A 65-year-old woman comes to the emergency department due to vision disturbances in her left eye. The patient underwent cataract extraction with intraocular lens implantation in the left eye 4 months ago. The surgery was uncomplicated, and the patient experienced no vision issues until this morning, when she suddenly noticed a "dark web" in her peripheral vision. She has also experienced bright flashes of light with left eye movement. The patient has had no eye pain, eye trauma, headache, fever, or chills. Vital signs are within normal limits. Left eye examination shows clear conjunctiva and cornea, a sluggish pupillary reflex to direct light, and decreased peripheral vision in the temporal visual field. Right eye examination is unremarkable. Which of the following is the most likely diagnosis?
Show Explanatory Sources
This patient, who is experiencing bright flashes of light and an isolated defect in her left eye peripheral vision, most likely has retinal detachment, which occurs when there is separation of the retinal neurosensory layer from the underlying retinal pigment epithelium and choroid. Retinal detachment may be a complication (acute or delayed) of intraocular surgery; other common risk factors include advanced age, myopia, and ocular trauma.
Retinal detachment is most commonly caused by posterior vitreous detachment (PVD). When the gel-like vitreous, which is usually strongly attached to the retina, separates from the retina, it can cause mechanical depolarization within the neurosensory layer of the retina. Patients experience the depolarization as flashes of light (photopsia). Vitreous debris, referred to as floaters, is experienced as dark spots or webs. PVD can also tear the retina; if fluid seeps behind the tear, retinal detachment occurs. Retinal detachment typically begins in the periphery, causing a peripheral visual field defect, before progressing centrally.
Examination may show a relative afferent pupillary defect or a sluggish pupil in the affected eye depending on the degree of detachment and number of functional photoreceptors remaining. Ophthalmoscopic examination typically reveals retinal tears and/or an area of gray, elevated retina that may have a wrinkled appearance. Surgical repair (eg, retinopexy) is usually required.
(Choice A) Central retinal artery occlusion is also characterized by a sudden, painless loss of vision in one eye. However, vision deficits are usually centrally located and more severe and are not associated with photopsia or floaters.
(Choice B) Intraocular lens dislocation is a rare complication that can occur days to years after lens implantation. It can cause vision disturbances (typically decreased visual acuity or double vision), but it does not typically cause photopsia or impaired pupillary reflex.
(Choice C) Optic neuritis can cause acute monocular vison loss. However, it is usually painful (vs painless) and affects central (vs peripheral) vision.
(Choice D) Panuveitis occurs when there is simultaneous inflammation of the anterior (ie, iris, ciliary body) and posterior uvea (ie, choroid). It is typically painful (vs painless) and causes photophobia, tearing, perilimbal injection, and/or hypopyon, similar to isolated anterior uveitis.
Educational objective:
Retinal detachment commonly presents with an acute, painless, monocular vision disturbance accompanied by flashes of light and/or floaters. Detachment most commonly begins in the periphery, affecting peripheral vision first. Ophthalmoscopic examination typically shows an area of gray, elevated retina, often with a wrinkled appearance.