Long Case: Retinal Detachment — What to Show and What to Say

A good retinal-detachment long case is a map, not a list of symptoms. State the eye, the likely type of detachment, extent, macular status, retinal breaks or traction, proliferative vitreoretinopathy (PVR), and relevant fellow-eye findings. Then say what remains uncertain. That sequence tells the examiner that you can examine a detached retina systematically before discussing management.¹

Exam-education boundary: this is a framework for presenting and discussing a case with examiners. It is not a patient-specific treatment plan. In clinical practice, retinal detachment requires prompt assessment within the appropriate service and current local/specialist guidance.

The 30-second presentation

Do not begin with “This patient has retinal detachment and needs surgery.” Begin with the evidence in front of you.

“This is a [age]-year-old [patient] with [right/left] [duration] of flashes, floaters and/or a field defect, with [state the visual-function effect actually documented]. On dilated examination, there is a [rhegmatogenous/tractional/exudative, if supported] retinal detachment involving [clock hours or quadrants], extending from [landmark] to [landmark]. The macula is [on/off/indeterminate on the information available]. I identify [number and position] break(s), or no break on this examination. There is [describe observed PVR or traction], and the fellow eye shows [relevant finding]. My provisional diagnosis is [type] retinal detachment in the [eye]. I would complete documentation of [uncertain feature] before a definitive management discussion.”

The template is deliberately conditional. Do not call a detachment macula-off solely because central vision is poor, and do not call it rhegmatogenous because a patient reports floaters. Symptoms guide the history; the retinal configuration and examination evidence support the diagnosis.

First, show that you can make a retinal map

Retinal detachment describes separation of neurosensory retina from the retinal pigment epithelium. The three broad mechanisms are rhegmatogenous, tractional and exudative; mixed mechanisms are possible.¹ In a long case, identifying the mechanism is useful only if you then point to the supporting features.

Use either clock hours or quadrants and stay consistent. Clock-hour language is generally more precise for breaks: “a horseshoe tear at 11 o’clock with surrounding detached retina” is easier to act on intellectually than “a superior break.” If the view is limited, say why: media opacity, a small pupil, poor patient cooperation or incomplete peripheral visualisation. “No break identified on this examination” is a careful observation. It is not proof that no break exists.

Build the history around mechanism, not a generic ophthalmic script

The history earns marks when it explains why you looked for specific signs. Ask about onset and sequence of flashes, floaters, a curtain or field loss, and whether central function changed. Then look for the context that changes the differential: high myopia, trauma, previous cataract or vitreoretinal surgery, uveitis, diabetic retinopathy, tumour history, prematurity or systemic inflammatory/malignant disease where relevant.

For a suspected rhegmatogenous detachment, the useful story is vitreoretinal traction and a break allowing liquefied vitreous to enter the subretinal space. For tractional detachment, ask what could create fibrovascular or other vitreoretinal traction. For an exudative detachment, ask what could produce subretinal fluid in the absence of a retinal break. These are exam prompts, not permission to infer a diagnosis before you examine.¹

In your presentation, separate a patient’s words from your conclusion:

This distinction is especially useful under viva pressure. Examiners often give a plausible history and wait to see whether you turn it into an unsupported label.

Examine in an order that makes omissions difficult

Start with what establishes severity and context: visual acuity, pupils, confrontation field if the station permits, anterior segment, lens status and IOP. Document the view. A dense cataract, vitreous haemorrhage or corneal problem changes what you can say about the fundus; it also makes a request for appropriate imaging or senior retinal assessment reasonable in a real clinical setting.

Then describe the posterior segment in layers.

1. Confirm the detached retina and its boundaries. State where attached retina becomes detached and whether the configuration is shallow, bullous, concave or fixed. Do not confuse a descriptive appearance with a final mechanism.
2. Locate the macula. If it is visible, say whether it is involved. If not, state the limitation rather than guessing. OCT, when available in the case, may clarify a macula whose status is difficult to assess clinically; say it is evidence you would use, not a routine answer to every station.¹
3. Search systematically for breaks. Take the examiner through the periphery in a reproducible order. Record number, clock hour, type and any relation to lattice, atrophy, previous laser or detached retina. A break can be small; the exam reward is the disciplined search, not false certainty.
4. Look for PVR and traction. PVR is clinically important because membrane formation and retinal contraction can complicate repair. Describe folds, membranes, stiffness, shortening or a fixed configuration before using a classification label.²
5. Examine the fellow eye. The correct detail depends on the case. A normal fellow eye can be stated briefly; relevant lattice, tears, prior retinopexy or lens status should be included explicitly.

In a real clinic, indirect ophthalmoscopy with scleral depression and appropriately selected imaging may be needed to evaluate a suspected retinal break or detachment. In an exam, do not mime procedures you were not asked to perform. Explain what you would seek and what the supplied findings show.

Distinguish the three mechanisms from the evidence

The common viva question is, “What type of detachment is this?” Answer with a short mechanism and two or three supporting observations. Avoid a memorised catalogue.

The phrase “subject to complete examination” is not evasive. It shows that you understand diagnostic confidence has a limit. The NCBI review also notes that combinations can occur, so a tidy three-box classification should not make you ignore contradictory signs.¹

How to discuss management without overreaching

For an exam case, management discussion should start with priorities and determinants, not an operation name. State that a suspected retinal detachment needs prompt specialist assessment. Then identify the features that a vitreoretinal team uses to individualise the approach: mechanism, break number and position, extent, macular status, lens status, PVR, media clarity, fellow-eye findings, previous surgery and the patient’s broader context. Surgical approaches for rhegmatogenous RD may include pneumatic retinopexy, scleral buckling, pars plana vitrectomy or a combination; their selection is case-specific.¹

That is sufficient for most long-case vivas. If asked, move from anatomy to principle:

Do not promise visual recovery. Do not state that a particular procedure is “best” without a fully specified case and current specialist guidance. That is sound clinical reasoning and safer exam communication.

The PVR question: describe first, classify second

PVR is a process of cellular proliferation and contractile membrane formation associated with retinal detachment and repair complexity. The classic Retina Society classification was intended to describe increasing severity; later schemes and clinical practice should not turn it into a set of labels recited without a retinal description.²

When you see a fold or membrane, say where it is and what it does to the retina. For example: “There are fixed inferior retinal folds with reduced mobility, raising concern for PVR.” This is more defensible than announcing a letter grade from memory. If the examiner asks for a grade, offer the descriptive signs first and state the classification only if you can support it from the station.

A practical long-case checklist

Before you finish, run this silent checklist:

• Have I stated the eye, symptom chronology and current visual function?
• Have I said what makes the detachment rhegmatogenous, tractional, exudative or still uncertain?
• Have I mapped extent and macular status rather than merely saying “RD present”?
• Did I look for and document every identifiable break or explicitly state that none was identified?
• Did I describe PVR/traction rather than over-grade it?
• Did I mention the fellow eye when relevant?
• Did I frame management as prompt specialist assessment plus case determinants, rather than a promise about outcome?

Practise the checklist aloud with a fundus photograph, then repeat it with a different configuration. The aim is not a polished speech. It is a sequence that still works when the break is not obvious, the macula cannot be assessed, or the case contains a red herring.

For wider retinal terminology and pattern revision, use the Retina study guide. If handwritten, topic-organised material suits your revision system, review the sample for Retina Deciphered. For the practical examination format, the OSCE, Practical & Viva Voce Ready bundle is the relevant on-site resource; it does not replace supervised clinical training. DNB candidates can also use the DNB Ophthalmology preparation guide to connect theory revision with practical preparation. OphthaMCQ is independent and is not affiliated with examining colleges or societies.

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