References:
- Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition, ISBN 978-197-51-6103-3, by Janice L. Hinkle, Kerry H. Cheever, and Kristen J. Overbaugh (Ch. 58, [ebook] pp. 5098–5101)
The separation of the retinal pigment epithelium (RPE) from the neurosensory layer. There are four types:
- Rhegmatogenous Retinal Detachment: the most common form, where a hole or tear develops in the sensory retina, allowing liquid vitreous to seep through and detach the RPE. People at risk for this form include those with high myopia or are aphakic. Trauma may also play a role. Between 5% to 10% of this form are from proliferative retinopathy, which is associated with diabetic neovascularization.
- Traction Retinal Detachment: a tension or pulling force physically detaches the RPE from the neurosensory layer. In general, patients with this type have developed fibrous scar tissue that exert a pulling force on the delicate retina. This tissue may form in diabetic retinopathy, vitreous hemorrhage, or retinopathy of prematurity. All the scars or bands of fibrous material providing traction are released.
- Combined form of Retinal Detachment
- Exudative Retinal Detachment
Clinical Manifestations
Patients feel no pain, but RD is an ocular emergency requiring immediate surgical intervention. Patients report a sensation of a “shade” or “curtain” coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters.
Diagnostic Examination
All degenerative changes, retinal breaks, and fibrous bands that may be causing traction on the retina must be identified.
- Determine visual acuity
- Dilated fundus examination using an indirect ophthalmoscopy an d slit-lamp biomicroscopy
- Stereo fundus photography and fluorescein angiography are commonly used.
- Optical coherence tomography and ultrasound are used for complete retinal assessment, especially if the view is blocked by a dense cataract or vitreal hemorrhage.
Surgical Management
In rhegmatogenous retinal detachment, an attempt is made to surgically reattach the sensory retina to the RPE. In traction retinal detachment, an all sources of traction must be removed and the sensory retina reattached. The most common procedures include:
- Scleral Buckle: the globe is compressed with a scleral buckle or silicone band to indent the scleral wall from the outside of the eye, bringing the two retinal layers in contact with each other.
- Vitrectomy: a light source is introduced intraocularly through an incision, and a second incision allows for the vitrectomy. Traction may be relieved through vitrectomy, and may be combined with scleral buckling to repair retinal detachments. A gas bubble, silicone oil, or perfluorocarbon may be injected into the vitreous cavity to help push the sensory retina up against the RPE.
Nursing Management
Educate the patient and provide supportive care.
- Postoperatively, if a gas bubble is used, the patient is positioned prone to ensure the gas functions as a tamponade, applying consistent pressure to reattach the sensory retina. Inform the patient and family prior to procedure to ensure maximal comfort.
- Complications may include increased IOP, endophthalmitis, retinal detachment, and cataract development. Educate the patient about the signs and symptoms of these complications (esp. IOP and infection).