DR M SAQUIB RETINAL DETACHMENT

1. RETINA – RETINAL DETACHMENT 11 th June 2020 May
2020AL KERATITIS
DR M SAQUIB
MBBS,MS , FSCEH DELHI,FHVDESAI PUNE,
EX REGISTRARA JNMCH,AMU
CONSULTANT OPHTHALMOLOGIST
HOD D/O OPHTHALMOLOGY
G.S .MEDICAL COLLEGE
Founder sec: MEDICS India ,
Mail-dms2k5@gmail.com , 9634123800

2. • Seperation of Neurosensory Retina from the Retinal
Pigment Epithelium ,with the accumulation of sub
retinal fluid condition ..Retinal Detachment
• vitreous liquid leaks through retinal tear and accumulates
underneath retina retina can peel away from underlying
layer of blood vessels
• Firmly Adherent To The Underlying Bruch’s Membrane of choroid
• And Loosely Arranged To The Layer Of Rods And Cones
• The Potential Space Between RPE And The Sensory Retina Is Called Subretinal Space

3. • Rhegmatogenous RD
• Tractional RD
• Exudative RD

4. Rhegmatogenous RD
• 1: 10000
• Both Eye eventually involved 10%
• 45-65 years
• Early Age if Predisposed

5. For asymptomatic patients who are at risk for retinal
detachment, a dilated fundus examination should be performed
at the first examination and periodically thereafter. Common risk
factors include
• Aging - More Common In People Older Than 40
• Previous Retinal Detachment In One Eye
• Family History Of Retinal Detachment
• Extreme Nearsightedness
• Previous Eye Surgery
• Previous Severe Eye Injury Or Trauma
• Capsulotomy (Especially The 6 Months Following The Procedure)
• Proliferative Retinopathies (Proliferative Stage Diabetes, Sickle Cell, Branch Retinal Vein Occlusion)
• Lattice Degeneration
• Open-angle Glaucoma In Myopic Patients Treated With Strong Miotic Agents

6. High myopia—the thin, stretched retina of high myopic eyes is at risk for tears
(greater than 5 diopters 2% risk, greater than 10 diopters, 5% risk).

9. Pathogenesis
• POSTRIOR VITREOUS DETACHMENT :
Separation of Cortical Vitreous from Internal Limiting
Membrane of the Neurosensory Retina posterior to
the vitreous base .

11. Primary prevention
• Risk factors for retinal detachment should have
serial dilated fundus examinations with scleral
depression, often yearly.
• Protective eyewear is recommended for
individuals with high myopia that participate in
contact sports.
• Patients undergoing cataract surgery should be
counseled about the importance of reporting
symptoms of retinal tears and detachments.

12. History
• New onset significant photopsias and/or persistent new
floaters should be suspected of having a retinal tear,
which could lead to a retinal detachment.
• A patient with constant fixed or slowly progressive visual
field loss should be suspected of having a detachment
until proven otherwise.
• onset of symptoms, presence and duration of decreased
central visual acuity, prior trauma, prior surgery,
Haemorrhage, and a complete past medical history and
review of systems.

14. Symptoms
• Photopsia – Flashes of Light ,Vitro-Retinal
irriation
• Floaters : bits of debris in field of vision that look
like spots, hairs or strings
• Shadow Encroaching to field of vision / Curtain
like effect .
• Sudden Painless loss of vision

15. External Examination
Signs
• Intraocular Pressure-Slighty lower
• Marcus Gunn pupil –RAPD
• Distant direct Ophthalmoscopy –No Red Reflex , Greyish Reflex
• Ophthalmoscopy – Direct /Indirect with Indentation
• Visual Field Charting – Relative to Absolute scotoma
• ERG –Abnormal to Absent
• Ultrasonography - Role in Dense cataracts ,Vitreous haemorhage ,
Hazy media

16. Ophthalmoscopy
• Freshly Detached Retina – Grey Reflex , convex
configuration , Oscillate with movement of eye Bullous
RD , Funnel RD ,Total TRTD
• Retinal Break- Periphery , Upper-Temporal
• Vitreous pigments : Anterior vitreous ( tobacco dusting
/shaffer sign ) with PVD
• Old Retinal Detachment

17. Clinical Diagnosis
Clinical diagnosis
• Rhegmatogenous Retinal Detachment Has A Corrugated
Appearance And Undulates With Eye Movements.
• Tractional Detachments Have Smooth Concave Surfaces With
Minimal Shifting With Eye Movements.
• Serous Detachments Show A Smooth Retinal Surface And Shifting
Fluid Depending On Patient Positioning.
• In The Vast Majority Of Cases, A Retinal Break Will Be Identified
With Proper Examination, Thus Confirming A Rhegmatogenous
Retinal Detachment.
• Without Visualization Of A Retinal Break, The Diagnosis Of
Rhegmatogenous Retinal Detachment Should Be Questioned,

19. Differential Diagnosis
• Retinal Detachment Includes Retinoschisis,
Choroidal Mass. Rhegmatogenous Retinal
Detachment Is Most Often Confused With
Retinoschisis And Serous Retinal Detachment.
Retinoschsis Can Be Distinguished From Retinal
Detachment By Appearance On Ultrasound,

21. COMPLICATION
• Longstanding RD
• Proliferative Vitroretinopathy (PVR)
• Complicated cataract
Uveitis

22. TREATMENT
• Principles :
Sealing of Retinal Breaks
Reducing the Vitreous Traction on Retina
Flattening of Retina by SRF Drainage
Tamponade ( External/Internal )

23. • 1.SEALING OF RETINAL BREAK – Aseptic
Chorioretinitis Cryocoagulation/Photocoagulation /
Diathermy
• 2.Drainage of SRF – Apposition between sensory Retina
and RPE .Fine needle through the sclera and choroid into
subretinal space .Not required in all cases

24. 3.Maintenance Of Chorioretinal Apposition
• Pneumatic retinopexy Injection of an intraocular gas bubble
along with retinopexy using cryotherapy or laser., An important
part in the successful repair of retinal detachment with pneumatic
retinopexy involves head positioning so that the gas bubble
tamponades the retinal tear. Pneumatic retinopexy is typically only
used with retinal detachments due to retinal tears in the superior
eight clock hours and involving a single break less than one clock
hour.
• Scleral buckles are silicone bands permanently placed around the
outside of the globe under the extraocular rectus muscles to relieve
any traction and support retinal tears. Scleral buckling is combined
with retinopexy, typically cryotherapy. oldest ,excellent results .

25. • Pars plana vitrectomy /Endolaser Photocoagulation and Internal
Tamponade with 20 gauge, 23 gauge, 25 gauge, or 27 gauge instruments
involves removal of the vitreous by way of cutting the vitreous strands with a
vitrectomy machine/handpiece and flattening of the retina through a direct
intraocular process.
• Indication- Complicated primary RD , Primary vitrectomy in Buckling case ,
Tractional RD
• Steps- Pars plana vitrectomy 3 port –internal Drainage of SRF –Retina
flattening by Injecting Silicone Oil /Perfluorocarbon liquid – Endolase – Internal
tamponade ( Silicone oil or exchanged with gas like Sulfur Hexafluoride or
Perfluoropropane)
•

26. Prophylaxis
• Retinal Break Laser or Cryo
• Lattice degeneration “ “
• Myopia
• Aphakia
• RD in fellow Eye
• Family History

27. TRACTION RETINAL DETACHMENT
• Progressive contraction of fibrovascular
membrane over large areas of vitroretinal
adhesions .

29. Causes
• Proliferative Diabetic Retinopathy (PDR)
• Retinopathy Of Prematurity
• Retinal Vein Occlusion
• Proliferative retinopathy in Eale’s disease
• Trauma ( Penetrating Posterior Segment )
• Sickling Hemoglobinopathies
• Idiopathic Vasculitis

30. Presentation
• Vitreoretinal Bands
• Retinal mobility Reduced/ No shifting Fluid
• NO Photopsia ,Floaters
• No Vitreoretinal Traction is insidious and not associated
with Acute PVD
• DOV
• Slow visual Field Defect

31. Signs
• I.O : RD with Concave configuration
• Sub Retinal Fluid –Shallow , Immobile
• RD rarely extend to Ora serrata .
• No Retinal Break

32. Treatment
• Systemic cause
• Vision threatening -0 Pars Plana VitrectomyPars
Plana Vitrectomy to cut vitreoretinal Tractional
Bands and Internal Tamponade with Long Acting
Gas or Silicone Oil
• Prognosis-Poor
•

33. EXUDATIVE( Serous,Solid ) RETINAL
DETACHMENT
• Seperation of Neurosensory Retina from Retinal
Pigment epithelium with the accumulation of
Subretinal fluid or Neoplasm, SRF is derived
from Retinal or Choroidal Vessels .

34. Causes
• OCULAR
• Inflammation : Posterior scleritis,Orbital cellulitis ,Sympathetic
ophthalmia Harada’s Disease
• Congenital Abnormalties– Choroidal Coloboma ,Familial Exudative
Vitreoretinopathy( FEVR),Optic Pit
• Vascular Disease- Central serous retinopathy ,Coat’s Retinopathy
• Malignant- Choroidal Tumoour,Exophytic Retinoblastoma ,Haemangioma
• Sudden Hypotony – Post Operative
• Uveal Effusion Syndrome- Bilateral Detachment of
Peripheral Choroid
• Choroidal Neovascularisation

35. Systemic
• Toxaemia of Pregnancy
• Renal Hypertension
• Blood dyscrasias
• Polyarteritis Nodosa

36. Presentation
• No Photopsia ( No Vitro Retinal Traction )
• No Retinal Break
• Floaters - +/- If Vitritis is present
• Visual Field Defect – Sudden ,Progressive
• Simultaneous Bilateral Involvement

37. Signs
• IO – Covex configuartion , Smooth Surface
• SRF -Deep , Mobile – Shifting Fluid
• Cause of RD may be apparent
• Scattered Subretinal Pigment Clumps may be
seen after Resolution ( Leopard Spots )

38. • For Rhegmatogenous Detachments, All Retinal
Breaks Should Be Identified, Treated And Closed.
Techniques For Repair Include Pneumatic
Retinopexy, Scleral Buckle Or Vitrectomy, Or
Combinations Of These Techiques.

39. In tractional detachments, tractional elements
(usually epiretinal or subretinal membranes) must
be relieved. This is typically accomplished with
pars plana vitrectomy, but may be combined with
scleral buckling as an adjunct.
• serous detachments, management is nonsurgical.
Any inflammatory disease or underlying mass
should be identified and treated if possible.