Retinal Detachment: Types, Lincoff Rules and Surgery Choice
Last updated: October 2026
Retinal detachment is a time-critical diagnosis. The resident's job is to recognise the type, find the break, judge urgency by the macula, and know which operation suits which eye.
Three types, three mechanisms
| Type | Mechanism | Clinical clues |
|---|---|---|
| Rhegmatogenous (RRD) | A retinal break lets liquefied vitreous pass under the retina | Flashes and floaters, pigment in the anterior vitreous (Shafer sign), convex corrugated detachment, a break can be found |
| Tractional (TRD) | Fibrovascular membranes pull the retina off (PDR, ROP, trauma) | Concave, smooth, immobile detachment; often no symptoms until the macula is involved |
| Exudative (serous) | Fluid leaks from choroid or retinal vessels (VKH, tumours, CSCR, posterior scleritis, toxaemia) | Smooth bullous detachment, shifting fluid with posture, no break |
Finding the primary break: Lincoff rules
- Superior temporal or nasal detachment: the break is within 1.5 clock hours of the highest border of the detachment in 98% of cases.
- Total or superior detachment crossing 12 o'clock: in 93% of cases the break is at 12 o'clock, or in a triangle whose apex is at the ora serrata and whose sides extend 1.5 clock hours either side of 12.
- Inferior detachment: in 95% of cases, the higher side of the detachment shows which side of the disc the break lies on.
- Inferior bullous detachment: inferior bullae in a rhegmatogenous detachment originate from a superior break.
Always examine with scleral indentation, and always examine the fellow eye.
Urgency: is the macula on or off?
- Macula on (central vision still good): urgent surgery, ideally within about 24 hours. Superior bullous detachments threaten the macula fastest.
- Macula off: still needs surgery soon, but the visual outcome depends largely on how long the macula has been detached. Ask exactly when central vision went.
- Position the patient while waiting so that gravity keeps fluid away from the macula, and advise rest.
Choosing the operation
| Procedure | Best suited to |
|---|---|
| Pneumatic retinopexy | Detachment from a single break (or breaks within one clock hour) in the upper two-thirds of the retina, with a patient who can posture. The PIVOT trial showed better visual function than vitrectomy in suitable eyes. |
| Scleral buckle | Young phakic patients without a posterior vitreous detachment, retinal dialysis, atrophic holes with lattice, and inferior detachments in young eyes |
| Pars plana vitrectomy | Pseudophakic eyes, posterior or multiple breaks, giant retinal tears, vitreous haemorrhage obscuring the view, and established PVR |
Proliferative vitreoretinopathy (PVR)
- PVR is the main cause of surgical failure. Risk factors include large or multiple breaks, vitreous haemorrhage, prolonged detachment, uveitis and previous surgery.
- The classic grading runs from A (vitreous haze and pigment clumps) through B (rolled edges, retinal wrinkling) to C (full-thickness fixed retinal folds). See our PVR page.
- Silicone oil and C3F8 gas are better tamponades for PVR than SF6 (Silicone Study).
Prophylaxis: which lesions to laser
- Treat: symptomatic horseshoe (flap) tears, and tears associated with a vitreous haemorrhage.
- Usually observe: asymptomatic lattice degeneration, atrophic holes and operculated holes without symptoms.
- Consider treatment in higher-risk situations, such as a fellow eye of a giant retinal tear or Stickler syndrome, after discussion with a vitreoretinal specialist.
- Teach every patient the warning symptoms: new flashes, a shower of floaters, or a curtain over the vision means return the same day.
Viva pearls
- Roughly 10–15% of patients with an acute symptomatic posterior vitreous detachment have a retinal tear; an associated vitreous haemorrhage raises that risk considerably.
- Retinal dialysis is classically inferotemporal in young people after blunt trauma.
- Long-standing RRD shows demarcation lines, intraretinal cysts and subretinal bands.
Related: emergencies on call and post-vitrectomy rebleeding.
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