Retinal tear and rhegmatogenous detachment

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

The neurosensory retina normally lies against the retinal pigment epithelium, which supports its metabolic environment. A retinal break creates an opening through which liquefied vitreous can pass, separating these layers. The word rhegmatogenous identifies this break-related mechanism. A tear is not itself synonymous with an established detachment: some breaks remain local, while others allow progressive subretinal fluid. This distinction explains why timely treatment of an appropriate tear can prevent a larger problem and why examination must establish both the break and the extent of any fluid.

Symptoms often begin during vitreous separation, when traction produces brief flashes and new vitreous opacities. A patient may then notice an area of missing vision that remains fixed or spreads. Ask whether central tasks such as reading have changed, but do not wait for central impairment before arranging urgent care. A detachment can be peripheral while the macula remains attached and acuity appears excellent. Conversely, central blur does not allow a community examiner to date macular separation reliably or declare the opportunity for useful treatment lost.

The retinal team determines the location and number of breaks, the area detached, macular status, lens status and any scarring or associated pathology. These findings guide laser, cryotherapy, vitrectomy, scleral buckling or a selected gas-based repair. The aim is to close the route for fluid, relieve relevant traction and support retinal attachment while a durable seal forms. Anatomical success and final visual function are related but different outcomes: an attached retina can still have reduced function after macular injury or other complications.

Key points

Rhegmatogenous detachment requires a full-thickness retinal break through which fluid reaches the subretinal space.
Vitreous traction commonly contributes to tearing; myopia, previous ocular surgery and trauma are relevant risk factors.
The presentation is usually painless, with photopsia, new floaters and a fixed or enlarging field shadow.
Macula-on and macula-off describe whether the central retina is still attached, not whether referral is necessary.
Selected retinal tears can be treated with laser retinopexy or cryotherapy, while established detachment commonly requires surgery.
After gas tamponade, avoid flying and nitrous oxide exposure until the gas has fully disappeared and the retinal team has confirmed the relevant precautions.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Vitreous traction and retinal breaks

Evolving posterior vitreous separation can exert focal traction and tear the retina. A pre-existing peripheral lesion may also provide a route for fluid to pass beneath the retinal tissue.

Ocular predisposition

Myopia, previous cataract or retinal surgery and trauma can increase susceptibility. Fellow-eye detachment or a relevant family history provides additional context for assessing a new episode.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Fluid entry through a break
Liquefied vitreous enters the space beneath the neurosensory retina through a full-thickness retinal defect. Continued fluid movement can enlarge the detached area beyond the original lesion.
2
Loss of retinal support
Separation disrupts the relationship between photoreceptors and the supporting retinal pigment epithelium. Function deteriorates within the detached region, producing a fixed visual-field deficit.
3
Central retinal involvement
When separation extends to the macula, central detailed vision is affected. The extent and duration of injury influence how much function returns after anatomical reattachment.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Progressive peripheral shadow

A curtain or dark sector that persists in the same part of the visual field is concerning for retinal detachment. The eye may remain white and comfortable despite substantial retinal separation.

Acuity and macular status

Central acuity can remain normal in a macula-on detachment. New central loss suggests macular involvement or another complication, but the exact anatomy requires retinal examination and sometimes OCT.

Break-associated vitreous findings

Pigment cells, a new vitreous bleed or a symptomatic tear increases concern for active vitreoretinal injury. Absence of a visible tear in a limited view is insufficient reassurance.

Higher-risk ocular history

Previous detachment or tear, long axial length, high myopia, cataract surgery and trauma influence suspicion. A dangerous traumatic mechanism also requires assessment for an open globe before pressure-based examination.

Red flags requiring action

A progressive curtain or missing field following flashes or floaters requires emergency same-day retinal assessment.
Preserved central acuity with a new peripheral shadow may represent a macula-on detachment and increases the importance of rapid referral.
A symptomatic retinal tear, anterior vitreous pigment or vitreous haemorrhage warrants emergency referral even before a detachment is visible.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Acuity, pupils and visual fieldsFirst step
Why
Document function and establish information needed for urgent handover.
Interpretation and limitations
Describe central and peripheral deficits separately. Preserved acuity does not downgrade a suspected macula-on detachment, and severe loss should not be assumed irreversible without assessment.
02
Dilated indirect retinal examination
Why
Identify breaks, determine detachment extent and evaluate the fellow eye.
Interpretation and limitations
The examiner maps retinal findings and macular involvement using appropriate peripheral techniques. Multiple breaks may be present, so identifying one lesion does not end the examination.
03
Macular optical coherence tomography when useful
Why
Clarify central retinal attachment and associated macular pathology.
Interpretation and limitations
OCT can resolve subtle macular fluid when the view permits. It should answer a focused question without delaying urgent retinal-team decisions or replacing the peripheral examination.
04
Ophthalmic B-scan for an obscured fundus
Why
Assess retinal attachment when blood or other media opacity prevents direct inspection.
Interpretation and limitations
The specialist interprets the scan alongside the history and examination, recognising limitations for small peripheral breaks. Avoid pressure-based ocular ultrasound when globe rupture is suspected.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Uncomplicated PVD

Vitreous separation can produce flashes and floaters while the retina remains attached. A fixed field defect, blood or pigment requires reassessment for a retinal complication.

Tractional retinal detachment

Contractile membranes can lift the retina, particularly in proliferative diabetic retinopathy. A break is not required, although tractional and break-related mechanisms may coexist.

Exudative retinal detachment

Subretinal fluid can accumulate from vascular leakage, inflammation or a mass without a retinal break. The underlying cause changes treatment and must be established by specialist assessment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Suspected detachmentSecure emergency retinal assessmentFirst stepA new fixed shadow, visual decline or examination finding suggests retinal separation.

1Contact the receiving retinal service immediately, communicating onset, field change, acuity and whether central vision remains intact.
2Provide the relevant history of trauma, prior surgery, fellow-eye disease and antithrombotic medicines, and arrange safe transport.
3Follow the retinal team's instructions about fasting, activity and any preoperative positioning; do not invent a universal head position or delay referral for routine investigations.

02Retinal break without established detachmentAssess the need for preventive retinopexyExamination identifies a tear or hole and determines its symptoms and surrounding retinal status.

1Arrange urgent retinal review for an acute symptomatic break, particularly with persistent traction, pigment or haemorrhage.
2Explain that laser or cryotherapy can create adhesion around an appropriate lesion, with the treatment selected from the lesion's features.
3Ensure follow-up and warning advice continue after treatment because another break or a new detachment may still occur.

03Established detachmentRepair the retina and plan recoveryThe retinal surgeon confirms detachment requiring an operative approach.

1Discuss the planned repair, anticipated visual benefit and the possibility of further procedures, taking macular status and scarring into account.
2Before discharge, confirm the tamponade material, exact posturing instruction, eye-drop schedule, review appointment and emergency contact.
3Explain gas-related travel and anaesthetic restrictions clearly, and ask the patient to seek urgent help for increasing pain, worsening vision or another curtain.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Persistent visual impairment

Macular injury, photoreceptor dysfunction or associated disease may limit visual recovery despite successful reattachment. Counselling should distinguish restoring anatomy from guaranteeing full visual function.

Recurrent detachment

An untreated or new break, persistent traction or contractile scarring can cause further separation. A recurrent curtain or new visual decline requires urgent examination.

Treatment-related ocular problems

Surgery can be complicated by pressure disturbance, infection, bleeding, cataract or altered refraction. The follow-up plan monitors these alongside the state of retinal attachment.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Retinal follow-up assesses anatomical attachment, healing around breaks, pressure, inflammation and visual recovery, with timing set by the operative findings.
Record whether gas, air or silicone oil was used; the patient's restrictions depend on the material and whether any gas remains.
Check that the patient can follow the specified posture and administer the actual prescribed drops, seeking early support when neck disease, disability or limited help makes this difficult.
New flashes, a shower of floaters or a recurrent field shadow in either eye requires urgent review even after apparently successful treatment.
Evaluate persistent visual impairment after anatomical repair and offer refraction, low-vision support or other rehabilitation when recovery has stabilised sufficiently for assessment.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Macula-off still needs urgent care

Loss of central attachment affects prognosis but is not a reason to abandon or routinely defer assessment. The retinal surgeon considers duration, extent and other findings when selecting the operative timing.

A tear is a treatment opportunity

An acute symptomatic break may be amenable to retinopexy before fluid spreads. The presence of a hole alone does not establish the same risk as an actively tractional symptomatic tear.

Scarring can complicate reattachment

Proliferative vitreoretinopathy involves contractile membranes that can distort the retina and contribute to recurrent detachment. This may require a more complex repair than closing the original break alone.

Travel advice follows residual gas

A calendar estimate of gas absorption cannot substitute for the retinal team's advice. Even a remaining small bubble matters for air travel, altitude exposure and nitrous oxide used for analgesia or anaesthesia.

11Common pitfallsFrequent interpretation and management errors.

01
Waiting for central visual loss before referring a patient whose peripheral curtain may spare the macula.
02
Assuming every visible retinal hole needs the same intervention without considering symptoms, traction and surrounding fluid.
03
Describing successful anatomical surgery as a guarantee that the patient's original visual acuity will return.
04
Allowing discharge without establishing whether gas remains and without communicating the posturing and urgent-return instructions.