RETINAL DETACHMENT
Acknowledgement
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? Photographs in this presentation are courtesyof Dr.Freund. K. Bailey (The Retinal Atlas,2nd Ed.)
and
Dr.Brad Bowling (Kanski's Clinical Ophthalmology,
8thEd.)
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Learning ObjectivesAt 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.--- Content provided by FirstRanker.com ---
Normal Fundus
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Layers of the retina
1. Retinal Pigment Epithelium
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2. Layer of Rods & Cones3. 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 Layer8. 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 tearsa. Complete U-tear
d. Operculated
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b. Linear
e. Dialysis
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c. Incomplete L-shapedDEFINITION
? 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 toRPE 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 orretinal break
exudative
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Classification
? Clinico-etiologically ? Three types of retinal
detachment
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1. Rhegmatogenous(or primary) retinaldetachment
2. Tractional retinal detachment
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3. Exudative retinal detachmentClassification-
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RhegmatogenousExudative
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 ophthalmoscopyCondensing 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 biomicroscopyGoldmann 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 RDRetina
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 carrywhich 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 retinaOccasional 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 PumpPathogenesis
? Retinal breaks are due to
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dynamic vitreoretinal tractionand
predisposing retinal degeneration
? Degenerated fluid vitreous seeps through
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retinal break and collects as SRF betweensensory retina and RPE leading to RD
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Pathogenesis of rhegmatogenous RDTwo 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) withappearance 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: Tobaccodust(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 diagnosisespecially 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 foldstobacco dust
stiffness
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? Vitreous condensations
? Rolled edges of tears
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and strandsDifferential 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 immediateapposition 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 burnsmedia hazy
Technique of cryotherapy
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? Surround lesion with single row of
cryo-applications
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? Preferred for treatment of largeareas
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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 whitetip 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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HaemorrhageRetinal 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 unrollingInjection 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 ofmembranes
? 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 thevitreous.
? 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 tractionEndophotocoagulation
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 vascularlesions.
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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PrimaryMetastatic
2. Intraocular inflammation
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Harada's Disease
Posterior Scleritis
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3. Intraocular inflammationToxemia of pregnancy
Hypoproteinemia
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Pathogenesis and Causes of Exudative RD
4. Vascular
? CSR
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? Coat's disease5. Iatrogenic
? RD surgery
? Excessive retinal photocoagulation
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6. Miscellaneous? Choroidal neovascularization
? Uveal effusion syndrome
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? NanophthalmosSigns 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 aplaque 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 spontaneousretinal 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 asCoats 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/serousHole/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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-- ShiftingSRFNevrreacheslens Shallow Mayreach/touch
Course
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lens
Progresive/Static Progresive Waxes/wanes
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MayresolvebyitselfManagement
Surgical
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Surgical Medical/surgical
Conclusion
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? Retinal Detachment is defined as theseparation 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.