Other / Other / MRI

Retinal detachment

Retinal detachment presents with photopsia, floaters, and progressive peripheral visual field loss; imaging is indicated when an underlying cause such as malignancy needs to be ruled out or for surgical planning.

Key Images

Retinal detachment

Types of detachment

Types of detachment

Retinal detachment

Sub-retinal Hemorrhage

Serous Choroidal Detachment

Hemorrhagic Choroidal Detachment

Look For First
  • Bright, continuous, smooth folded membrane within the vitreous on ultrasound with independent aftermovement
  • Triangular or V-shaped configuration with insertion into the optic disc on ultrasound
  • Folded membrane with subretinal fluid (hyperdense on CT) converging posteriorly on the disc on cross-sectional imaging
Key Image Findings
  • Ultrasound shows a bright, reflective, freely moving membrane within the vitreous that demonstrates aftermovements with extraocular muscle recruitment, distinguishing acute from chronic detachment
  • Acute retinal detachment is mobile on ultrasound real-time imaging with pronounced movements, whereas long-standing detachments show progressively decreased mobility
  • Total or extensive detachment appears as a characteristic triangular or V-shaped configuration with insertion at the optic disc and anterior extent limited by the ora serrata
  • On CT/MRI, folded membrane with subretinal space fluid (hypodense on MRI, hyperdense on CT) that converges posteriorly on the optic disc, distinguishing it from choroidal detachment which diverges at the disc
  • The anterior limit of retinal detachment is bounded by the ora serrata, while choroidal detachment extends beyond the ora serrata
  • Post-treatment imaging may demonstrate a scleral band from scleral buckle surgery used to relieve vitreous traction and promote closure of retinal defects
Differential Diagnosis
  • Choroidal detachment: does not demonstrate aftermovements on ultrasound and diverges at the optic disc (rather than converging) and extends beyond the ora serrata on cross-sectional imaging
  • Posterior vitreous detachment: less mobile than acute retinal detachment and lacks the characteristic triangular configuration with optic disc insertion
  • Vitreous hemorrhage: appears as echogenic material without the characteristic smooth membrane architecture or aftermovements
  • Retinal tear without detachment: similar photopsia and floaters but no membrane or subretinal fluid on imaging
Discussion

Rhegmatogenous retinal detachment (most common type) results from fluid ingression through a retinal break in the setting of posterior vitreous detachment, trauma, or predisposing lesions like lattice degeneration

Myopia is the most common risk factor; post-cataract surgery patients (aphakic or pseudophakic) are at significantly increased risk due to loss of the supportive lens

Macula-on retinal detachments where the fovea remains attached have better prognosis and visual outcomes compared to macula-off detachments involving the central retina

Non-rhegmatogenous detachments (tractional and exudative) are secondary phenomena from conditions like proliferative diabetic retinopathy, sickle cell retinopathy, central serous chorioretinopathy, or choroidal neoplasms

Ultrasound's real-time evaluation with aftermovements is key to acute detection and differentiation from structural mimics, making it the primary imaging modality when clinical suspicion is high

Cross-sectional imaging (CT/MRI) is reserved for evaluating underlying orbital pathology or when malignancy such as choroidal melanoma is in the differential

Reporting Pearls

Report the location and extent of retinal detachment (macula-on vs. macula-off, quadrant, and percentage involvement), describe the morphology (triangular/V-shaped with optic disc convergence), confirm mobility/aftermovements on ultrasound to establish acuity, and note any associated findings such as subretinal fluid characteristics or signs of underlying choroidal pathology.

Pitfalls
  • Confusing retinal detachment with choroidal detachment: remember that choroidal detachment does NOT show aftermovements and diverges at the optic disc, whereas retinal detachment converges at the disc
  • Mistaking a long-standing detachment for a posterior vitreous detachment: chronic detachments show decreased mobility; comparison with real-time ultrasound motion and morphology helps differentiate
  • Over-relying on cross-sectional imaging when ultrasound is superior for detecting mobility and confirming acute detachment; ultrasound should be first-line imaging
  • Failing to distinguish macula involvement: macula-on vs. macula-off status critically impacts prognosis and requires careful anatomic assessment of foveal attachment
Source: Reference source