Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 51 Retinal Detachment Lecture Notes
RETINAL DETACHMENT
Acknowledgement
? Photographs in this presentation are courtesy
of Dr.Freund. K. Bailey (The Retinal Atlas,2nd Ed.)
and
Dr.Brad Bowling (Kanski's Clinical Ophthalmology,
8thEd.)
Learning Objectives
At the end of the class, students shall be able to
? Define and classify the various types of retinal
detachments (R.D.)
? Understand the pathophysiology and signs and
symptoms of retinal detachments
? Have a basic understanding of the management
of various types of retinal detachments
What is the retina?
? Innermost coat of the eyeball.
? Thin, delicate, transparent membrane.
? Externally related to the choroid & sclera.
? Thickness
? Near optic disc ? 0.56 mm
? Equator ? 0.18 to 0.2 mm
? Ora-serrata ? 0.1 mm
? Thinnest at Fovea.
Normal Fundus
Layers of the retina
1. Retinal Pigment Epithelium
2. Layer of Rods & Cones
3. External Limiting Membrane
4. Outer Nuclear Layer
5. Outer Plexiform Layer
6. Inner Nuclear Layer
7. Inner Plexiform Layer
8. Ganglion Cel Layer
9. Nerve Fibre Layer
10.Internal Limiting Membrane
RETINAL DETACHMENT (RD)
1. Definitions and classifications
? Retinal breaks
? Retinal detachment
Definition and classification
? Break - full-thickness defect in sensory retina
? Hole - caused by chronic retinal atrophy
? Tear - caused by dynamic vitreoretinal traction
Morphology of tears
a. Complete U-tear
d. Operculated
b. Linear
e. Dialysis
c. Incomplete L-shaped
DEFINITION
? RETINAL DETACHMENT (R.D.) is defined as the
separation of neurosensory retina (NSR) from
retinal pigment epithelium (RPE) caused by
breakdown of forces that attach the NSR to
RPE resulting in accumulation of sub retinal
fluid (SRF) in the potential space between the
NSR and RPE.
Retinal detachment (RD)
Separation of sensory retina from RPE by subretinal fluid (SRF)
Rhegmatogenous - caused by a
Non-rhegmatogenous - tractional or
retinal break
exudative
Classification
? Clinico-etiologically ? Three types of retinal
detachment
1. Rhegmatogenous(or primary) retinal
detachment
2. Tractional retinal detachment
3. Exudative retinal detachment
Classification-
Rhegmatogenous
Exudative
Tractional
Predisposing factors for RD
? Myopia
? Aphakia (& Pseudophakia)
? Trauma
? Retinal Degenerations
? PVD
Rhegmatogenous retinal detachment
? Is usually associated with a retinal break
(hole/tear)
? Sub retinal fluid(SRF) seeps and separates the
neurosensory retina from the retinal pigment
epithelium(RPE)
Indirect ophthalmoscopy
Condensing lenses
Technique
? The higher the power, the less the
? Keep lens parallel to patient's iris plane
magnification, the shorter the working
? Avoid tendency to move towards
distance , greater the field of view
patient
? Ask the patient to move eyes and head
into optimal positions for examination
Scleral indentation
Retinal breaks in detached Enhanced visualization of
retina without indentation breaks with indentation
Slitlamp biomicroscopy
Goldmann triple-mirror lens
View of peripheral fundus
? Equatorial mirror (largest and
?
oblong) - from 30 to equator
?Image is upside down
? Peripheral mirror (square) -
from equator to ora serrata
? Gonioscopic (smallest)
Predisposing peripheral degenerations
Typical lattice degeneration
? Present in about 8% of general population
? Present in about 40% of eyes with RD
Retina
Vitreous
? Spindle-shaped islands of retinal thinning
? Overlying vitreous liquefaction
? Network of white lines within islands
? Exaggerated attachments
? Variable associated RPE changes
around margin of lesion
? Smal round holes within lesions are common
Snail track degeneration
Sharply demarcated, frost-like bands Large round holes which carry
which are longer than lattice
high risk of RD
Indications for prophylaxis - presence of holes
White-without-pressure
Translucent grey appearance of retina
Occasional giant tear formation along
posterior margin of lesion
Indications for prophylaxis - giant tear in other eye
Why is normal retina attached?
? Vitreous tamponade
? Acid mucopolysaccharides (Bio glue)
? Hydrostatic pressure( Less pressure in the sub
retinal space)
? RPE Pump
Pathogenesis
? Retinal breaks are due to
dynamic vitreoretinal traction
and
predisposing retinal degeneration
? Degenerated fluid vitreous seeps through
retinal break and collects as SRF between
sensory retina and RPE leading to RD
Pathogenesis of rhegmatogenous RD
Two components for retinal break formation
? Acute posterior vitreous detachment (PVD)
? Predisposing peripheral retinal degeneration
Possible sequelae of acute PVD
Uncomplicated PVD (85%) Retinal tear formation and Avulsion of retinal vessel &
haemorrhage (10-15%)
haemorrhage (uncommon)
Clinical features
? Prodromal symptoms
Floaters (dark spots)
Photopsia (flashes of light)
? Symptoms of RD
Loss in the field of vision(Localised and relative
progressing to total loss)
Painless loss of vision(usually rapid) with
appearance of cloud/veil in front of affected eye
Signs of R.D.
? External examination: Usually normal
? Intra ocular pressure: Slightly lower or normal
? Pupils: Normal reaction or Relative Afferent
Pupillary Defect in extensive RD
? Plane mirror examination: Greyish reflex
Signs of R.D.
? Ophthalmoscopy: Indirect Ophthalmoscopy
with scleral indentation: Tobacco
dust(Shafer's sign)
? Retinal breaks
? Convex configuration with folds(corrugations)
? Loss of the choroidal pattern
? Retinal blood vessels - darker than in flat
retina
Fresh rhegmatogenous RD - signs
? Annual incidence - 1:10,000 of population
? Eventual y bilateral in 10%
? Convex, deep mobile elevation
? Loss of choroidal pattern
extending to ora serrata
? Retinal breaks
? Slightly opaque with dark blood vessels
Signs of old RD
? Retinal thinning (due to atrophy)
? Sub retinal demarcation line/high water mark
(due to RPE proliferation)
? Secondary intra retinal cysts
Longstanding rhegmatogenous RD - signs
? Frequently inferior with small holes
? Demarcation lines (high-water marks)
? Very thin retina
? Secondary intraretinal cysts
Investigations
? Ultrasonography confirms the diagnosis
especially when media is hazy.
? Visual field charting : scotomas
(relative/absolute)
? ERG: subnormal or absent
Complications
? Proliferative vitreo retinopathy(PVR)
? Complicated cataract
? Uveitis
? Phthisi bulbi
Proliferative vitreoretinopathy
Grade A (minimal)
Grade B (moderate)
Grade C (severe)
? Vitreous haze and
? Retinal wrinkling and
? Rigid retinal folds
tobacco dust
stiffness
? Vitreous condensations
? Rolled edges of tears
and strands
Differential diagnosis of RD
Degenerative retinoschisis Choroidal detachment Uveal effusion syndrome
? Frequently bilateral
? Associated with hypotony ? Idiopathic
? Smooth, thin and immobile ? Unilateral, brown, smooth, ? Rare, unilateral
? Occasionally breaks in one solid and immobile
? Combined choroidal
or both layers
? Ora serrata may be visible & exudative detachments
Aims of management of RD
? Seal/close retinal breaks with
photocoagulation or cryotherapy
(or diathermy ? Jules Gonin -Ignipuncture)
? Sub Retinal Fluid drainage : for immediate
apposition between sensory retina and RPE
(Not in all cases)
Aims of management of RD
? Maintain chorioretinal apposition/adhesion by
1. Scleral Buckling to provide external
tamponade
2. Pneumatic retinopexy
3. Pars plana vitrectomy (to relieve traction on
retina)
Technique of laser photocoagulation
Surround lesion with two rows of
Difficult for anterior lesions and if
confluent burns
media hazy
Technique of cryotherapy
? Surround lesion with single row of
cryo-applications
? Preferred for treatment of large
areas
Cryotherapy
While viewing with indirect ophthalmo-
Freeze break until sensory retina just
Scope indent sclera gently with
turns white
tip of cryoprobe
Drainage of subretinal fluid
Indications
? Difficulty in localizing break
? Immobile retina
? Longstanding RD
? Inferior RD
Technique
Complications
Haemorrhage
Retinal incarceration
Pneumatic retinopexy
Indications
RD with superior breaks
Technique
(a) Cryotherapy
(b) Gas injection
(c) Postoperative positioning
(d) Flat retina
Vitrectomy for giant tears
Unrolling of flap with light Completion of unrolling
Injection of silicone oil or
pipe and probe
heavy liquid
Vitrectomy for PVR
? Dissection of star folds and peeling of
membranes
? Injection of expanding gas or silicone oil
Tractional Retinal detachment
? Occurs due to mechanical pull/traction on the
retina by contraction of fibrous tissue in the
vitreous.
? Etiology
?Proliferative Diabetic Retinopathy (PDR)
?Penetrating posterior segment trauma
?Retinopathy of prematurity
Signs of tractional RD
?
? Concave, shallow immobile elevation
Slow progression and variable fibrosis
?
? Highest at sites of vitreoretinal traction
Does not extend to ora serrata
Vitrectomy for tractional RD
Release of circumferential Release of antero-
traction
posterior traction
Endophotocoagulation
Exudative Retinal detachment
? Occurs due to the retina being pushed away
by a neoplasm or fluid accumulation beneath
the retina following inflammatory or vascular
lesions.
Pathogenesis and Causes of Exudative RD
? Damage to RPE by subretinal disease
? Passage of fluid derived from choroid into subretinal space
1. Choroidal tumours
Primary
Metastatic
2. Intraocular inflammation
Harada's Disease
Posterior Scleritis
3. Intraocular inflammation
Toxemia of pregnancy
Hypoproteinemia
Pathogenesis and Causes of Exudative RD
4. Vascular
? CSR
? Coat's disease
5. Iatrogenic
? RD surgery
? Excessive retinal photocoagulation
6. Miscellaneous
? Choroidal neovascularization
? Uveal effusion syndrome
? Nanophthalmos
Signs of exudative RD
? Convex, smooth elevation
? Subretinal pigment (leopard spots)
? May be very mobile and deep with
after flattening
shifting fluid
Medical Management
? Inflammatory conditions
(such as scleritis and Vogt-Koyanagi-Harada syndrome)
anti-inflammatory agents.
? Tumors-
v External beam radiation therapy or brachytherapy with a
plaque may be used for choroidal melanoma.
v Metastatic lesions respond to chemotherapy or localized
radiation therapy.
v Choroidal hemangiomas may respond to laser
photocoagulation or plaque brachytherapy.
v Retinoblastomas may be shrunk with chemotherapy and
then treated local y with heat, laser, or cryotherapy.
Medical Management
? Infectious aetiologies -antibiotics.
? Exudative retinal detachments secondary to
chronic renal failure may have spontaneous
retinal reattachment following renal
transplant or renal dialysis.
? Anti-VEGF agents -Coats disease.
Surgical Management
? Conditions with vascular anomalies, such as
Coats disease-laser- cryotherapy
vitrectomy
? Congenital anomalies, such as optic pits or
colobomas
-vitrectomy and endolaser techniques.
Differences between types of RD
Rhegmatogenous Tractional
Exudative/serous
Hole/Break
Surface
+
- -
Convex,corugated Concave,
scalloped Convex,smoth
SRF shift
Height of RD
Rare
-- ShiftingSRF
Nevrreacheslens Shallow Mayreach/touch
Course
lens
Progresive/Static Progresive Waxes/wanes
Mayresolvebyitself
Management
Surgical
Surgical Medical/surgical
Conclusion
? Retinal Detachment is defined as the
separation of neurosensory retina (NSR) from
retinal pigment epithelium (RPE).
? It may be rhegmatogenous, tractional or
exudative.
? Is one of the causes of significant visual loss.
? Management is mainly surgical.
This post was last modified on 07 April 2022