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RETINAL DETACHMENT

Dr Laltanpuia Chhangte
PG 3
GMC, Haldwani

Retinal detachment (RD) is a


separation of the neurosensory
retina from the retinal pigment
epithelium with the
accumulation of fluid in the
potential space between them.

TYPES OF RD
RHEGMATOGENOUS

- associated with break(s).


TRACTIONAL
- associated with traction,
without breaks
EXUDATIVE
- due to fluid exudation which
may resolve spontaneously

RD HISTORY
Beer

1817 first to detect RD


clinically.
Von Helmholtz 1851 invented the
ophthalmoscope.
Coccius 1853 first to find retinal
breaks (r.b.).
De Wecker 1870 first suggested
that r.b. were the causes of RD.

RD History: cont.
Leber

1882 found r.b. in 70% of RD, vit.


deg. And collapse traction r.b. RD.
Changed to pre-retinal memb. r.b. (in
PVR).
Jules Gonin 1919 Father of RD surgery.
Performed the first RD operation to close
r.b. Ignipuncture of Thermocautery.

RD EPIDEMIOLOGY
Incidence

1: 10,000 / year, eventually BE

in 10%
In aphakics: 1 3%.
In the second eye (-): 5%.
In the second eye (+): 10%.
99% of untreated symptomatic RE
blindness.
5 15% of population with retinal break(s)
7% of these develop new break(s).

Normal anatomical
landmarks

Normal variants of ora


serrata

Anatomy of vitreous base

3-4 mm wide zone straddling ora serrata


Strong adhesion of cortical vitreous
Anterior limit of posterior vitreous detachment

APPLIED PHYSIOLOGY
Retina stays attached because:Acid mucopolysaccharide (GAG) b/w RPE

and the sensory retina acts as a biological


glue.
RPE cell sheaths mechanically hold the
sensory retina
RPE pump and hydrostatic pressure the
SRF is pumped out by the RPE ATP-ase
dependent pump, which lowers the
hydrostatic pressure and the vitreous
pressure flattens the retina.
Vitreous tamponade cortical vitreous

Mechanics of RD formation
Vitreous liquefaction
Partial/complete posterior vitreous

detachment, VR traction
Retinal breaks
tear
hole
dialysis
Eye movements (Edies current)

PVD
to loss of hyaluronic acid collapse
of vit. collagen with liquifaction.
Rare before 30 yrs.
Increases with age (63% in > 70 yrs.)
15% of acute PVD have a retinal tear.
Increases significantly after cataract
extraction: pathologic vs physiologic PVD.
Due

RD
PVD

13-19% of PVD have vit. Hem.

PVD + hem. 70% with tears.

PVD + no hem. 2-4% with tears.

Acute

PVD:-

Examine periphery.

+ vit. Hem.
- rest, patching examine.

U/S.

RRD Risk factors


Myopia

Retinal pigment

epithelial clumps
Glaucoma
Trauma
Proliferative
Lattice degeneration
Snail track degeneration retinopathies
- Diabetes
Zonular retinal traction
- BRVO
tufts
- Sickle cell, ROP
Degenerative
Infections
retinoschisis
RD in fellow eye or F/H
Retinal pits and
of RD
rarefaction
Aphakia

ERD Risk factors

TRD Risk factors

1. Myopia and RD
Myopia constitute 10% of the general

population and over 40% of RD occur in


myopic eyes.
High myopia >6D
60 year myope risk of RD is 2.5%
whereas normal risk is 0.06%

2. Lattice and other


peripheral deg.

Present in 8% of the population.


In SA 9.1%
As a cause of RD in 20-30%.
In RDs with L.D.:30-45% Atrophic holes.
55-70% A tear at edge of L.D.

Predisposing peripheral degenerations

Innocuous peripheral retinal degenerations

Microcysto
id
degenerat
ion

Honeycom
b
(reticular)
degenerat
ion

Pavingstone
degeneratio
n

Peripheral druse

3. CATARACT Surgery

Increases PVD: Does it convert physiological


PVD to a pathological one?
1.3% RD in aphakes.
ICCE > ECCE.
Risk of RD increased with:- P.C. otomy: 1.3%.
- Vit. loss.
50% of RDs in 1st year.

4. Glaucoma

In general population 1% COAG.


In RD patients 4-7% COAG.
> in pigment dispersion synd.
? myopia.
Miotics & RD.

5. Hereditary factors
The most common hereditary conditions

associated with RD are axial myopia and


lattice degeneration.

6. TRAUMA

7. Intraocular inflammations

CLINICAL EVALUATION
SIGNS AND SYMPTOMS
Sudden increase in Floaters
Photopsia
VISUAL FIELD DEFECT
Metamorphopsia and sudden
DOV
Sudden
VA

ASSOCIATED CONDITIONS
Drugs use; Glaucoma ; Past

strabismus surgery ; Post cataract


surgery

SYSTEMIC HISTORY
CVS, RS, anticoagulants intake, DM

FAMILY HISTORY
RD myopia, lattice degeneration,

familial VR degenerations
Genetic diseases marfan,
homocystinuria, sticklers syndrome

EXAMINATION
VA

Pupils

VF

SCLERA

AMSLER grid

Anterior segment

Refractive error

IOP

Lens
Ext. Ocular examination

Post segment : blood,

pigment (shafers sign)


in the vitreous
Careful Binocular IO
with scleral indentation

Examination techniques
Indirect ophthalmoscopy
Scleral indentation
Fundus drawing
Slit lamp biomicroscopy
Ultrasonography B scan

DETERMINE FRESH &


OLD RD

U-tear in
detached
retina

shallo
w
temp
oral
retina
l
detac
hmen

superior
bullous
retinal
detachment

Proliferative
vitreoretinopathy

etina society grading of proliferative vitreoretinopathy

Assessment of Breaks

Finding the 1 break


Symptoms
Traction
Size of detachmen
Type of break Vitreous status

Age of break Aphakia


Size of break Family history of d
Number of breaks
Other disease sta
Location of break

Lincoffs RULE

Saleh Al Amro, MD, FRCS, FCOPHTH

Criteria For Seriousness Of


Breaks

Differences between RRD, TRD and ERD


Rhegmatogenous

Tractional

Exudative

Symptom

Floaters and
flashes

Absent

Absent

VF defect

Develops fast

Develops slowly
may remain statis
for months

Develops fast

Laterality

U/L other eye may


be involved later

U/L other eye may


be involved later

Involves both eyes


simultaneously

PVD

Usually follows PVD


which is complete

Not associated
with PVD, which is
incomplete

Not associated
with PVD

Break

Always present

Absent

Absent

RPE PUMP

Intact

Not affected

Occurs d/t RPE


failure

Configuration

Convex, bullous,
corrugated folds

Concave

Convex but surface


is smooth, no folds

Mobility of retina

Mobile in fresh
case, restricted in
old case

Restricted

Mobile

Extent

Extends to ora

Seldom extends

Extends to ora

PVR

Present in due
course of time

Absent

Absent

SRF SHIFT

No shitt

Shallous and no

Shift with posture

Differences between RRD and CD


RRD

CD

Symptoms

Flashes and floaters


positive

Absent

Visual field defect

Develops fast

Absent unless it is
very extensive i.e.,
kissing choroidals

AC and IOP

Normal AC, IOP is


low

Shallow AC, IOP is


very low

Break

Present

Absent

Configuration

Greyish white,
corrugated, retinal
fold, mostly mobile

Convex, dome
shaped brownish,
smooth and not
mobile

Extent

From disc to ora

Mostly anterior to
equator, it usually
extends beyond ora

Treatment

Surgical

Mostly there is

RETINAL DETACHMENT TREATMENT

PRINCIPLES OF SURGERY
Emergency.
Localization of break(s).
Creation of C-R adhestion around the
break(s).
Closure of break(s).
Relief of V-R traction.

Creation of C-R adhesion


It can be achieved by
Cryotherapy
Diathermy
Photocoagulation

Advantages

1. CRYOTHERAPY

Disadvatages

1. Full thickness buckle can be


applied to full thickness sclera,
which is not damaged

1. Difficult to see reaction in deep


SRF

2. No thermal damage to vitreous or


sclera easy reoperations

2. Excessive cryo release of RPE cells


into the vitreous cavity. This has
been linked to PVR.

3. Can be applied transconjunctivally


or directly to sclera

Thus direct freezing over the breaks


has been discouraged recently

4. No damage to large vessels,


vortex veins or ciliary vessels
lesser risk of ant. Seg ischaemia
5. Can be safely over
staphylomatous areas taking care to
allow complete thawing before
removing the probe
6. By forcing fluid during indentation,
it may allow for buckcle placement
without drainage

2. DIATHERMY

3. Photocoagulation
Laser delivery systems coupled with indirect

ophthalmoscope
Great precision in intensity and location
Causes less breakdown of blood ocular barrier.
The thermal effect is confined to retina and RPE
sparing choroid and sclera
Induces adhesive reaction within 24 hours
However an attached retina is prerequisite and
hence SRF needs to be drained before laser
retinopexy.
Select a spot size of 200 m and set the duration to
0.1 or 0.2 seconds
Surround the lesion with two rows of confluent burns
of moderate intensity

RD TREATMENT CONTD/
LA/GA

Surgical techniques:Scleral buckle.


Orbital balloon.
Pneumatic retinopexy.
Primary vitrectomy + GFX, Long-term
tamponade.

By Earnst custodi

1. ENCIRCLAGE BUCKLES
360 deg buckling effect that relieves the

vitreoretinal traciton
Support the suspected but non visualized
pathology b/w the ora and equator
Achieve buckling effect with band only
Occupy volume replacing the drained fluid
Support a contracted retina in early PVR
FALSE ORA created prevents further hole
formation and detachment; this in practice
needs for deep indent and is not
recommended
Undetected holes are sealed when no

2. RADIAL BUCKLES
Used in
Wide horse shoe tears b/c they cause

lesser fish mouthing of the posterior edge


Very posterior breaks easier to place
sutures as well as reach posteriorly

3. CIRCUMFERENTIAL
BUCKLES
Used in
Dialysis
Multiple tears
Uncertain about breaks SRF not located,

failed RD, aphakia


GRT
Thin sclera
Statis vitreoretinal traction

Factors promoting
attachment
Physiologic adhesion of retina and

RPE
Thermal chorioretinal adhesions
Scleral buckling promotes
retinochoroidal approximation
Traction on retinal surface
reduced/eliminated
Buckles may favourably influence
fluid flux

Factors favouring
detachment
Vitreous traction
Fluid movements and retinal breaks
Epiretinal membranes

Promoting attachment of retina to


the eyewall
SRF drainage
Intravitreal bubble of gas or air
Reducing vitreretinal traction

By Hilton and Grizzard

Gases

Physical characteristics
of gases
Purity
Expansion Longetivit Non
y

expansile
conc.

Air

5- 7 days

0%

SF6

99.9

2x

10- 14 days

18%

C3F8

99.7

4x

30-35 days

14%

Xe

99.995

Contraindications to pneumatic
retinopexy
a. Breaks larger than one clock
hour or multiple breaks over more
than one clock hour
b. Breaks in inferior four clock hours
c. Proliferative vitreoretinopathy grade
C or D
d. Physical disability or mental
incompetence preventing
maintainance of head positioning
4. Severe uncontroled glaucoma/recent
Catract surgery
5. Cloudy media preventing adequate

Complications of pneumatic retinopexy


Intraoperative complications

Postoperative complications

Elevated iop

New retinal breaks

Vitreous haemorrhage

Infective endophthalmitis

Vitreous incarceration

Cataract

Subconjunctival gas

Intravitreal proliferation

Extension of detachment

Low anatomic success rate

Multiple gas bubbles


Subretinal gas
Enlargement of tears

By Robert Machemer

OTHER MODALITIES
1. Lincoff balloon
2.
3.
4.
5.

(Orbital/Episcleral)
Absorbable scleral buckles
fascia lata or Gelatin
Suprachoroidal hyaluronic acid
Subretinal fluid drainage and
intraocular gas injection
Primary vitrectomy without
buckling

1. LINCOFF BALLOON (orbital


/episcleral)
Used to create a temporary scleral

buckling
A deflated balloon with catheter is
inserted into the tenon space via a
conjunctival incision, which is then
inflated by fluid to cause scleral
indentation
Cryotherapy before or
photocoagulation after insertion to
create C-R adhesion

2. Absorbable scleral buckles


Fascia lata - it has excellent strength and

mild elasticity with easy manipulation and


no immunogenic reactivity
It eventually gets bonded to the episclera
It has low rate of extrusion and reinforces
thin sclera
It can also be layered or coiled to achieve
great thickness and width
Other materials used preserved sclera,
plantaris tendon, Achilles tendon, Cartilage,
tarsus, perichondrial tissue, dura matter,
embryonic bone and human skin

2. Absorbable scleral buckles


cont/
Gelatin : available as thin dehydrated sheets, which

are then hydrated and cut to required sizes


May produce severe allergic reactions
Usually used with scleral dissection and embedded in
the scleral bed
Can be used in non drainage surgery since its
buckle height increases on absorbing fluid
Slowly absorbed in 2-24 months and then its effect
disappears
Can be used beneath the silicone buckle
Other absorbable materials : collagen, catgut and
fibrin (not commercially available)

3. Suprachoroidal hyaluronic
acid
By injecting materials like

hyaluronic acid into the


suprachoroidal space, the
choroid and the RPE are pushed
against the retina and apposed.

4. SRF drainage and intraocular gas


injection
Scleral buckling is not done
Drainage is f/b subsequent intraocular

gas injection
Combines the advantages of
pneumatic retinopexy with that of
conventional RD surgery
CANDIDATE small or medium sized
breaks in the superior quadrants
without significant vitreoretinal traction

5. Primary vitrectomy without


buckling
Usually reserved for complicated

detachments wherein it decreases


the risk and difficulties associated
with scleral buckling
Helps to relieve the traction and
assists in introducing a sizeable
amount of intravitreal gas

6. Nd: Yag laser vitreolysis


Nd:Yag is used to cut the flap of hourshoe

shaped retinal tears


Traction is understood to be relieved when
the flap becomes a free operculum and is
pulled centrally into the vitreous

7. Combination of techniques
The most commonly used methods

are scleral buckling and intraocular


gas tamponade
Other alternatives : combining
pneumatic retinopexy with orbital
balloon or aspiration of liquid
vitreous or absorble scleral
buckling materials

PROPHYLAXIS OF RD
CANDIDATES

1.Symptomatic holes
2. Aphakic holes
3. Fellow eye with detachment
and breaks
4. Asymptomatic holes in
dialysis, GRT
5. Snail tract degeneration with
holes
6. Lattice degeneration in fellow
eyes, aphakia and myopia

Complication of RD surgery

Complication of RD surgery
contd/

COMPLICATIONS OF RD SX
contd/

late glaucoma
Pupillary
block
glaucoma

cataract in
an eye with
(inverted
pseudohypopyon

band keratopathy

LATE REDETACHMENT

RD prognosis & VA:


90-95%

- Approx. success.

Overall

40-50% 20/50 or >


25% 20/60 20/100
25% 20/200 or <

RD prognosis & VA: cont.


If

macula off < 1 wk 75% 20/70 or >.

If

macula off 1-8 wk 50% 20/70 pr >.

If

macula on 90% Preop. VA pucker,

CME, recurrent RD.

RD Prognosis:
1.

Excellent prognosis (nearly 100%):


Detachments due to dialysis or to small or
round holes.
Detachments with demarcation lines.
Detachments with minimal subretinal fluid.

RD Prognosis: cont.
2.

Slightly poorer prognosis (95%):

Aphakic detachments.
Total detachments.
Detachments with associated de-tachment of
the nonpigmented epithelium of the pars
plana.
Detachments caused by flap tears.

RD Prognosis: cont.
3.

Poor prognosis (50 to 70%):

Detachments with associated choroidal


detachment
Detachments with breaks larger than 180.
Detachments with PVR.
Detachments in patients with sticklers
syndrome.
Detachments caused by acute retinal
necrosis.

Clinical Trials

Gas Injection: PR
Tornambe published experiences in 302

eyes, in which he found a single


injection attachment rate of 68%
and a final attachment rate after
reoperations of 95%, with a minimum
follow-up of 6 months.
He found that the extent of retinal
detachment, the number of breaks and
the lens status affects the rate of
attachment.
In a subgroup where less than 25% of
the retina is detached with a single

Gas Injection: PR contd/


Recently, Ellakwa evaluated long-term data

after PR in a prospective interventional


case series of 40 patients and found a
stable reattachment of the retina in
60% after a single injection
The final anatomical success rate after
additional procedures was reported as
96.1%, additional breaks were found
in 11.7% and PVR occurred in 5.2%
according to a review by Chanet al.

Gas Injection: PR contd/


In a recently published retrospective chart analysis

of 213 patients receiving PR, Daviset al. found a


single injection success rate of 64% with a followup of at least 6 months. T
They found that vitreous hemorrhage and large
detachments (>4.5 clock hours) are indicators for a
high risk of failure.[
Single injection success rates are different between
phakic and nonphakic eyes. In phakic eyes, success
rates are reported to be between 71 and 84% and in
nonphakic eyes the success rates are between 41 and
67%.

Complications of PR were new retinal

breaks (733%), cystoid macular edema (0


8%), subretinal gas (04%), PVR (313%),
cataract formation (120%) and epiretinal
membranes (211%)

Primary Pars Plana Vitrectomy


In a retrospective comparative case series

Kinoriet al. found a reattachment rate of 81.3% in


patients treated with vitrectomy alone, whereas the
reattachment rate after one surgery was 87.1% in
patients where vitrectomy was combined with an
encircling band.
The difference was not statistically significant.
There was also no difference in final visual acuity
between the two groups.
In that study all patients were included if they had either
ppV or ppV and SB. Patients after trauma, with PVR C or
worse, giant retinal tears, children under 16 years,
patients with previous vitreoretinal procedures and
patients with proliferative retinal diseases were excluded

Primary Pars Plana Vitrectomy contd/


In another retrospective study by Mehta

and coworkers, a significant difference in


reattachment rates occurred in phakic
patients; 83% in the vitrectomy alone
group versus 97% in the vitrectomy and
encircling band group. In pseudophakic
patients no difference was found
In another study by Weichelet al.,
reattachment rates in pseudophakic retinal
detachments were 92.6% in the vitrectomy
alone group and 94% in the ppV and SB
group, which was not significant. Also, the
rate of complications was statistically not

Primary Pars Plana Vitrectomy


contd/
Wickhamet al.found no difference in the

reattachment rates between vitrectomy


with or without a buckle in detachments
caused by inferior breaks.[

Primary Pars Plana Vitrectomy contd/


Another debate is the use of transconjunctival techniques

using 23, 25 or even 27 gauge instruments for


vitrectomy.
In a retrospective chart review, Muraet al.found a single
success rate of 92.4% after 25-gauge vitrectomy
These very good data were confirmed by Bourlaet al. with
single surgery success rates of 97.4% in a retrospective case
series with a follow-up of 3 months.
Similar data were reported by Milleret al. (92.9%)and
Mendrinoset al. (92%).
However, only 74% were reported by Lai and coworkers.[
For 23 gauge vitrectomy, good single surgery success rates
were also reported. In Tsanget al.'s prospective case series,
this rate was 91.7%

Primary Pars Plana Vitrectomy contd/


In a retrospective comparison between 25- and 20-

gauge vitrectomy, von Frickenet al.reported


single surgery success rates of 90.6% for 25gauge vitrectomy and 91.8% for the 20-gauge
group.
Colyer and coworkers compared success rates of
transconjunctival 25-gauge vitrectomy with the
standard 20-gauge approach.
They found a single operation success rate after 25gauge transconjunctival vitrectomy in 83.3% and
in 89.6% after 20-gauge vitrectomy in
pseudophakic eyes with inferior breaks, indicating
no difference

SB versus Primary Vitrectomy


Schaalet al. noted

reattachment rates of 86% for


SB, 90% for ppV alone, 94% for
the combination of SB and ppV
and 63% for PR after 1 year.
For pseudophakic retinal
detachments Le Rouicet al.
found similar reattachment
rates for SB as well as for ppV

SB versus Primary Vitrectomy


contd/
In SPR TRIAL,
In phakic eyes, primary reattachment was achieved

in 63.6% with SB and in 63.8 % with vitrectomy. Final


anatomical success was also the same. However,
final visual acuity was worse in the vitrectomy group
because of cataract progression.
In pseudophakic eyes, primary reattachment was
achieved in 53.4% of eyes after SB but in 72.0% of
eyes after vitrectomy. This difference was statistically
significant.
The final anatomic success again was the same;
however, in the SB group more patients needed
further intervention

SB versus Primary Vitrectomy


contd/
Azadet al. did not find a

statistically significant difference


between SB and ppV with respect to
retinal reattachment rates (80.6%
for SB vs 80% for vitrectomy).
Cataract progression in the
vitrectomy group was the major risk
factor for worse visual outcome,
confirming the SPR findings

PR versus SB
The Retinal Detachment Study was a prospective

clinical trial where SB was compared with PR in a


multicenter setting.
A total of 198 patients were followed over 6 months.
Patients were recruited with retinal breaks not greater
than 1 o'clock diameter and located in the superior twothird of the fundus. Significant PVR was excluded.
The single operation reattachment rate was 82%
for SB and 74% for PR.
Final success rates were 98 and 99%, respectively.
The occurrence of PVR was not significantly different
between the groups but the morbidity was less in the PR
group and the visual acuity was better in the PR group.
Therefore, PR was recommended for those types of
retinal detachments meeting the admission criteria

PR versus SB contd/
Mulvihillet al. conducted a small

prospective clinical trial comparing ten


patients with PR and ten patients with SB.
They reported a final success rate of
90% in the PR group and 100% in the
SB group after one or more
procedures

PR versus SB contd/
In the comparative case series of Hanet

al., single procedure success rates were


reported for PR as 62% and for SB as
84%.
In this series, 50 eyes in each group were
followed for a minimum postoperative
period of 6 months.
However, the final reattachment rate was
98% in both groups.
For phakic eyes the visual outcome was
comparable in both groups

RECOMMENDATIONS FOR VR SX
Simple detachment (phakic eye, one

break less than 1 o'clock size, shallow


detachment, no PVR, no visible traction,
and good visibility): SB or PR (if the
resources for SB are not given);
Complex detachment (pseudophakic eye
or bad visibility, PVR, large breaks, multiple
breaks, irregular breaks, central breaks or
other complicating factors): primary
vitrectomy or primary vitrectomy plus SB

THANK YOU