
tear may form hereContinued traction pulls on the adherent retina during posterior vitreous separation.
FULL-THICKNESS RETINAL TEAR
The tear creates a pathway between the vitreous cavity and the potential subretinal space.
FLUID PASSES THROUGH THE BREAK
Liquefied vitreous passes through the tear and accumulates beneath the neurosensory retina.
RHEGMATOGENOUS RETINAL DETACHMENT
Progressive subretinal fluid separates the neurosensory retina from the retinal pigment epithelium.
Posterior Vitreous Detachment
A posterior vitreous detachment (PVD) is the separation of the posterior vitreous cortex, or posterior hyaloid, from the internal limiting membrane of the retina. [2]
PVD usually begins around the macula and progresses across the posterior pole towards the optic disc. The OCT-based Uchino classification describes this progression in four stages. [5]
EARLY PERIFOVEAL SEPARATION
fovea still attached- Incomplete perifoveal PVD in up to three quadrants.
- Vitreous remains attached at the fovea and optic disc.
PERIFOVEAL SEPARATION IN ALL QUADRANTS
fovea + disc attached- Perifoveal vitreous separation extends through all quadrants.
- Attachment persists at both the fovea and optic disc.
NEAR-COMPLETE PVD
disc attachment remains- The vitreous has separated over the posterior pole.
- Residual attachment remains at the optic disc.
COMPLETE PVD
disc attachment released- The posterior vitreous separates from the optic disc.
- Peripapillary glial tissue may become visible clinically as a Weiss ring.
Weiss Ring
The posterior vitreous is firmly attached around the optic disc margin. When this peripapillary attachment releases during posterior vitreous detachment, a Weiss ring may become visible. [2]
FORMATION
peripapillary release- The posterior vitreous separates from its attachment around the optic disc.
- Peripapillary glial tissue may remain attached to the posterior vitreous cortex.
CLINICAL APPEARANCE
circular or incomplete- Appears as a circular, oval or incomplete ring floating anterior to the optic disc.
- It may move with changes in eye position.
INTERPRETATION
clue—not reassurance- Supports release of the peripapillary vitreous attachment.
- Does not prove that the vitreous has separated completely from the peripheral retina.
- Does not exclude an associated retinal tear.
Symptoms of Retinal Detachment
Retinal detachment is usually painless. Symptoms may begin during acute posterior vitreous detachment and progress as subretinal fluid extends. [1] [2]
FLOATERS
moving shadows- Perceived as spots, lines, cobwebs, insects or rings moving through the visual field.
- May arise from condensed vitreous collagen, a Weiss ring, retinal pigment or vitreous haemorrhage.
- A sudden shower of new floaters may indicate an acute PVD with a retinal tear.
PHOTOPSIAS
flashes of light- Brief flashes caused by mechanical vitreoretinal traction.
- Often noticed in the peripheral visual field, particularly in dim illumination or during eye movement.
- May precede the formation of a retinal tear or retinal detachment.
In a large prospective study, approximately one in ten patients presenting with symptomatic PVD had a retinal tear or rhegmatogenous retinal detachment at the initial examination. [4]
VISUAL-FIELD LOSS
The perceived visual-field defect lies opposite the anatomical location of the detached retina.
- A dark shadow, veil or curtain appears in the peripheral visual field.
- The defect enlarges as the retinal detachment progresses.
- Central acuity may remain relatively preserved while the macula remains attached.
- Marked central visual loss develops when subretinal fluid reaches the fovea.
| Retinal detachment | Visual-field defect |
|---|---|
| Superior retina | Inferior field |
| Inferior retina | Superior field |
| Temporal retina | Nasal field |
| Nasal retina | Temporal field |
Example: A superotemporal retinal detachment produces an inferonasal visual-field defect.
Clinical Examination
The external eye may appear normal in uncomplicated retinal detachment. Examination should therefore proceed systematically, with particular attention to the anterior vitreous and peripheral retina. [1] [2]
VISUAL ACUITY
check macular status- Central acuity may remain relatively preserved while the macula is attached.
- Vision usually falls when subretinal fluid reaches the fovea.
PUPILLARY EXAMINATION
RAPD if extensive- A relative afferent pupillary defect may be present in an extensive retinal detachment.
- It is not expected in every case.
INTRAOCULAR PRESSURE
often mildly lower- Intraocular pressure may be lower in the affected eye.
- Normal pressure does not exclude retinal detachment.
RED REFLEX
nonspecific clue- A large elevated detachment may produce a grey or altered reflex in the involved quadrant.
- This finding is nonspecific and may also result from corneal, lenticular or vitreous opacity.
ANTERIOR VITREOUS EXAMINATION
look for pigment or blood- Examine for retinal pigment granules.
- Look for red blood cells or vitreous haemorrhage.
DILATED FUNDUS EXAMINATION
identify every break- Perform binocular indirect ophthalmoscopy.
- Use scleral indentation to examine the retina up to the ora serrata.
- Document the extent of detachment and whether the macula is attached.
- Identify the number, type and location of retinal breaks.
- Look for lattice degeneration, chronicity and proliferative vitreoretinopathy.
- Examine the fellow eye. [2] [7]
Why Scleral Indentation Matters
Retinal breaks may lie very anteriorly, close to the ora serrata, and can be missed when only the posterior retina is examined. Scleral indentation brings the peripheral retina into view during binocular indirect ophthalmoscopy. [2]
EXTENDS THE EXAMINATION
up to the ora serrata- Brings the far peripheral retina into the examiner’s field of view.
- Allows systematic examination of each retinal quadrant.
IMPROVES BREAK DETECTION
small tears may hide anteriorly- Helps identify small horseshoe tears and anterior retinal holes.
- Is particularly important when examining for retinal dialysis or breaks near the vitreous base.
- In a prospective symptomatic-PVD study, some retinal tears were detected only with indented indirect ophthalmoscopy. [4]
REVEALS VITREORETINAL TRACTION
dynamic examination- Elevation of the peripheral retina makes the break margin easier to recognise.
- Movement of the retina during indentation can help demonstrate persistent vitreoretinal traction.
Fresh versus Old Retinal Detachment
The appearance of a retinal detachment changes with duration. A fresh detachment is usually elevated and mobile, while a longstanding detachment becomes thinner, less mobile and increasingly fixed. [1] [7]
Fresh Retinal Detachment
- Colour: grey or opaque compared with the normal orange-red fundus.
- Elevation: retina is raised anteriorly from the retinal pigment epithelium.
- Surface: corrugated and thrown into folds.
- Mobility: undulates with eye movement.
- Retinal vessels: appear dark and pass over the elevated retinal surface.
- Bullous RD: a markedly elevated detachment may develop a balloon-like configuration.
Old Retinal Detachment
- Retinal thickness: detached retina becomes thin and atrophic.
- Mobility: reduced undulation with a more fixed appearance.
- Pigmentary change: chronic alterations may develop within and around the detached retina.
- Demarcation line: RPE proliferation may form a subretinal line at the junction of attached and detached retina.
- Intraretinal cysts: may develop in longstanding detachments.
- PVR: fixed retinal folds may indicate proliferative vitreoretinopathy.
When the Fundus Cannot Be Seen
When media opacity prevents direct retinal examination, B-scan ultrasonography can confirm the presence and configuration of a retinal detachment. [1] [7]
WHEN IS B-SCAN NEEDED?
A complete retinal detachment appears as a highly reflective membranous echo attached posteriorly at the optic disc and extending anteriorly towards the ora serrata.
Important: Ultrasonography does not replace a detailed dilated peripheral retinal examination when the fundus view is adequate.
Proliferative Vitreoretinopathy
Proliferative vitreoretinopathy (PVR) is an abnormal scarring response that may develop after retinal detachment or retinal detachment surgery. Contractile fibrocellular membranes distort and shorten the retina, making reattachment more difficult. [8]
CELL DISPERSION
Retinal breaks and tissue disruption allow cells to enter the vitreous cavity and subretinal space.
MEMBRANE FORMATION
Cells proliferate on the retinal surfaces, within the retina and along the posterior vitreous.
CONTRACTION
Fibrocellular membranes contract, producing retinal shortening, distortion and fixed folds.
Fine surface distortion may progress to fixed retinal folds.
The detached retina becomes stiff rather than freely undulating.
Contraction prevents the retina from lying flat against the RPE.
Traction may prevent closure of an existing retinal tear.
Continued traction may maintain the detachment or cause it to return after surgery.
CLINICAL CLUES
- Reduced mobility of the detached retina
- Retinal surface wrinkling
- Rolled or irregular edges of a retinal tear
- Fixed full-thickness retinal folds
PVR converts a mobile retinal detachment into a contracted, mechanically shortened retina.
Classification of PVR
Proliferative vitreoretinopathy is graded according to the severity and anatomical distribution of retinal surface contraction. [9] [10]
EARLY CELLULAR ACTIVITY
- Vitreous haze
- Pigment clumps within the vitreous
RETINAL SURFACE WRINKLING
- Wrinkling of the inner retinal surface
- Increased retinal vessel tortuosity
- Reduced mobility of the detached retina
- Rolled or irregular edges of retinal tears
FIXED FULL-THICKNESS FOLDS
- Full-thickness retinal folds
- Fixed retinal contraction
- Progressive shortening and distortion of the retina
How Grade C Is Recorded
Grade C is further described by the location and circumferential extent of the fixed folds. [9]
Fixed folds located posterior to the equator.
Fixed folds located anterior to the equator.
For example, CP3 means posterior Grade C PVR extending over three clock hours.
Funnel Retinal Detachment
A funnel configuration develops when severe vitreoretinal contraction draws the detached retina centrally. It describes the shape of an advanced detachment, not a separate primary type of retinal detachment. [8] [9]
Open Funnel
The detached retina is drawn centrally, but the anterior and posterior openings of the funnel remain relatively wide.
Closed Funnel
Marked retinal shortening narrows or closes the funnel, producing a tightly contracted and relatively immobile retinal configuration.
A progressively narrowing funnel suggests increasing traction and advanced proliferative vitreoretinopathy. The retina becomes more difficult to flatten because it is mechanically shortened rather than simply displaced by subretinal fluid.
Complications of Retinal Detachment
The final visual outcome depends on the duration and extent of retinal separation, macular involvement, proliferative vitreoretinopathy and the success of retinal reattachment. [1] [7]
Prolonged separation from the retinal pigment epithelium disrupts photoreceptor metabolism and may cause irreversible photoreceptor damage, particularly when the macula is detached.
Retinal Detachment: Rapid Review
Retinal detachment is best understood by linking its mechanism, symptoms and examination findings.
Recognise the symptoms → search for the retinal break → define macular status, chronicity and PVR.
References
Clinical sources used to develop and verify this companion note.
- Lin JB, Narayanan R, Philippakis E, et al. Retinal detachment. Nature Reviews Disease Primers. 2024;10:18. doi:10.1038/s41572-024-00501-5
- Kim SJ, Bailey ST, Kovach JL, et al. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Preferred Practice Pattern®. Ophthalmology. 2025;132(4):P163–P196. doi:10.1016/j.ophtha.2024.12.023
- Mitry D, Fleck BW, Wright AF, Campbell H, Charteris DG. Pathogenesis of rhegmatogenous retinal detachment: predisposing anatomy and cell biology. Retina. 2010;30(10):1561–1572. doi:10.1097/IAE.0b013e3181f669e6
- Nixon TRW, Davie RL, Snead MP. Posterior vitreous detachment and retinal tear: a prospective study of community referrals. Eye. 2024;38:786–791. doi:10.1038/s41433-023-02779-3
- Uchino E, Uemura A, Ohba N. Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Archives of Ophthalmology. 2001;119(10):1475–1479. doi:10.1001/archopht.119.10.1475
- Amer R, Nalcı H, Yalçındağ N. Exudative retinal detachment. Survey of Ophthalmology. 2017;62(6):723–769. doi:10.1016/j.survophthal.2017.05.001
- Sultan ZN, Agorogiannis EI, Iannetta D, Steel D, Sandinha T. Rhegmatogenous retinal detachment: a review of current practice in diagnosis and management. BMJ Open Ophthalmology. 2020;5(1):e000474. doi:10.1136/bmjophth-2020-000474
- Idrees S, Sridhar J, Kuriyan AE. Proliferative vitreoretinopathy: a review. International Ophthalmology Clinics. 2019;59(1):221–240. doi:10.1097/IIO.0000000000000258
- Machemer R, Aaberg TM, Freeman HM, Irvine AR, Lean JS, Michels RM. An updated classification of retinal detachment with proliferative vitreoretinopathy. American Journal of Ophthalmology. 1991;112(2):159–165. doi:10.1016/S0002-9394(14)76695-4
- Hilton G, Machemer R, Michels R, Okun E, Schepens C, Schwartz A; Retina Society Terminology Committee. The classification of retinal detachment with proliferative vitreoretinopathy. Ophthalmology. 1983;90(2):121–125. doi:10.1016/S0161-6420(83)34588-7
