Download MBBS Ophthalmology PPT 51 Retinal Detachment Lecture Notes

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? 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.)

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Learning Objectives

At the end of the class, students shall be able to

? Define and classify the various types of retinal

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detachments (R.D.)

? Understand the pathophysiology and signs and

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symptoms of retinal detachments

? Have a basic understanding of the management
of various types of retinal detachments

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What is the retina?

? Innermost coat of the eyeball.
? Thin, delicate, transparent membrane.
? Externally related to the choroid & sclera.

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? Thickness

? Near optic disc ? 0.56 mm
? Equator ? 0.18 to 0.2 mm
? Ora-serrata ? 0.1 mm

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? Thinnest at Fovea.

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Normal Fundus

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Layers of the retina

1. Retinal Pigment Epithelium

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2. Layer of Rods & Cones

3. External Limiting Membrane

4. Outer Nuclear Layer

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5. Outer Plexiform Layer

6. Inner Nuclear Layer

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7. Inner Plexiform Layer

8. Ganglion Cel Layer

9. Nerve Fibre Layer

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10.Internal Limiting Membrane

RETINAL DETACHMENT (RD)

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1. Definitions and classifications

? Retinal breaks

? Retinal detachment

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Definition and classification

? Break - full-thickness defect in sensory retina

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? Hole - caused by chronic retinal atrophy

? Tear - caused by dynamic vitreoretinal traction

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Morphology of tears

a. Complete U-tear

d. Operculated

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b. Linear

e. Dialysis

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c. Incomplete L-shaped

DEFINITION

? RETINAL DETACHMENT (R.D.) is defined as the

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separation of neurosensory retina (NSR) from

retinal pigment epithelium (RPE) caused by

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breakdown of forces that attach the NSR to

RPE resulting in accumulation of sub retinal

fluid (SRF) in the potential space between the

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NSR and RPE.


Retinal detachment (RD)

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Separation of sensory retina from RPE by subretinal fluid (SRF)

Rhegmatogenous - caused by a

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Non-rhegmatogenous - tractional or

retinal break

exudative

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Classification

? Clinico-etiologically ? Three types of retinal
detachment

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1. Rhegmatogenous(or primary) retinal

detachment

2. Tractional retinal detachment

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3. Exudative retinal detachment


Classification-

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Rhegmatogenous

Exudative

Tractional

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Predisposing factors for RD

? Myopia
? Aphakia (& Pseudophakia)

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? Trauma
? Retinal Degenerations
? PVD

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Rhegmatogenous retinal detachment

? Is usually associated with a retinal break
(hole/tear)
? Sub retinal fluid(SRF) seeps and separates the

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neurosensory retina from the retinal pigment

epithelium(RPE)

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Indirect ophthalmoscopy

Condensing lenses

Technique

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? The higher the power, the less the

? Keep lens parallel to patient's iris plane

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magnification, the shorter the working

? Avoid tendency to move towards

distance , greater the field of view

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patient
? Ask the patient to move eyes and head

into optimal positions for examination

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Scleral indentation

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Retinal breaks in detached Enhanced visualization of

retina without indentation breaks with indentation

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Slitlamp biomicroscopy

Goldmann triple-mirror lens

View of peripheral fundus

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? Equatorial mirror (largest and

?

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oblong) - from 30 to equator

?Image is upside down

? Peripheral mirror (square) -

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from equator to ora serrata

? Gonioscopic (smallest)

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Predisposing peripheral degenerations

Typical lattice degeneration
? Present in about 8% of general population

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? Present in about 40% of eyes with RD

Retina

Vitreous

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? Spindle-shaped islands of retinal thinning

? Overlying vitreous liquefaction

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? Network of white lines within islands

? Exaggerated attachments

? Variable associated RPE changes

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around margin of lesion

? Smal round holes within lesions are common

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Snail track degeneration

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Sharply demarcated, frost-like bands Large round holes which carry

which are longer than lattice

high risk of RD

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Indications for prophylaxis - presence of holes

White-without-pressure

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Translucent grey appearance of retina

Occasional giant tear formation along

posterior margin of lesion

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Indications for prophylaxis - giant tear in other eye
Why is normal retina attached?

? Vitreous tamponade

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? Acid mucopolysaccharides (Bio glue)
? Hydrostatic pressure( Less pressure in the sub

retinal space)

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? RPE Pump

Pathogenesis

? Retinal breaks are due to

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dynamic vitreoretinal traction
and
predisposing retinal degeneration
? Degenerated fluid vitreous seeps through

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retinal break and collects as SRF between

sensory retina and RPE leading to RD

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Pathogenesis of rhegmatogenous RD

Two components for retinal break formation

? Acute posterior vitreous detachment (PVD)

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? Predisposing peripheral retinal degeneration

Possible sequelae of acute PVD

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Uncomplicated PVD (85%) Retinal tear formation and Avulsion of retinal vessel &

haemorrhage (10-15%)

haemorrhage (uncommon)

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Clinical features

? Prodromal symptoms
Floaters (dark spots)

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Photopsia (flashes of light)
? Symptoms of RD
Loss in the field of vision(Localised and relative

progressing to total loss)

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Painless loss of vision(usually rapid) with

appearance of cloud/veil in front of affected eye

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Signs of R.D.

? External examination: Usually normal
? Intra ocular pressure: Slightly lower or normal
? Pupils: Normal reaction or Relative Afferent

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Pupillary Defect in extensive RD

? Plane mirror examination: Greyish reflex

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Signs of R.D.

? Ophthalmoscopy: Indirect Ophthalmoscopy

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with scleral indentation: Tobacco

dust(Shafer's sign)

? Retinal breaks

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? Convex configuration with folds(corrugations)
? Loss of the choroidal pattern
? Retinal blood vessels - darker than in flat

retina

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Fresh rhegmatogenous RD - signs

? Annual incidence - 1:10,000 of population
? Eventual y bilateral in 10%

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? Convex, deep mobile elevation

? Loss of choroidal pattern

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extending to ora serrata

? Retinal breaks

? Slightly opaque with dark blood vessels

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Signs of old RD

? Retinal thinning (due to atrophy)

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? Sub retinal demarcation line/high water mark
(due to RPE proliferation)
? Secondary intra retinal cysts

Longstanding rhegmatogenous RD - signs

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? Frequently inferior with small holes

? Demarcation lines (high-water marks)

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? Very thin retina

? Secondary intraretinal cysts
Investigations

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? Ultrasonography confirms the diagnosis
especially when media is hazy.
? Visual field charting : scotomas

(relative/absolute)

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? ERG: subnormal or absent

Complications

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? Proliferative vitreo retinopathy(PVR)
? Complicated cataract
? Uveitis
? Phthisi bulbi

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Proliferative vitreoretinopathy

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Grade A (minimal)

Grade B (moderate)

Grade C (severe)

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? Vitreous haze and

? Retinal wrinkling and

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? Rigid retinal folds

tobacco dust

stiffness

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? Vitreous condensations

? Rolled edges of tears

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and strands

Differential diagnosis of RD

Degenerative retinoschisis Choroidal detachment Uveal effusion syndrome

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? Frequently bilateral

? Associated with hypotony ? Idiopathic

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? Smooth, thin and immobile ? Unilateral, brown, smooth, ? Rare, unilateral

? Occasionally breaks in one solid and immobile

? Combined choroidal

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or both layers

? Ora serrata may be visible & exudative detachments
Aims of management of RD

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? Seal/close retinal breaks with
photocoagulation or cryotherapy
(or diathermy ? Jules Gonin -Ignipuncture)

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? Sub Retinal Fluid drainage : for immediate

apposition between sensory retina and RPE

(Not in all cases)

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Aims of management of RD

? Maintain chorioretinal apposition/adhesion by
1. Scleral Buckling to provide external

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tamponade

2. Pneumatic retinopexy
3. Pars plana vitrectomy (to relieve traction on

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retina)


Technique of laser photocoagulation

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Surround lesion with two rows of

Difficult for anterior lesions and if

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confluent burns

media hazy

Technique of cryotherapy

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? Surround lesion with single row of

cryo-applications

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? Preferred for treatment of large

areas

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Cryotherapy

While viewing with indirect ophthalmo-

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Freeze break until sensory retina just

Scope indent sclera gently with

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turns white

tip of cryoprobe

Drainage of subretinal fluid

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Indications

? Difficulty in localizing break

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? Immobile retina

? Longstanding RD

? Inferior RD

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Technique

Complications

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Haemorrhage

Retinal incarceration

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Pneumatic retinopexy

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Indications

RD with superior breaks

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Technique

(a) Cryotherapy

(b) Gas injection

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(c) Postoperative positioning

(d) Flat retina

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Vitrectomy for giant tears

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Unrolling of flap with light Completion of unrolling

Injection of silicone oil or

pipe and probe

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heavy liquid

Vitrectomy for PVR

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? Dissection of star folds and peeling of

membranes
? Injection of expanding gas or silicone oil

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Tractional Retinal detachment

? Occurs due to mechanical pull/traction on the

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retina by contraction of fibrous tissue in the

vitreous.

? Etiology

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?Proliferative Diabetic Retinopathy (PDR)
?Penetrating posterior segment trauma
?Retinopathy of prematurity

Signs of tractional RD

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?

? Concave, shallow immobile elevation

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Slow progression and variable fibrosis

?

? Highest at sites of vitreoretinal traction

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Does not extend to ora serrata


Vitrectomy for tractional RD

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Release of circumferential Release of antero-

traction

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posterior traction

Endophotocoagulation

Exudative Retinal detachment

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? Occurs due to the retina being pushed away

by a neoplasm or fluid accumulation beneath

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the retina following inflammatory or vascular

lesions.
Pathogenesis and Causes of Exudative RD

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? Damage to RPE by subretinal disease
? Passage of fluid derived from choroid into subretinal space

1. Choroidal tumours

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Primary

Metastatic

2. Intraocular inflammation

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Harada's Disease

Posterior Scleritis

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3. Intraocular inflammation

Toxemia of pregnancy

Hypoproteinemia

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Pathogenesis and Causes of Exudative RD

4. Vascular
? CSR

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? Coat's disease
5. Iatrogenic
? RD surgery

? Excessive retinal photocoagulation

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6. Miscellaneous
? Choroidal neovascularization

? Uveal effusion syndrome

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? Nanophthalmos


Signs of exudative RD

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? Convex, smooth elevation

? Subretinal pigment (leopard spots)

? May be very mobile and deep with

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after flattening

shifting fluid

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Medical Management

? Inflammatory conditions

(such as scleritis and Vogt-Koyanagi-Harada syndrome)

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anti-inflammatory agents.

? Tumors-

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v External beam radiation therapy or brachytherapy with a

plaque may be used for choroidal melanoma.

v Metastatic lesions respond to chemotherapy or localized

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radiation therapy.

v Choroidal hemangiomas may respond to laser

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photocoagulation or plaque brachytherapy.

v Retinoblastomas may be shrunk with chemotherapy and

then treated local y with heat, laser, or cryotherapy.

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Medical Management

? Infectious aetiologies -antibiotics.
? Exudative retinal detachments secondary to

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chronic renal failure may have spontaneous

retinal reattachment following renal

transplant or renal dialysis.

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? Anti-VEGF agents -Coats disease.

Surgical Management

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? Conditions with vascular anomalies, such as

Coats disease-laser- cryotherapy

vitrectomy

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? Congenital anomalies, such as optic pits or

colobomas

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-vitrectomy and endolaser techniques.
Differences between types of RD

Rhegmatogenous Tractional

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Exudative/serous

Hole/Break

Surface

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+

- -

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Convex,corugated Concave,

scalloped Convex,smoth

SRF shift

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Height of RD

Rare

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-- ShiftingSRF

Nevrreacheslens Shallow Mayreach/touch

Course

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lens

Progresive/Static Progresive Waxes/wanes

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Mayresolvebyitself

Management

Surgical

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Surgical Medical/surgical

Conclusion

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? Retinal Detachment is defined as the

separation of neurosensory retina (NSR) from

retinal pigment epithelium (RPE).

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? It may be rhegmatogenous, tractional or

exudative.

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? Is one of the causes of significant visual loss.
? Management is mainly surgical.