Retinal Detachment

Retinal Detachment in Children

Some complaints are just challenging to decipher. This is particularly true with children. Sometimes our ability to communicate with them can be the issue. Other complaints are more challenging because the physical exam may be difficult to perform. For instance, any eye complaint in a child. Yes, I want to simply attribute all “red eyes” to “conjunctivitis,” but it isn’t always that simple (ex, Glaucoma, Uveitis). Let’s now ponder an eye complaint that is doubly challenging as it can present with a head-scratching complaint and is coupled with a difficult exam – Retinal Detachment:

Retinal Detachment: Basics

  • Retinal detachment = separation of the neurosensory retina from its underlying membrane (the retinal pigment epithelium). [Cadis, 2019]
    • Fluid accumulates in the potential space created by this tear.
    • As the more retina is involved, the macula may become involved and threaten vision.
  • 3 Basic Forms of Retinal Detachment exist: [Read, 2018]
    • Rhegmatogenous form
      • Most common form in children.
      • Tear in retina allows vitreous humor to further separate the two layers.
    • Traction form
      • Less common in children.
      • Retina is pulled away by abnormal tissue (fibrosis seen in diabetic retinopathy or retinopathy of prematurity).
    • Exudative form
      • Underlying barrier dysfunction leads to collection of exudative material disrupting the retinal layers.
      • Examples: Vascular disease, Intraocular tumors
  • It less common in children, but still can occur. [Cadis, 2019]
    • Annual incidence of 0.38-0.69 / 100,000.
    • Mean and median ages for children = 9 and 13 years.
  • Risk Factors for Retinal Detachment: [Chen, 2020; Tsai, 2019; Drenser, 2019; Sin, 2017; Rahimi, 2014; Buzzard, 2009]
    • Trauma
    • Myopia
    • Previous intraocular surgery
    • Congenital and/or Developmental abnormalities
  • Children are more challenging to diagnose early. [Cadis, 2019; Tsai, 2019; Buzzard, 2009]
    • Only 40-70% of children with retinal detachment report “classic symptoms.”
      • Increase in “floaters.”
      • Light flashes
      • Dark curtain being pulled down
    • More often have gradual evolution of the condition.
      • The child may naturally adapt with the changes until vision is significantly impaired.
      • Complaints may not be appreciated by adults as being significant.
    • Diagnosis is usually later than in adults and, thus, outcomes may be worse.

Retinal Detachment: Evaluation

  • Consider Retinal Detachment in the Ddx:
    • Easier to consider when complaint is “loss of vision,” but children may present with other neurologic complaints instead (ex, difficulty ambulating). [Cadis, 2019]
    • Retinal detachment should also be considered alongside:
  • Physical Exam:
    • Visual Acuity (the vital sign of the eye!)
    • Thorough ocular exam (portable, handheld slit lamp can be helpful here)
    • Fundoscopic exam (only way to see the retina right??)
      • This is a super difficult exam in a fully cooperative patient… the wiggly 9 year old may be near impossible to do this on.
      • but… we have another tool…
      • OCULAR ULTRASOUND! [Cadis, 2019; Buzzard, 2009]
        • Yes, you still need a cooperative child, but prepare them and use warm gel!
        • High sensitivity and specificity.
  • Urgent ophthalmology consultation is indicated. [Cadis, 2019; Tsai, 2019]
    • Maintain a high index of suspicion.
    • Failure to correct the retinal detachment can lead to permanent vision loss.
    • Surgical correction can be successful, but to a lesser degree in children than adults, possibly due to the later presentations and greater severity of associated vitreous hemorrhage.

Moral of the Morsel

  • It may not be classic, but it still can be a problem. Don’t cross Retinal Detachment off of your Ddx list just because the child didn’t describe classic symptoms.
  • Don’t overlook the Basics … they are important! Visual Acuity = the Vital Sign of the Eye!
  • Augment your vision! If you cannot see the retina yourself, grab your ultrasound!!

References

Chen C1, Huang S1, Sun L1, Li S1, Huang L1, Wang Z1, Luo X1, Ding X2. Analysis of Etiologic Factors in Pediatric Rhegmatogenous Retinal Detachment with Genetic Testing. Am J Ophthalmol. 2020 Feb 26. PMID: 32112773. [PubMed] [Read by QxMD]
Cadis C1, Wang A1, Julakanti M1, Juergens A1. Bilateral Retinal Detachment in a Pediatric Patient. J Emerg Med. 2019 Apr;56(4):e55-e57. PMID: 30826081. [PubMed] [Read by QxMD]
Smith JM1, Ward LT2, Townsend JH3, Yan J4, Hendrick AM4, Cribbs BE4, Yeh S4, Jain N4, Hubbard GB 3rd5. Rhegmatogenous Retinal Detachment in Children: Clinical Factors Predictive of Successful Surgical Repair. Ophthalmology. 2019 Sep;126(9):1263-1270. PMID: 30419297. [PubMed] [Read by QxMD]
Tsai ASH1,2,3, Wong CW1,2,3, Lim L1,2,3, Yeo I1,2,3, Wong D1,2,3, Wong E1,2,3, Ang CL1,2,3, Ong SG1,2, Lee SY1,2,3, Tan G1,2,3. PEDIATRIC RETINAL DETACHMENT IN AN ASIAN POPULATION WITH HIGH PREVALENCE OF MYOPIA: Clinical Characteristics, Surgical Outcomes, and Prognostic Factors. Retina. 2019 Sep;39(9):1751-1760. PMID: 30015760. [PubMed] [Read by QxMD]
Drenser K. Pearls for Managing Pediatric Retinal Detachments. Ophthalmology. 2019 Sep;126(9):1271-1272. PMID: 31443787. [PubMed] [Read by QxMD]
Read SP1, Aziz HA1, Kuriyan A1, Kothari N1, Davis JL1, Smiddy WE1, Flynn HW Jr1, Murray TG2, Berrocal A1. RETINAL DETACHMENT SURGERY IN A PEDIATRIC POPULATION: Visual and Anatomic Outcomes. Retina. 2018 Jul;38(7):1393-1402. PMID: 28858062. [PubMed] [Read by QxMD]
Sin HPY1, Yip WWK2, Chan VCK2, Young AL2. Etiologies and surgical outcomes of pediatric retinal detachment in Hong Kong. Int Ophthalmol. 2017 Aug;37(4):875-883. PMID: 27628429. [PubMed] [Read by QxMD]
Rahimi M1, Bagheri M1, Nowroozzadeh MH1. Characteristics and outcomes of pediatric retinal detachment surgery at a tertiary referral center. J Ophthalmic Vis Res. 2014 Apr;9(2):210-4. PMID: 25279123. [PubMed] [Read by QxMD]
Buzzard AK1, Linklater DR. Pediatric retinal detachment due to Coats’ disease diagnosed with bedside emergency department ultrasound. J Emerg Med. 2009 Nov;37(4):390-2. PMID: 18226872. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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