A 58-year-old man presents to the ophthalmology clinic with sudden onset of floaters and flashing lights in his right eye for the past 3 days. He is myopic (−8 D) and has a history of posterior vitreous detachment diagnosed 6 months ago. On examination, visual acuity is 6/9 in the right eye. Fundoscopy reveals a grey, elevated retinal fold extending from the optic disc towards the macula, with retinal folds radiating outward. The retina appears to be in place at the periphery. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Tractional Retinal Detachment with Proliferative Vitreoretinopathy (PVR) ### Key Clinical Features **Key Point:** The presence of radial retinal folds ("star folds") and a grey, elevated retinal surface that appears wrinkled is pathognomonic for tractional retinal detachment with PVR. **High-Yield:** Tractional detachment occurs when fibroglial proliferation on the retinal surface contracts, mechanically pulling the retina off the underlying RPE. Unlike rhegmatogenous detachment, there is NO retinal break. ### Distinguishing Features | Feature | Tractional RD (PVR) | Rhegmatogenous RD | |---------|-------------------|-------------------| | **Retinal folds** | Radial, star-shaped (wrinkled appearance) | Smooth, concentric | | **Retinal break** | Absent | Present | | **Elevation pattern** | Immobile, fixed | Mobile, follows gravity | | **Progression** | Slow, gradual | Rapid | | **Macula involvement** | Often central | Often superior initially | | **Vitreous inflammation** | Marked (white vitreous) | Minimal | ### Pathophysiology of PVR 1. Initial retinal break or detachment triggers RPE migration into vitreous 2. Fibroblasts proliferate and form epiretinal membranes 3. Contraction of these membranes creates mechanical traction 4. Retina is pulled inward, creating characteristic folds **Clinical Pearl:** The "star fold" pattern radiating from the optic disc is a hallmark sign of PVR. The retina appears grey and immobile because it is being pulled by contractile membranes, not floating freely as in rhegmatogenous detachment. ### Why This Is Tractional, Not Rhegmatogenous - **No break visible:** Fundoscopy shows no retinal tear or hole - **Fixed, wrinkled appearance:** The retina is mechanically tethered, not mobile - **Radial folds:** Characteristic of membrane contraction, not gravity-dependent pooling - **History of PVD:** While this increases risk of rhegmatogenous RD, the clinical presentation here is clearly tractional **Mnemonic: PVR = Proliferation → Fibrosis → Retraction (Traction)** ### Management Implications - **Surgical approach:** Vitrectomy with membrane peeling (not scleral buckle) - **Prognosis:** More guarded than rhegmatogenous RD; visual recovery depends on macula involvement and PVR grade - **Prevention in rhegmatogenous RD:** Early repair and anti-inflammatory management reduce PVR risk [cite:Boyd & Manzouri, Retinal Detachment Handbook]