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:
    • Vitreous hemorrhage
    • Endophthalmitis
    • Dry Eye
    • Migraine
    • Intracranial Mass
    • Hyperviscosity syndromes (ex, leukemia)

• 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