2. RETINAL DETACHMENT
DEFINITION AND MEANING:
Retinal detachment occurs when there is a
separation of the neurosensory retina from
the under lying pigment epithelium layer of
the retina .
Because the neurosensory retina the part
of the retina containing rods and cones is
detached from the nourishing retinal
pigment epithelium , these photosensitive
cells can not perform there visual function
and loss of sight results.
3. CAUSES:
Congenital malformations
Metabolic disorders
Vascular disease
Intraocular inflammation
Neoplasm
Trauma
Degenerative changes in in the vitreous or
retina
Most commonly they are caused by the
mechanical forces associated with posterior
vitreous detachment and retinal tears.
Tear-induced (rhegmatogenous) detachment
are the most common detachment
4. PREDISPOSING CONDITIONS
-Cataract extraction
-Mostly occurs between the age of 50and 70
-The over all incidence is 1 in 15000 people per
year
-High Myopia
-Lattice degeneration
- Aphakia (surgical removal of part or all of the
crystalline lens)
-Trauma
-Degenerative changes (Liquefaction)
-associated with aging
5. PATHOPHISIOLOGY:
Due to any causes or predisposing factor the
retina is separated from its choroidal blood
supply.
It will die and Small gap is developed in between
retina and choroidal part .
Exudative serous fluid is collected in this gap.
The retinal tissues are at the high risk of
vascular necrosis because they are delicate
structures and have a high metabolic rate.
That part of retina is detached and accordingly
visual defect is seen in the patient .
6. E.G. If a tear in the temporal region , which
is affected more frequently , create a visual
defect in the nasal area..
So visual field is impaired in opposite
quadrant of the actual detachment.
7. CLINICAL MANIFESTATIONS and
DIAGNOSTIC FINDING
A patient usually reports a history of floaters or
flashing lights or both.
The floaters may be perceived as tiny dark spot s or
cobwebs
Later the patient may notice a spreading shadow or
curtain moving across the field of vision, resulting
in blurred vision and loss of visual field as the retina
separates from the pigmented epithelium.
Dimness of vision gradually increased without
pain
The onset is usually sudden
Decreased central acuity or loss of central vision
indicates that the macula area is involved
8.
9. Examination (ophthalmoscopy)
1.Examination with direct and indirect
ophthalmoscope reveals the portion of
the retina involved and the extent of the
detachment .
2.A scleral depressor also may be used
externally on the lid or conjunctiva to assist
in rotating the eyeball and to indent the
retina for increased viewing ability .
3.Area of detachment appear bluish-gray as
opposed to the normal red pink color.
4.Tears are most often horseshoe-shaped but
may be round.
11. MANAGEMENT:
EMERGENCY CARE
If not treated promptly, a retinal
detachment may progress to involve the
macula ; this greatly compromises visual
acuity. A retinal detachment is an
ophthalmic emergency and even more so if
visual acuity is still normal.
There is no known medical treatment for a
retinal detachment
12. SURGICAL MANAGEMENT
The goal of surgical repair of retinal
detachment is to place the retina back in
contact with the choroid and to seal the
accompanying holes and breaks.
13. LASOR PHOTOCOAGULATION
CRYOPEXY
Cryopexy means by using of a freesing
probe seal the hole if it has not progressed
to detachment .
Both methods create inflammation around
the area which scars and seal the hole.
Some exudative or serous retinal
detachment due to tumor or inflammatory
that produces sub retinal fluid without a
retinal break respond to laser
photocoagulation
14. Laser procedures form scar tissue on the
retina, sealing it to the pigmented
epithelium.
Diabetic retinopathy or trauma with
vitreous hemorrhage may require vitreous
surgery to relieve the tractional forces to the
retina that they cause.
15. RADIATION
Radiation therapy may be useful in treating
retinal detachments associated with
intraocular tumors.
16. SCLERAL BUCKLING :
It is the primary surgical procedure performed
to reattach the retina.
Transscleral cryotherapy is applied around
each retinal tear, producing a chorioretinal
adhesion that seals the break so that liquid
vitreous can no longer pass through in to the
sub retinal space .
A piece or pieces of silicone are sutured and
infolded in to the sclera , physically indenting ,
of buckling , the sclera , choroids , and
photosensitive layers up to the pigmented
epithelium , supporting the breaks .
17. When the retina thus comes in to contact
with the underlying, supportive tissue,
normal physiological function is restored.
Often, external syringe drainage of sub
retinal fluid is necessary to bring the
detached retina closer to the buckled area so
that the retina can be reattached.
18. During surgery it may be necessary to inject
inert gas (e.g. sulphahexalfuoride SF6,
octofluroptopane C3F8, or air bubble) into
the vitreous body to maintain intraocular
pressure or to assist in flattening the retina.
Depending on which gas is used, the bubble
will be reabsorbed and replaced by aqueous
fluid in 3 days to 2 months.
19. Between 90% and 95% of retinal detachments can be
reattached and good visual acuity achieved with scleral
buckling, although more than one procedure may be
needed.
Full visual recovery may not be achieved, even with
successful reattachments, in patient with chronic
retinal detachment or in those macular involvements.
Detachment that can not be reattached by scleral
buckling may require vitreous surgery.
20. Approximately 25% of patient with complex retinal
detachments do not respond to conventional surgical
procedures.
Instillation of perfluorocarbon liquid as an adjunt to
treatment of these patients has improve ed visual
outcome .
21.
22. PREOPERATIVE CARE:
Written consent
Vaccination , Inj. Tetanus toxoid 0.5ml
intramuscular state
NBM after 10.00 pm previous night
Laxative previous night
Covering of head by cloth and give O.T.
dress to the patient .
Dilate the pupil on the day of operation.
23. Preoperative nursing care involves to
preparing the client for out-door surgery or
over night stay in the hospital .
Assess the clients current level of
knowledge and understanding of the
implication of retinal detachment and the
expectations for the surgery procedure.
Because retinal detachment repair may take
several hours, general anaesthesia is used in
many cases.
The pupil must be widely dilated before the
operation, and client may be given a
sedative.
24. POST OPERATIVE MANAGEMENT:
1.Post operatively, observe the eye patches for
any drainage.
2.Blood loss in retinal detachment surgery is
minimal, and only serous drainage is
expected on
the post operative dressing.
3 Activity restriction may be necessary if an
air or gas bubble has been injected.
4.The client will need to be positioned so that
the bubble can apply maximum pressure on
the retina by the force of gravity.
25. The position usually head down and to one
side, it maintain for several days
Provide suggestions for comfort and support
with the positioning.
6. Post operative segment surgery such has
schlera kuckling procedure , results in
considerably more discomfort then an
anterior segment procedures.
7. Ocular muscles are separate , and globe is
manipulated. To reach the posterior portion
of the eye ball. Narcotic may be needed
during the first 24 hours after surgery .
8 Nausea and vomiting may also require
management.
26. 9. Intravenous Acetazolamide (diamox)
may be used to reduced increased
intraocular pressure .
10.The intraocular pressure is monitored
closely during the first 24 hours.
11.Encourage the client to resume a
regular diet and fluids as tolerated.
12.The eye patch and shield are removed
the next morning.
27. 13.Redness and swelling of the lids and
conjunctiva should be expected from the
surgical manipulation. After several days , the
swelling and echymosis of the lids subsides ,
but conjunctiva may remain red or pink for a
few weeks.
14.Post operative eye medication generally
includes an antibiotics-steroid combination
drops to prevent infection and reduce swelling .
15.Cyclopesic agents are prescribe to dilate pupil
and relax the cilliary muscles, which decreases
discomfort and helps prevent the formation of
iris adhesions to the corneal endothelium.
28. 16.Either warm or cold compresses may be
applied for comfort several times a day.
17.Instruct the client to clean the eye with
warm tap water using a clean wash cloth.
Warm compress may be continues at home.
18.Either an eye shield or glasses should be
worn during the day. And shield should be
worn during naps and at night.
29. 19.The client is usually instructed to avoid
vigorous activities and heavy lifting during
the immediate postoperative period.
20.If an air or gas bubble has been injected, it
may take several weeks to totally absorb. 21
Client is advised to avoid air travel during
this time because the gas and air expand at
high altitudes.
30. .COMPLICATION;
Increased intraocular pressure
Glaucoma
Infection
Choroidal detachment
Failure of the retina to reattached or
Redetachment of the retina
31. LATE COMPLICATION:
Infection
Extrusion of the buckling material through
the conjunctiva or
Erosion through eyeball
Proliferative vitreoretinopathy (scar tissue
involving the retina)
Diplopia
Refractive error or
Astigmatism
