4/2/06njm

**Q. How do you manage retinal detachment in pregnancy?**

A. Management depends on which of the types of retinal detachment. See
details

I saw a patient in the clinic this morning that was referred at about 37
weeks of her first pregnancy with a several month history of progressive
blurred vision in her right eye. When she finally ended up seeing an
ophthalmologist yesterday he diagnosed a retinal tear (detachment) in
her right eye.

The ophthalmologist feels that there is no urgent treatment required.
She is otherwise well and has normal blood pressure. I tried to find
information about this but could not find much related to the
obstetrical part of the management: i. e., elective vaginal delivery
with early epidural and shortened second stage of labor and assisted
delivery (no or minimal pushing) or cesarean delivery. Any other
recommendations?

**Briefly:**

The obstetric management often depends on the type of the lesion, but is
most often expectant.

Here is a quote from one of the only review articles on the subject
([Elsherbiny
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Elsherbiny+SM"%5BAuthor%5D)
et al)

"...no evidence to support a causative link between labour and
rhegmatogenous (versus serous) retinal detachment, even in eyes
predisposed to that condition..."

A passive second stage is a reasonable choice, if the extent of the
disease is unknown. A cesarean delivery would depend on the extent and
the unstable nature of the retinal lesion, but cesarean may be
completely unnecessary if the ophthalmologist is otherwise recommending
only expectant therapy.

**NB:**

One should also consider other diagnoses if the patient with new onset
of visual symptoms, e.g., pre-eclampsia.

Less common in late pregnancy would be

-Vitreous hemorrhage

-Vitreous inflammation (eg, Toxoplasma chorioretinitis)

-Ocular lymphoma

-Intraocular foreign body

Retinal detachments can be rhegmatogenous (caused by a break in the
retina, rhegma is Greek for tear) or serous (caused by leakage or
exudation from beneath the retina or vitreous traction on the retina in
the absence of a retinal tear).

**OPHTHALMOLOGIC SUMMARY AND RECOMMENDATIONS**

**Course, definitions, and pathophysiology**

-Without treatment, most symptomatic retinal detachments will progress
and result in a complete loss of vision

-Retinal detachments are classified as \"rhegmatogenous\" if they are
the result of a full thickness retinal hole or retinal tear and as
\"nonrhegmatogenous\" otherwise

-Rhegmatogenous detachments are most common and they are most commonly a
consequence of posterior vitreous detachment (PVD), a normal event in
people between the ages of 50 and 75. In some patients, areas of
adhesion during PVD can pull on the retina and cause a tear.

-Rhegmatogenous detachments can also occur after ocular trauma

-Nonrhegmatogenous detachments can occur in patients with proliferative
diabetic retinopathy, retinal neovascularization, trauma, and in other
settings

**Risk factors and clinical presentation**

-Risk factors for rhegmatogenous detachments include myopia and a focal
thinning of the periphery of the retinal called lattice degeneration.
Asymptomatic retinal breaks do not typically progress to retinal
detachment

-Patients with a symptomatic PVD who develop a full-thickness retinal
tear are at high risk for retinal detachment. The most common symptom of
PVD is an increasing number of floaters in one eye. Flashes of light
(photopsias) are also common during PVD, and if a small retinal vessel
is torn the patient may note a shower of black spots or a marked
decrease in vision

-Patients with retinal detachment (due to PVD or other etiologies) will
typically note a peripheral visual field defect

**Diagnosis and management**

-Patients with symptoms of a PVD should be quickly examined by an
ophthalmologist to exclude a retinal tear or detachment. Patients with a
new and progressive visual field defect suggestive of a retinal
detachment require urgent evaluation

-In the absence of retinal breaks or tears, most patients with PVD
require no specific treatment but should be reexamined by an
ophthalmologist in three months (or somewhat sooner in patients with
photopsias or evidence of retinal bleeding)

-Patients with a retinal hole or tear in the presence of a symptomatic
PVD should generally be treated by an ophthalmologist with laser
photocoagulation or cryoretinopexy to prevent retinal detachment

-Patients with a retinal detachment will generally be treated with one
or more of the following procedures: pneumatic retinopexy; scleral
buckle; vitrectomy. Patients with small peripheral retinal detachments
may be treated with barrier procedures such as laser photocoagulation.
Some patients with asymptomatic rhegmatogenous retinal detachments may
be closely monitored without therapy or treated with barrier procedures

**PREVENTION** --- It is impossible to prevent a spontaneous PVD. A
major limitation of prophylactic therapy is that most retinal
detachments are due to retinal tears that develop in areas of the retina
that appear normal prior to vitreous detachment. Thus treatment of
visible lesions associated with retinal detachment may prevent a tear at
those sites, but not a tear in normal appearing retina. A systematic
review of studies involving patients with asymptomatic vitreoretinal
abnormalities found no trials that met their inclusion criteria and thus
no conclusions could be made about prophylactic therapy in this setting.

In the absence of definitive data, the most important aspect of
prevention is education of the patient about the symptoms of retinal
tear or retinal detachment. Early identification of retinal tears and
rapid treatment of this problem usually results in the prevention of a
retinal detachment and significant loss of vision.

**Summary**

1.) It is of utmost importance that any patient with the symptoms of a
PVD, retinal tear, or retinal detachment be seen as soon as possible and
undergo a careful dilated retinal examination. Patients who are referred
to an ophthalmologist or retina specialist undergo a careful history and
ophthalmic examination.

2.) Most patients who present with posterior vitreous detachment
management and do not have any retinal breaks or retinal tears on a
360-degree scleral depressed examination, require only reassurance and
education. While studies have tried to identify subsets of patients who
may not require additional evaluation after the initial examination,
some suggest that most patients should be seen in follow-up at about
three months. Patients who describe photopsias, or have evidence of
retinal bleeding, but no full thickness or retinal detachment, may
require an earlier follow-up in approximately one to two months.

The floaters often resolve over a period of 3 to 12 months; they settle
down outside the visual axis, and/or become less noticeable or
bothersome. In some cases, however, floaters may be a permanent symptom.

In general, patients with a PVD do not require any specific activity
limitations. Patients who develop worsening symptoms of flashes,
significantly more floaters, and/or loss of peripheral or central vision
should be reevaluated with a careful scleral depressed peripheral
retinal examination.

3.) The obstetric management is most often expectant, unless otherwise
specified by the ophthalmologist. There is no evidence to support a
causative link between labour and rhegmatogenous (versus serous) retinal
detachment, even in eyes predisposed to that condition. An extensive
review of the literature in 2003 indicated that rhegmatogenous had never
been reported formally in association with childbirth. This is
consistent with the fact that 'bearing down' during vaginal delivery is
unlikely to increase vitreous traction on susceptible retinal areas.

**Resources**

**Retinal tear and detachment, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=priophth/8273&type=A&selectedTitle=1~7>

[Elsherbiny
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Elsherbiny+SM"%5BAuthor%5D),
[Benson
MT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Benson+MT"%5BAuthor%5D).
Retinal detachment and the second stage of labour: a survey of regional
practice and literature review. [J Obstet
Gynaecol.](javascript:AL_get(this, 'jour', 'J Obstet Gynaecol.');) 2003
Mar;23(2):114-7.\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12745550]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12745550)

[Kent-Smith
BT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kent-Smith+BT"%5BAuthor%5D),
[Wilson
GA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wilson+GA"%5BAuthor%5D).
Management of rhegmatogenous retinal detachment in a full-term
pregnancy. [Clin Experiment
Ophthalmol.](javascript:AL_get(this, 'jour', 'Clin Experiment Ophthalmol.');)
2005 Feb;33(1):101.\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15670091]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15670091)

**Now, for those of you want more background, let's go back to square
one**

What is the difference between a rhegmatogenous retinal detachment and a
serous retinal detachment?

**Ophthalmologic standpoint**

Retinal detachments can be rhegmatogenous (caused by a break in the
retina, rhegma is Greek for tear) or nonrhegmatogenous (caused by
leakage or exudation from beneath the retina or vitreous traction on the
retina). On occasion the retina appears to be detached but is actually
not; this is termed pseudo retinal detachment.

**Rhegmatogenous retinal detachment** --- Rhegmatogenous retinal
detachments are the most common type of retinal detachment. By
definition they are caused by a full thickness retinal hole or retinal
tear. Although distinct from traction retinal detachments these full
thickness holes or tears are also usually caused by vitreous traction on
the retina. Unlike a traction retinal detachment, however, the traction
does not directly pull the retina off the underlying tissue; instead,
fluid that leaks through the hole or tear results in retinal detachment.

Holes and tears can be asymptomatic or symptomatic; asymptomatic breaks
in the retina are much more common than symptomatic breaks, but much
less likely to lead to retinal detachment. Thus, most retinal holes or
tears found in an asymptomatic patient do not result in retinal
detachment, whereas symptomatic retinal breaks often result in retinal
detachment.

**Lattice degeneration** --- Lattice degeneration is a relatively common
condition characterized by focal thinning in the periphery of the
retina. An atrophic retinal hole may occur within a patch of lattice
degeneration, which can cause a slowly developing and often asymptomatic
peripheral retinal detachment in young patients with myopia.

Thus, lattice degeneration can be viewed as an asymptomatic precursor to
retinal detachment. These lesions have been considered for prophylactic
therapy to prevent retinal detachment.

**Posterior vitreous detachment** --- Posterior vitreous detachment
(PVD) is the most common cause of rhegmatogenous retinal detachment .
The vitreous is a clear gel-like structure in the back of the eye
composed of collagen fibrils and [hyaluronic
acid](http://www.uptodateonline.com/utd/content/topic.do?topicKey=Drug_A_K/151799&drug=true)
that slowly liquefies throughout life. These pockets of liquid can break
through the posterior vitreous face and cause PVD from the retina. This
event, which occurs typically in patients between the ages of 50 and 75
years, results in a new onset of cobweb-like floaters and/or increased
floaters.

Vitreous detachment usually occurs over one week, but may take up to
three months to completely develop. Any areas in which there might be an
abnormally strong vitreoretinal adhesion are areas that, due to vitreous
traction, may develop a full thickness horseshoe retinal tear or
operculated retinal tear. The aforementioned lattice degeneration is an
example of an area that has an abnormally strong vitreoretinal
connection. Anything that tugs on the retina will cause photopsias or
flashes of light that last seconds and may be associated with eye
movement. In addition, patients who develop a full thickness retinal
tear may also tear a small retinal blood vessel, resulting in an
increasing number of floaters.

Thus, nontraumatic rhegmatogenous retinal detachments begin with the
normal and acute development of PVD. If the patient also has areas of
abnormally strong vitreoretinal adhesion, as in areas of lattice
degeneration, liquid vitreous within the eye can percolate through the
retinal break creating retinal detachment.

**Traumatic retinal detachment** --- Patients who sustain an ocular
injury also can develop a full thickness retinal break or retinal
dialysis. These may lead to subretinal migration of liquid vitreous and
the development of a retinal detachment. This is much less common than
spontaneous rhegmatogenous detachment.

**Nonrhegmatogenous retinal detachment**

**Traction retinal detachment** --- Traction retinal detachments occur
when the vitreous has an abnormally strong attachment to the retina and
contracts, thus pulling the retina off the back of the eye. This is
typically seen in patients who have proliferative diabetic retinopathy
and retinal neovascularization. The areas of neovascularization and
fibrosis between the retina and the vitreous create a strong adhesion
between these two tissues. With vitreous contraction the retina is
pulled away from the back of the eye and a traction retinal detachment
is created.

Traction retinal detachment can also occur in patients who have had
perforating trauma and have developed a fiberoptic transvitreal retinal
band that contracts. In addition, there are rare cases of patients who
have an abnormally strong adhesion between the vitreous and the macula
(the central part of the retina). Vitreous contraction in these cases
can lead to a localized macular traction detachment called vitreo-macula
traction syndrome.

**Exudative retinal detachment** --- Exudative retinal detachment occurs
in patients who do not have a full thickness retinal break, but rather
have an accumulation of fluid beneath the retina. These types of retinal
detachments are often associated with inflammatory conditions, may occur
spontaneously as with central serous retinopathy, or can occur in
association with choroidal neoplasms/metastases. Traditional retinal
reattachment surgeries are not effective since exudative retinal
detachments are not associated with a full thickness retinal break.
Diagnosing and treating the underlying etiology of the exudative retinal
detachment is critical in curing the problem and restoring vision.

**Pseudo retinal detachment** --- There are a number of cases in which
the retina appears to be detached but it is not:

-Peripheral senile retinoschisis is a splitting of the peripheral retina
with an elevated retinal layer

-White without pressure is a normal white reflex seen in some patients

-Choroidal lesion or swelling or infolding due to choroidal neoplasms,
swelling, or hypotony

These causes of a pseudo retinal detachment need to be diagnosed by a
retina specialist or ophthalmologist.

**CLINICAL PRESENTATION** --- Patients with the most common cause of
retinal detachment, rhegmatogenous detachment following spontaneous PVD,
usually complain of an increasing number of floaters in one eye. The
floaters may look like a cobweb, or like one particularly large floater
that appears to move in and out of central vision. The large floater is
sometimes described as \"a large housefly.\"

These symptoms are usually associated with acute PVD and result from the
sudden separation of the vitreous gel from the surface of the retina.
This sometimes dramatic presentation of vitreous floaters or debris can
range from being an inconvenience or a nuisance to being visually
disabling. The floaters usually resolve with time, settle down outside
the visual access, and/or become less noticeable.

As the posterior vitreous face separates from the underlying retinal
surface, it may encounter areas of abnormally strong vitreoretinal
adhesions. At these sites the separating vitreous will tug on the
surface of the retina and create a mechanical depolarization of the
axons running through the nerve fiber layer of the retina. This is
usually interpreted by the patient as a flash of light or photopsia that
lasts less than one second and is sometimes associated with eye
movement. These photopsias may be more easily seen in the dark or at
night and are usually pinpointed to the affected eye. This appearance
contrasts with the fortification spectra often described in patients
with ocular migraines; this zigzagging light typically lasts 10 to 20
minutes, is seen with both eyes, and is sometimes associated with blurry
central vision.

Small retinal vessels may avulse or a small horseshoe retinal tear can
be created if sufficient vitreoretinal traction is applied to the
retina. In this circumstance, patients complain of a shower of black
spots consistent with vitreous hemorrhage. Sometimes this shower of
spots progresses, leaving the patient with a large vitreous hemorrhage
and only count fingers or light perception vision. Patients who are
found to have a dense vitreous hemorrhage associated with an acute PVD
have a relativity high risk of also having a retinal tear and developing
a retinal detachment.

Approximately 50 percent of patients who develop a full thickness
horseshoe retinal tear in the setting of a symptomatic vitreous
detachment will go on to develop a rhegmatogenous retinal detachment.
Liquefied vitreous fluid has a tendency to percolate through the retinal
break causing a neurosensory retinal detachment. Patients who reach this
stage often complain of a slowly progressive peripheral visual field
defect in the affected eye. Interestingly, they frequently describe a
photo stress response in the area of the detached retina. In other
words, when they are exposed to a bright light, the retinal
photopigments in the area of the detached retina are bleached, thereby
resulting in darkening of the visual field defect.

The rate of progression of retinal detachment varies depending upon the
size of the retinal break, location of the break, and movements of the
eye. Large horseshoe retinal tears or giant retinal tears that have
persistent vitreoretinal traction will usually allow a retinal
detachment to progress over the period of hours to days. In contrast,
small horseshoe retinal tears or operculated holes often result in more
slowly progressive retinal detachment that can take one to four weeks to
develop.

As the retinal detachment progresses from the full thickness retinal
breaks posteriorly towards the macula, the size of the visual field
defect will enlarge in a corresponding fashion. Patients will lose the
ability to read once the retinal detachment involves the macula or the
central area of the retina responsible for reading vision. Vision in
patients with macular off rhegmatogenous retinal detachment usually
ranges between 20/50 and count fingers.

**Differential diagnosis** --- Idiopathic vitreous floaters are the most
common cause of floaters. In addition to PVD and full thickness retinal
tear, the other causes of floaters include:

-   Vitreous hemorrhage

-   Vitreous inflammation (eg, Toxoplasma chorioretinitis)

-   Ocular lymphoma

-   Intraocular foreign body

One other possible resource is Dr. Klaus Lucke, a retinal surgeon with a
large clinic in Germany.  His e-mail
[[k.lucke@retina.to]{.underline}](mailto:k.lucke@retina.to) and his
website is [[http://www.retina.to/]{.underline}](http://www.retina.to/)