The retina is the light-sensing layer at the back of the eye. The macula (center) provides sharp central and color vision; the peripheral retina provides side and night vision. Retinal disorders are usually painless, so any sudden change in vision must be treated as potentially urgent.

Risk factors

• RD: high myopia, prior eye surgery (including cataract surgery), eye trauma, previous RD in the other eye, older age
• AMD: age over 50–55, smoking (strongest modifiable factor), family history, White race
• DR: duration of diabetes, poor glucose and blood pressure control, pregnancy, kidney disease

Retinal detachment — classic warning signs

• Flashes of light (photopsia)
• Sudden shower of new floaters ("cobwebs," "spots")
• A shadow or "curtain" moving across the visual field
• Painless

AMD

• Blurred or dark area in the center of vision; difficulty reading and recognizing faces
• Metamorphopsia — straight lines look wavy or broken
• Peripheral vision preserved

Diabetic retinopathy

• Often no symptoms until advanced — hence screening
• Blurred or fluctuating vision (DME); sudden floaters or dark vision (vitreous hemorrhage)

CRAO

• Sudden painless loss of vision; pale retina with a cherry-red spot at the macula on fundoscopy

Retinitis pigmentosa

• Night blindness, bumping into objects at the sides, trouble adapting to dim light

Diabetic retinopathy screening (ADA)

• Type 1 diabetes: first dilated exam within 5 years of diagnosis
• Type 2 diabetes: exam at diagnosis
• Then every 1–2 years if no retinopathy and good glycemic control; at least yearly if any retinopathy
• Pregnancy with pre-existing diabetes: before conception or in the first trimester, then monitor each trimester and for 1 year postpartum as indicated

Retinal detachment — surgical emergency (especially while the macula is still attached)

• Laser or cryotherapy to seal a tear before detachment
• Pneumatic retinopexy (gas bubble injected, then laser/cryo), scleral buckle, or vitrectomy with gas or silicone oil tamponade
• The gas bubble presses the retina in place; the client must hold a specific head position (often face-down) for days

Wet AMD and DME — intravitreal anti-VEGF injections (aflibercept, ranibizumab, bevacizumab, faricimab)

• Given monthly at first, then extended intervals
• Aim: stabilize vision and slow loss; some clients gain vision, but improvement is not guaranteed and is not immediate
• Risks: endophthalmitis, raised IOP, RD, rarely intraocular inflammation; possible systemic thromboembolic events

Dry AMD

• AREDS2 supplement (vitamins C and E, zinc, copper, lutein, zeaxanthin) for intermediate AMD or advanced AMD in one eye; the AREDS2 formula replaced beta-carotene, which raised lung cancer risk in smokers
• Geographic atrophy: complement inhibitors (pegcetacoplan, avacincaptad pegol, approved 2023) slow lesion growth but do not restore vision; risks include endophthalmitis, conversion to wet AMD, and intraocular inflammation, including rare occlusive retinal vasculitis (pegcetacoplan)
• Stop smoking

Diabetic retinopathy

• Control glucose, blood pressure, and lipids
• Panretinal photocoagulation (PRP) for proliferative disease — destroys ischemic peripheral retina to reduce new vessel growth; may reduce peripheral and night vision
• Anti-VEGF for DME and as an alternative for proliferative disease
• Vitrectomy for non-clearing vitreous hemorrhage or traction detachment

CRAO — treat as an acute stroke: immediate referral to an emergency department or stroke center; evaluate carotids, heart rhythm, and giant cell arteritis (ESR, CRP) in older adults.

Retinal vein occlusion: anti-VEGF or steroid implant for macular edema; laser for neovascularization.

Drug and procedure safety

Listed in priority order.

1. Recognize emergencies
   • Sudden flashes, floaters, or curtain → same-day ophthalmology (suspected RD)
   • Sudden painless vision loss → emergency pathway for CRAO (stroke equivalent)
   • Keep the client calm; limit head movement and eye movement until evaluated if RD is suspected
2. Postoperative care after retinal surgery
   • Maintain the prescribed head position exactly (face-down or side) — this is essential to success
   • Monitor for severe pain, nausea and vomiting (possible raised IOP), and new flashes, floaters, or shadows (re-detachment — a key complication after vitrectomy)
   • Give antiemetics and analgesics as ordered; avoid straining, coughing, heavy lifting
   • Eye shield at night; drops as ordered
   • Place a gas-bubble wristband alert if used
3. Vitreous hemorrhage (proliferative DR)
   • Elevate the head of the bed (semi-Fowler's) so blood settles in the lower vitreous and clears the visual axis; avoid strenuous activity
4. Safety and fall prevention for clients with low vision — orient to room, keep call light and belongings within reach, clear pathways
5. Low-vision support
   • Central loss (AMD): magnifiers, bright task lighting, large print, eccentric viewing training
   • Peripheral loss (RP, after PRP): teach scanning — turning the head side to side when walking; good lighting at night
6. Psychosocial: fear of blindness is common; refer to low-vision rehabilitation and support services

• Know RD warning signs (flashes, new floaters, curtain) and seek care the same day
• Amsler grid: check each eye separately daily with reading glasses on, at normal reading distance; report new wavy, broken, blurred, or missing lines promptly
• Anti-VEGF injections: expect a scratchy feeling or small red spot on the white of the eye; report increasing pain, worsening vision, or discharge within the first days. Treatment usually needs to continue long term; its goal is to keep vision stable
• After laser photocoagulation: side and night vision may decrease; use extra lighting and caution when driving at night
• After gas bubble surgery: keep the head position as instructed; no flying or high altitudes; tell any anesthetist about the bubble
• Diabetes: have a dilated eye exam on schedule even without symptoms; control glucose, blood pressure, and cholesterol
• Stop smoking; eat leafy green vegetables and fish; take AREDS2 supplements only when recommended

• Flashes + floaters + curtain = retinal detachment — emergency
• AMD: central vision loss, wavy lines; Amsler grid — report broken or distorted lines
• Wet AMD treatment: anti-VEGF injections stabilize vision; do not promise immediate improvement
• Smoking is the strongest modifiable risk for AMD; AREDS2 uses lutein/zeaxanthin, not beta-carotene
• Diabetic retinopathy is often silent — dilated exam at diagnosis for type 2, within 5 years for type 1
• PRP laser can narrow peripheral vision and reduce night vision
• Cherry-red spot + sudden painless loss = CRAO — treat as a stroke
• Retinitis pigmentosa: night blindness, tunnel vision; teach head scanning
• Central serous chorioretinopathy: linked to stress and steroid use
• After vitrectomy, watch for re-detachment and endophthalmitis; keep the prescribed head position
• Gas bubble: no flying, no nitrous oxide