2. • Retina consists of ten layers which form two distinct functional
components
• The retinal pigment epithelium and sensory retina
• These ten layers from without inward are :
1. Retinal pigment epithelium
2. Layer of rods and cones
3. External limiting membrane
4. Outer nuclear layer
5. Outer plexiform layer
6. Inner nuclear layer
7. Inner plexiform layer
8. Ganglion cell layer
3.
4. 9. Nerve fibre layer
10. Internal limiting membrane
• The potential space between RPE and sensory retina is called
subretinal space
• A separation of RPE and sensory retina is called Retinal detachment
5. Rhegmatogenous retinal detachment Exudative retinal detachment
Tractional retinal detachment
Combined – Rhegmatogenous plus
tractional
Retinal detachment is
mainly of three types :
Others : Macular hole associated detachment
7. Rhegmatogenous retinal detachment :
• Rhegma means break in Greek
• Separation of neural retina from RPE as a result of vitreous
through retinal defect ( retinal breaks ) into sub retinal space
• It is an important cause of visual disability
• If untreated symptomatic RRD progress to total blindness
8. Total RRD : Separation of entire retina
Subtotal : Detachment of most of it
Subclinical : SRF extending more than one DD from the break but less than
two DD
posterior to the equator
Retinal break without detachment : Subretinal fluid less than one DD
9. Epidemiology :
• Incidence is 5.3 – 12.6 cases per 100000
• Peak incidence is between 50 to 79 years
• Males are affected more than female
Pathogenesis :
• The main factors causing RRD are vitreous liquefaction ( synchysis )
and collapse ( syneresis )causing posterior vitreous detachment
10. synchysis and syneresis
PVD
focal retinal traction
retinal breaks
migration of liquified vitreous into subretinal space
detachment if involves macula
central vision loss
11.
12. • Vitreous liquefaction occurs due to degenerative changes in
collagen fibril hyaluronan matrix
• Liquefaction cause lacunae which progress to PVD
Conditions which cause liquefaction are :
Pathological myopia ( > 6 D )
Surgical / non surgical trauma
Intraocular inflammation – Viral retinitis
Congenital – Marfans , Stickler syndromes
Pseudophakia and aphakia
Proliferative vitreoretinopathy
13. Degenerative retinoschisis
Other inherited and acquired ocular disorders
• Common site for retinal break are at peripheral retina that is at
vitreous base
Aggravating factors :
Rotational and saccadic eye movements play a role
Young males with posterior capsular rent have high chances of RRD
Crystalline lens extraction cause early induction of PVD
14. Rotation of eye
Detached vitreous gel causes it to lag behind rotation of eye and
attached retina
Exerts equal and opposite force on retina
Retinal break
If vitreous remains attached to retina ( horse shoe tear flap at vitreous
base )
15.
16. Eye movements
Asymmetrical traction at flap holding it open
Liquified vitreous into subretinal space
When movements stop VRT in opposite direction
• When fluid flow into subretinal space overwhelm capacity of RPE to
pump fluid from this space
17. Other risk factors :
Mainly the peripheral retinal degenerations like
Lattice degeneration
Snail track degeneration
Vitreoretinal tufts
Meridonial folds
White with pressure and without pressure
18.
19. Retinal Breaks :
• They are either retinal tears or retinal holes
• Retinal tears are associated with vitreoretinal
traction while holes are atrophied tissue
• Full thickness retinal tear with persistent VRT
retinal flap tear ( Horse shoe shaped )
leads to RRD
• Dialyses are linear or circumferential retinal breaks along with ora
serrata mostly associated with blunt ocular trauma or
20. Ocular Manifestations :
• Sudden appearance of floaters – condensation of vitreous gel ,
pigment granules or VH released in process of break formation
• Fleeting photopsias ( flashes ) - due to vitreous traction on retina
resulting in neuronal activity by mechanical manipulation
• More following dark and following rotatory eye movement
21. Accumulation of SRF – relative scotomata
detachment progresses posterior to equator
symptomatic with loss of peripheral vision
curtain falling over visual field
SRF beneath macula
central vision loss
22. • Young patients with myopia may have slowly progressive
asymptomatic RD without PVD
• Most common in temporally and inferiorly
• If area of detachment is large there may be afferent pupillary defect
also
24. Visual acuity – spared if macula is spared
Visual field – Depends on location of detachment
IOP – usually is low – due to increased outflow of intraocular fluid
through
subretinal space
- sometimes raised IOP due to photoreceptor outer segment and
other debris clogging the trabecular meshwork – SCHWARTZ –
MATSON SYNDROME
Slit lamp – Mild anterior chamber reaction
- Presence of pigmented cells in anterior vitreous Tobacco
dust / Shafer sign
- Weiss ring
25. IO – RRD – convex configuration
retina slightly opaque – linear / arc shaped ripples which
hydration lines due to retinal edema
Acute detachment – retina mobile with eye movements
Chronic detachment – decreased mobility of detached retina
• Demarcation lines formed by migration of RPE at border of attached
and detached retina
• Retinal thinning due to atrophy
• Large intraretinal cysts
• Visible preretinal or subretinal membranes ( PVR )
26. Examination : It includes
1. Identifying the extent of retinal detachment
2. Finding of all retinal breaks
3. Determining whether RRD is macular on or off
4. Checking for associated features
5. Documenting the findings on Amsler Dubey chart
6. B scan ultrasound
27. 1. Extent of detachment :
• Detached area is opaque and corrugated
with undulating retinal folds during
eye movement
• Borders are convex and SRF is clear
and non shifting
28.
29. 2. Finding all retinal breaks :
• Lincoffs rule is useful for identifying precise location of retinal break in cases of
primary RRD
• The number , size and location of the breaks is noted
• If there are multiple breaks highest retinal break is considered as primary hole
30. Lincoffs rules :
Detachment area Primary break location
1. In shallow RD with SRF slightly higher on temporal
side
Inferiorly on that side
2. Inferior RD with equal fluid levels 6’0 clock
3. In inferior bullous RD Above the horizontal meridian
4. SRF around optic disc and raised on temporal side Upper nasal quadrant
5. Subtotal RD with a superior wedge of attached
retina
Periphery nearest its higher border
6. SRF crosses the vertical midline 12’0 clock corresponding to lower edge of break
33. B scan :
• Status of macula involved
• Presence of PVD
• Location of break
• Chronicity of RRD
RRD PVD
• High reflectivity
• High spikes on A scan
• Membrane within vitreous
cavity
• Mobility during eye
movements
• Visible with low gain
• OD attachment present
• Posterior hyaloid face
• Low spike on A scan
• High degree of mobility
during eye movements
• Disappears with low gain
• OD attachment present or
absent
34.
35. Proliferative viteoretinopathy :
• Caused by epiretinal or subretinal
membrane formation leading to
tangential retinal traction
• Complication of RRD or r surgery or
penetrating trauma
36.
37. Differential
Diagnosis :
TRD – PDR ,
penetrating
trauma
ERD – Inflammatory
disorders , choroidal
neoplasms , Retinal
vascular tumors and
others
Retinoschisis
– Age related
or congenital
Elevated choroidal
lesions – choroidal
detachments or
tumors
Vitreous
hemorrhage
38.
39. Management :
• Must counter the factors and forces that cause retinal detachment
and
• To reestablish conditions that maintain physiological contact
between neural retina and pigment epithelium
• RRDs with superior breaks that threaten macula require urgent
vitreoretinal intervention
• While awaiting definitive management patients should maintain
posture that prevents SRF from detaching macula
41. Barrier laser retinopexy :
• Indicated for localized detachments like subclinical retinal detachment
• Done under topical anesthesia
• Despite treatment RRD may progress and may require further surgery
42. Pneumatic Retinopexy :
• Creation of chorio retinal adhesion either by cryotherapy or laser
photocoagulation with injection of expansile intraocular gas as
tamponade
• Does not provide release of vitreoretinal traction like PPV or alter
tractional forces like scleral buckling surgery
43. Indication :
Phakic eye with superior retinal detachment with single retinal break
( located in superior 8 ‘0 clock hours or all breaks confined within 2 ‘0clock hours )
Contraindications :
• Large ( giant ) retinal tears
• Proliferative VitreoRetinopathy ( PVR )
• Advanced glaucoma
• Poor compliance with head posture
• Air travel
• Pseudophakia
44. Complications :
• Risk of new / mixed retinal breaks
• Gas migration into subretinal space
• CRAO due to raised IOP
• Vitreous incarceration into wound
• Accelerated cataract formation
• Endophthalmitis
Prognosis :
98 % cases – requires more than one procedure
45. Scleral buckle :
• Exoplant used to create indentation to create buckle effect on sclera
thereby moving the detached retina closer to RPE
• Buckle also alters vector forces and reduces VR traction
Indications :
• RRD in phakic eyes with high myopia and round holes especially
inferior holes without PVD
• RD due to dialyses
Contraindications :
• Giant retinal teras
• PVR
46. Advantages :
• No or reduced postoperative positioning
• Maintenance of crystalline lens
• Permanent protection of vitreous base
• Help to prevent recurrent retinal detachment
Disadvantages :
• Inability to drain SRF completely
• Risk for SRH in cases of external drainage
• Increased postoperative discomfort and inflammation
47. Procedure :
360 degree conjunctival peritomy
Recti muscles are slinged
Localising the break with binocular IO
Cryotherapy with or without external drainage of SRF
Inserting segmental and / or encircling or radial scleral buckle
48. Suturing and tightening of buckle
Check perfusion of CRA to determine need for AC paracentesis
Antibiotic wash around buckle
Conjunctiva is closed
Subconjunctival antibiotic and steroid injection given
49. Complications :
Intraoperative :
• Scleral perforation
• Recti muscle trauma or slip
• SRF drainage - Suprachoroidal haemorrhage
Hypotony
Retinal incarceration at drainage site
Postoperative :
• PVR formation
• Redetachment
• Buckle migration or exposure
50. • Buckle related infection
• Refractory changes
• Ocular motility disorders
• Anterior segment ischemia
• Glaucoma ( Due to vortex vein or
ciliary body compression )
Prognosis :
80 – 90 % cases – reattachment possible with single primary scleral
buckle
Study - MUSTARD
52. Steps :
Three sclerostomy ports ( infusion cannula , light probe , vitrectomy
cutter )
Core vitrectomy and shaving of vitreous base ( relieves vitreous traction over
break )
Perfluorocarbon to flatten retina and displace SRF via original retinal break
Retinopexy around break - laser photocoagulation
Fluid – air exchange Vitreous substitutes ( gas or silicone oil
53. Postop advice :
• Posturing to allow buoyant vitreous substitutes to tamponade the
break
• For intraocular gas , until the gas bubble has been resolved
Prognosis :
Success rate 64 to 96 %
55. Combination of vitrectomy and scleral buckle :
• Inferior retinal breaks ( esp. phakic eyes )
• Multiple retinal breaks
• Extensive lattice degeneration
• Conditions with abnormal vitreoretinal interface ( Stickler syndrome )
• Reoperations
• Poor outcomes of other eye with vitrectomy alone
• Relatively when the encircling band is chosen to protect vitreous base (
360 degree ) prior to PPV
56. Timing of surgery depends upon certain conditions :
• Status of macula – Macula On – within 24 hours
Macula Off – within a week
• Duration of detachment – Acute – prompt surgery
Chronic – Routine day
• Location of break – RRD with superior breaks progress faster than
detachments with inferior breaks
• Number of days of foveal detachment determines the maximum
number of days that can be awaited for surgery in macula off cases
• Surgery within three days of developing central vision loss has better
visual prognosis
57. Course and Outcome :
• Approximately 95 % of all RDs can be successfully repaired
• Failure of PPV is due to – Failure to identify all breaks
New retinal breaks
Proliferative vitreoretinopathy
Non compliance of patient to positioning
• Scleral buckle – Inadequate buckle height or position
Inadequate cryotherapy
PVR
Missed breaks
58. Outcome :
Outcomes are divided mainly into
Anatomical success Functional visual outcome
• Macula detached by SRF some degree of permanent damage to
vision occurs inspite of reattachment
• Macula on detachment – 73% greater than 20/40 vision occurs two
months after surgery
59. • Macula off Detachment – depends on duration of detachment
Less than 10 days 11 days to 6 weeks > 6 weeks
More than 20/40 vision
71 % 27% 14%
60. Other reasons for decreased vision are
Subsequent reattachment surgery
Progressive ischemic or infectious retinal damage
Persistent SRF despite closure of all breaks
