It is an unusual problem for children, but an optometrist presented with a young patient who has experienced unexplained visual loss should consider the diagnosis of retinal detachment as treatment delays can have permanent repercussions.
Retinal detachments (RD) in children are uncommon, even in a specialist retinal practice. During the past six months, three children have been referred to me with RDs. Their cases illustrate some key points to help prevent eye care practitioners from missing the diagnosis.
Case One
An 11-year-old myopic boy was under regular optometric follow-up for orthokeratology. He reported blurred right vision to his optometrist who found the right best corrected visual acuity (VA) to be 6/12 with a -3.5 D correction.
The VA had been 6/6 seven months previously. Because he was studying intensively for a selective school entrance exam, the optometrist attributed his symptoms to exam related stress. On review three weeks later, the right VA had dropped to 6/30. The optometrist found no abnormalities on corneal topography or fundus photography so the symptoms were still attributed to stress.
It often takes months or years for a RD to develop from a retinal dialysis following blunt trauma
The boy was referred to me the next day, at which stage the right VA was 6/45 and examination revealed a chronic shallow macula-off RD with inferior retinal holes (Figure 1A and B). Following successful RD surgery, the right VA recovered to 6/18 at five months post-op.
Case Two
A 13-year-old myopic girl reported a five-month history of a progressive superior visual field defect. Her optometrist documented a right VA of 6/120 with a -6 D correction and inferior retinal holes detected on dilated fundus examination. The right VA had been 6/6 when last examined 17 months previously. The patient was referred urgently and found to have a chronic shallow macula-off RD with inferior retinal holes (Figure 1C and D). RD surgery was performed. Seven weeks post-operatively the retina was successfully reattached but the VA remained 6/120.
Case Three
A 13-year-old girl presented to an optometrist complaining of a 12-month history of gradual right visual loss. Three years previously she had been hit in the right eye with a tennis ball and consulted a different optometrist who monitored her for two weeks, found no permanent damage and discharged her.
The new optometrist found the right VA to be counting fingers associated with a macula-off RD and urgently referred the patient to me. I identified a chronic right shallow macula-off RD secondary to an inferotemporal retinal dialysis (a retinal tear at the ora serrata, usually resulting from blunt ocular trauma) (Figure 2). Following RD surgery, the right VA improved to 6/24 at six months post-op.
The Take Home MessagesThese cases highlight a number of important principles.
Although RDs are uncommon in children, optometrists should be aware that they sometimes occur and should consider the diagnosis in any child with unexplained visual loss, especially if there is a history
of myopia or blunt eye trauma.
The most common associations of RD in children are blunt eye trauma and myopia. Anybody that suffers from significant blunt ocular trauma should have a dilated fundus examination with scleral indentation to look specifically for a retinal dialysis. If an eye care practitioner is not experienced in performing scleral indentation, they should refer the patient to somebody who is. It often takes months or years for a RD to develop from a retinal dialysis following blunt trauma.
RDs in children typically progress slowly because the vitreous is not syneretic, limiting the amount of fluid available to pass through retinal breaks into the subretinal space. Inferior RDs progress particularly slowly.
Retinal photography should complement but not replace clinical examination of the retina. Shallow retinal detachments can be overlooked on fundus photos (see Figures 1A and C) and are more readily identified with slit lamp biomicroscopy. The peripheral retina should be examined because RDs are more easily seen in the periphery where the retina is more elevated.
Although chronic macula-off RDs can be successfully repaired with surgery, the visual results are variable and some permanent visual impairment is typical, so it is imperative to make the diagnosis as soon as possible to avoid harmful delays in treatment.
Dr. Simon Chen MB BS (London), BSc (Hons), FRCOphth, FRANZCO is a retinal specialist. He has particular expertise in intravitreal anti-VEGF therapy and sutureless vitreoretinal surgery. He is a principal investigator for numerous international clinical trials of novel treatments for retinal disease. Dr. Chen practices at Vision Eye Institute clinics in Sydney.
