PANCE Blueprint EENT (7%)

Retinal detachment (Lecture)

Patient will present as → a 65-year-old man complaining of a sudden unilateral vision loss which he describes as "a curtain or dark cloud lowering over my eye." This was preceded by small moving flashing lights, and floaters. The fundoscopic exam reveals a detached superior retina.

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Retinal detachment is separation of the neurosensory retina from the underlying retinal pigment epithelium. The most common cause is a retinal tear (rhegmatogenous detachment).

  • If a patient complains of the new onset of floaters or flashes of light, the patient should undergo a dilated eye exam to rule out a retinal tear or retinal detachment.
  • Look for sudden increase or change in floaters along with curtain or veil across the visual field.
  • Often is spontaneous, but may have underlying cause – example recent cataract surgery.

Diagnosis is by funduscopy

  • Ultrasonography may help determine the presence and type of retinal detachment if it cannot be seen with funduscopy

Optho emergency: Intraocular gases or liquids, laser, cryotherapy, ocular surgery

  • Stay supine (lying face upward) with head turned towards the side of the detached retina
IM_NUR_Detached-Retina_V1.2_ A detached retina is caused by an accumulation of fluid leading to the separation of the sensory retina and underlying pigment epithelium. Symptoms may include flashes of light, floaters, and a curtain-like shadow. Interventions for retinal detachment include promoting bed rest, avoiding vigorous activity, wearing an eye patch, and preparing for immediate surgical repair.

Detached Retina Picmonic

Question 1
A 59 year-old male complains of "flashing lights behind my eye" followed by sudden loss of vision, stating that it was "like a curtain across my eye." He denies trauma. He takes Glucophage for his diabetes mellitus and atenolol for his hypertension. He has no other complaints. On funduscopic exam, the retina appears to be out of focus. Which of the following is the most likely diagnosis?
A
Central retinal vein occlusion
Hint:
Central retinal vein occlusion causes painless, variable loss of vision. Exam shows retinal hemorrhages in all quadrants and edema of the optic disk.
B
Retinal artery occlusion
Hint:
Retinal artery occlusion presents with sudden, painless loss of vision. Exam shows pale retina with normal macula, seen as a cherry-red spot.
C
Retinal detachment
D
Hyphema
Hint:
Hyphema is usually associated with trauma, and is a collection of blood in the anterior chamber
Question 1 Explanation: 
Patients with retinal detachment frequently complain of flashes of light or floaters that occur during traction on the retina as it detaches. This is followed by loss of vision. In small detachments, the retina may appear out of focus, but with larger detachments, a retinal fold may be identified.
Question 2
A 75 year-old patient with history of macular degeneration and hypertension presents with complaint of sudden onset of visual loss in the left eye. The patient denies pain. On examination you note a dome-shaped retina and subretinal fluid that shifts with position changes. Which of the following is the most likely diagnosis in this patient?
A
Central retinal vein occlusion
Hint:
Central retinal vein occlusion is characterized by sudden monocular visual loss on examination there would be disc swelling, venous engorgement, cotton-wool spots, and diffuse retinal hemorrhages.
B
Acute angle-closure glaucoma
Hint:
Acute angle-closure glaucoma is characterized by pain and blurred vision. On examination the eye is red, the cornea is steamy, and the pupil is moderately dilated and nonreactive to light.
C
Acute nongranulomatous anterior uveitis
Hint:
Acute nongranulomatous anterior uveitis presents with acute unilateral eye pain, redness, photophobia, and vision loss.
D
Serous retinal detachment
Question 2 Explanation: 
Serous retinal detachment is characterized by a dome shaped retina and subretinal fluid that shifts position with posture changes. Serous retinal detachment results from subretinal fluid accumulation which can occur in exudative age-related macular degeneration.
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