Download MBBS Ophthalmology PPT 51 Retinal Detachment Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 51 Retinal Detachment Lecture Notes



? Photographs in this presentation are courtesy
of Dr.Freund. K. Bailey (The Retinal Atlas,2nd Ed.)
Dr.Brad Bowling (Kanski's Clinical Ophthalmology,
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


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


? 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



? Clinico-etiologically ? Three types of retinal
1. Rhegmatogenous(or primary) retinal


2. Tractional retinal detachment
3. Exudative retinal detachment





Predisposing factors for RD

? Myopia
? Aphakia (& Pseudophakia)
? Trauma
? Retinal Degenerations

Rhegmatogenous retinal detachment

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

neurosensory retina from the retinal pigment


Indirect ophthalmoscopy

Condensing lenses


? 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

? 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



? 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


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


? Retinal breaks are due to
dynamic vitreoretinal traction
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


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

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


? ERG: subnormal or absent


? 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


? 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


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


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


? Preferred for treatment of large



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


? Difficulty in localizing break

? Immobile retina

? Longstanding RD

? Inferior RD




Retinal incarceration

Pneumatic retinopexy


RD with superior breaks


(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

? 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


? 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-


posterior traction


Exudative Retinal detachment

? Occurs due to the retina being pushed away

by a neoplasm or fluid accumulation beneath

the retina following inflammatory or vascular

Pathogenesis and Causes of Exudative RD

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

1. Choroidal tumours



2. Intraocular inflammation

Harada's Disease

Posterior Scleritis

3. Intraocular inflammation

Toxemia of pregnancy


Pathogenesis and Causes of Exudative RD

4. Vascular
? 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


? Congenital anomalies, such as optic pits or


-vitrectomy and endolaser techniques.
Differences between types of RD

Rhegmatogenous Tractional





- -

Convex,corugated Concave,

scalloped Convex,smoth

SRF shift

Height of RD


-- ShiftingSRF

Nevrreacheslens Shallow Mayreach/touch



Progresive/Static Progresive Waxes/wanes




Surgical Medical/surgical


? Retinal Detachment is defined as the

separation of neurosensory retina (NSR) from

retinal pigment epithelium (RPE).

? It may be rhegmatogenous, tractional or


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

This post was last modified on 07 April 2022