RD refers to separation of the neurosensory retina from the RPE Results in the accumulation of SRF in the potential space between the NSR and RPE

1. RETINA DETACHMENT
Presenter- Shayri Pillai
Liberia Eye Centre
JFK Memorial Medical Centre
LV Prasad Eye Institute
LIBERIA
17 FEBRUARY 2021

2. Retinal detachment (RD)
 RD refers to separation of the neurosensory retina from the RPE
 Results in the accumulation of SRF in the potential space between
the NSR and RPE

3. Innocuous peripheral retinal degenerations
 Tiny vesicles with indistinct boundaries on a greyish-white
background
 Retina appear thickened and less transparent adjacent to the
ora serrata and extends circumferentially and posteriorly with a
smooth undulating posterior border
 Present in essentially all adult eyes, increasing in extent with age
 May give rise to typical degenerative retinoschisis

4.  Discrete yellow–white patches of focal chorioretinal atrophy
that may have pigmented margins
 Found between the equator and the ora serrata
 More common in the inferior fundus
 Present to some extent in at least 25% of normal eyes

5. Microcystoid seen on scleral indentation Paving stone with adjacent
microcystoid

6.  An age-related change
 Fine network of perivascular pigmentation that sometimes extends
posterior to the equator
Honeycomb(reticular)

7.  Clustered or scattered small pale discrete lesions
 Hyperpigmented borders
 Similar to drusen at the posterior pole
 Usually occur in the eyes of older individuals
Peripheral drusen

8.  Clear-walled cysts usually small in size
 Derived from non-pigmented ciliary epithelium
 Present in 5–10% of eyes
 More common temporally
 They do not predispose to RD
Pars plana Cyst

9. Peripheral Lesions Predisposing to Retinal Detachment
Patients should be educated about the nature of symptoms and
the need to be reviewed urgently if these occur

10. Lattice degeneration
Prevalence
 Present in about 8% of the population
 Develops early in life, with a peak incidence during the second
and third decades
 Found more commonly in moderate myopes
 Most important degeneration directly related to RD
 Present in about 40% of eyes with RD

11. Pathology
 Discontinuity of the internal limiting membrane with variable
atrophy of the underlying NSR
 Vitreous overlying an area of lattice is synchytic but the
vitreous attachments around the margins are exaggerated
Vitreous changes associated with lattice
degeneration

12. Signs
 Bilateral, temporal and superior
 Spindle-shaped areas of retinal thinning, commonly located
between the equator and the posterior border of the vitreous
base
 Sclerosed vessels forming an arborizing network of white lines
is characteristic
 Some lesions may be associated with ‘snowflakes’, remnants of
degenerate Müller cells
 Associated hyperplasia of the RPE is common
 Small holes are common

13.  Associated hyperplasia of the RPE is common
 Small holes are common
Wide-field images of lattice degeneration
(A)Multiple lesions with small hole (B) sclerosed vessels forming a
characteristic white network; a vortex vein is seen
superonasally

14. Complications
 Do not occur in most eyes with lattice
 Tears may develop consequent to a posterior vitreous
detachment (PVD), when lattice is sometimes visible on the
flap of the tear
 Atrophic holes may rarely (2%) lead to RD
 Risk is higher in young myopes
Retinal detachment with lattice on the flap of the tear

15. Management
 Asymptomatic areas of lattice are generally not treated
prophylactically, unless particular risk factors are present
 RD in the fellow eye
 Treatment of the fellow eye when extensive lattice (more
than 6 clock hours) is present, or high myopia
 Routine annual review of eyes with lattice, with or without
asymptomatic round holes, particularly in young myopes

16. Snailtrack degeneration
 Sharply demarcated bands of tightly packed ‘snowflakes’
that give the peripheral retina a white frost-like appearance
 Marked vitreous traction is seldom present so that U-tears
rarely occurs
 Round holes are relatively common
 Prophylactic treatment is usually unnecessary, though
review every 1–2 years may be prudent as RD occurs in a
minority

17. A) Snailtrack degeneration; (B) and (C) wide-field images of lesions before
and after limited laser retinopexy

18. Cystic retinal tuft
 Known as a granular patch or retinal rosette, is a congenital
abnormality
 Consists of a small,round or oval, discrete elevated whitish
lesion
 Typically in the equatorial or peripheral retina, more commonly
temporally associated pigmentation at its base
 Comprised principally of glial tissue; strong vitreoretinal
adhesion is commonly present
 Small round holes and horseshoe tears can occur

19.  CRT are present in up to 5% of the population (bilateral
in 20%)
 Risk of RD in a given eye with CRT is probably well
under 1%
Cystic retinal tuft
(A) Isolated uncomplicated lesion (B) tuft with small round hole

20. Degenerative retinoschisis
Prevalence
 Present in about 5% of the population over the age of 20
years and is particularly prevalent in hypermetropia

21. Pathology
 Develop from microcystoid degeneration
 Gradual coalescence of degenerative cavities resulting in
separation or splitting of the NSR into inner and outer
layers with severing of neurones and complete loss of
visual function in the affected area
 In typical retinoschisis the split occurs in the outer
plexiform layer
 Reticular retinoschisis at the level of the nerve
fibre layer

22. Symptoms
 Photopsia and floaters are absent because there is no
vitreoretinal traction
 Rare for the patient to notice a visual field defect,
even with spread posterior to the equator
 Occasionally symptoms result from vitreous
haemorrhage or a progressive RD

23. Signs
 Bilateral in up to 80%
 Inner layer is thinner and tends to be more elevated
in the latter
 Early retinoschisis usually involves the extreme
inferotemporal periphery of both fundi, appearing as an
exaggeration of microcystoid degeneration with a smooth
immobile dome-shaped elevation of the retina
 Elevation is convex, smooth, thin and relatively immobile
unlike the opaque and corrugated appearance of a
rhegmatogenous RD

24.  Lesion progress circumferentially until it has involved the
entire periphery
 Typical form usually remains anterior to the equator
 Presence of a pigmented demarcation line is likely to
indicate the presence of associated RD
 Inner layer may show ‘snowflakes’(whitish remnants of
Müller cell footplates as well as sclerosis of blood
vessels, and the schisis cavity may be bridged by grey–
white tissue strands

25. A) Retinoschisis (B) composite image of the same lesion showing merging
microcystoid degeneration

26.  Inner layer breaks are small and round
 Outer layer breaks are usually larger, with rolled edges and
located behind the equator
 Microaneurysms and small telangiectases are common, in
the reticular type

27. Retinoschisis
(A) Inner and outer layer breaks (B) Large outer layer break;
retinal vessels in the inner layer can be
seen traversing the rolled edge
undiverted

28. Development of retinoschisis
(A) Histology showing intraretinal cavities bridged by Muller cells;(B) OCT
appearance showing separation principally in the outer plexiform layer; (C) OCT of
retinal detachment for comparison; (D) circumferential microcystoid degeneration
with progression to retinoschisis supero- and inferotemporally

29. Complications
 RD is rare; even in an eye with breaks in both layers the
incidence is only around 1%
 Detachment is almost always asymptomatic, infrequently
progressive and rarely requires surgery
 Posterior extension of RS to involve the fovea is very rare;
progression is generally very slow
 Vitreous hemorrhage is rare

30. Management
 Discussion of the symptoms is prudent in all patients,
especially those with double layer breaks
 A small peripheral RS discovered on incidental examination,
probably does not require routine review
 Large RS should be observed periodically
 Photography and visual field testing are useful, with
optical coherence tomography (OCT) imaging when
posterior extension is present
 OCT is also useful for distinguishing between RS and RD

31.  Retinopexy or surgical repair may be indicated for
relentless progression towards the fovea
 Prophylactic retinopexy of the posterior border of a large
bullous RS with substantial breaks to prevent progression to
symptomatic RD
 Recurrent vitreous hemorrhage may necessitate
Vitrectomy
 Progressive symptomatic RD should be addressed
promptly

32.  More than one procedure may be necessary
 Scleral buckling may be adequate for smaller RD with
small outer layer breaks
 Vitrectomy is generally indicated for more complex RD

33. Zonular traction tuft
 15% phenomenon caused by an aberrant zonular fibre
extending posteriorly to be attached to the retina near the
ora serrata
 Exerts traction on the retina at its base
 It is typically located nasally
 Risk of retinal tear formation is around 2%, and periodic
long-term review is generally recommended

34. White with pressure
 Refers to retinal areas in which a translucent white–grey
appearance can be induced by scleral indentation
 Each area has a fixed configuration
 It may also be observed along the posterior border of
islands of lattice degeneration, snailtrack degeneration
and the outer layer of acquired retinoschisis
 It is frequently seen in normal eyes and may be associated
with abnormally strong attachment of the vitreous gel

35. ‘White without pressure’ (WWOP)
 Appears as WWP but is present without scleral
indentation
 WWOP corresponds to an area of fairly strong adhesion of
condensed vitreous
 Regular review should be considered for treated and
untreated eyes,

36. A) White with pressure (B) white without pressure (C) strong
attachment of condensed vitreous gel to an area of ‘white without pressure’

37. White without pressure wide-field images
(A) Pseudo-break (arrow) (B) retinal tear and adjacent pseudo-break

38. Myopic choroidal atrophy
 Diffuse or circumscribed choroidal depigmentation,
associated with thinning of the overlying retina
 Occurs typically in the posterior pole and equatorial area of
highly myopic eyes
 Retinal holes developing in the atrophic retina may occasionally
lead to RD

39. Myopic choroidal atrophy

40. Retinal break
 Defined as any full-thickness defect in the neurosensory retina
 Breaks are clinically significant in that they may allow liquid
from the vitreous cavity to enter the potential space between the
sensory retina and the RPE, thereby causing RRD
Some breaks are caused by atrophy of inner retinal layers
(holes); others result from vitreoretinal traction (tears)

41. Retinal breaks may be classified as:
 Flap, or horseshoe, tears
 Giant retinal tears
 Operculated holes
 Retinal dialyses
 Atrophic retinal holes

42.  Flap tear occurs when a strip of retina is pulled anteriorly by
vitreoretinal traction, often in the course of a posterior vitreous
detachment or trauma
 A tear is considered symptomatic when the patient reports
photopsias, floaters, or both
 A giant retinal tear extends 90° (3 clock-hours) or more
circumferentially and usually occurs along the posterior edge
of the vitreous base
Operculated hole occurs when traction is sufficient to tear a
piece of retina completely free from the adjacent retinal
surface

43.  Retinal dialysis is a circumferential, linear break that occurs
at the ora serrata, with vitreous base attached to the retina
posterior to the tear’s edge; it is commonly a consequence of
blunt trauma
 An atrophic hole is generally not associated with vitreoretinal
traction and has not been linked to an increased risk of
retinal detachment

44. Retinal tears. (A) Large U-tear in an area of lattice – laser retinopexy has been
performed; (B) operculated tear;(C) round holes; the blue arrows show probable atrophic
holes, the circle arrow shows a probable operculated hole with
localized subretinal fluid; (D) retinal dialysis;

45. (E) giant retinal tear (F) vitreous attached to the anterior edge of a giant tear

46. Schematic illustration of retinal tears and holes

47. .

48. Classification
RDs are classified as
 Rhegmatogenous
 Tractional or Exudative
 Most common are rhegmatogenous retinal detachments (RRDs)
 Term is derived from the Greek rhegma, meaning “break”
 RRDs are caused by fluid passing from the vitreous cavity
through a retinal break into the potential space between the
sensory retina and the RPE

49.  Tractional detachments are caused by proliferative membranes
that contract and elevate the retina
 TD are less common
 Combinations of tractional and rhegmatogenous pathophysiologic
components may also lead to retinal detachment
 Exudative, or secondary, detachments are caused by retinal
or choroidal diseases in which fluid leaks beneath the sensory
retina and accumulates there

50. Rhegmatogenous Retinal Detachment
 Incidence of 12.6 per 100,000 persons in a primarily white
population
Risk factors includes
 Myopia
 Family history
 Fellow-eye retinal tear or detachment
 Recent vitreous detachment
 Trauma
 Peripheral high-risk lesions
 Vitreoretinal degenerations
 Current or recent use of fluoroquinolones(controversial)

51. Symptoms
 Flashing lights and floaters associated with acute PVD
 Curtain-like relative peripheral visual field defect and can
progress to involve central vision
 Loss of central vision may be due to involvement of the
fovea by SRF or, infrequently, obstruction of the visual axis
by a large bullous RD

52. .

53. Identification of Retinal Breaks
Distribution of breaks in eyes with RD is approximately as
follows:
 60% superotemporal quadrant, 15% superonasal,
15% inferotemporal and 10% inferonasal
 The upper temporal region should therefore be examined in
detail if a break cannot be detected initially
 50% of eyes with RD have more than one break, often within
90°of each other

54. Configuration of SRF
 SRF spread is governed by gravity, by
anatomical limits (ora serrata and optic nerve) and by the
location of the primary retinal break
 If the primary break is located superiorly, the SRF first spreads
inferiorly on the same side of the fundus as the break and then s
uperiorly on the opposite side, so that the likely location of the
primary retinal break can be predicted
(modified from Lincoff’s rules):

55. Distribution of subretinal fluid in relation to the location of the primary retinal break

56.  A shallow inferior RD in which the SRF is slightly higher
on the temporal side points to a primary break located
inferiorly on that side
 A primary break located at 6 o’clock will cause an inferior
RD with equal fluid levels
 In a bullous inferior RD the primary break usually lies
above the horizontal meridian

57.  If the primary break is located in the upper nasal
quadrant the SRF will revolve around the optic disc and
then rise on the temporal side until it is level with the
primary break
 A subtotal RD with a superior wedge of attached retina
points to a primary break located in the periphery nearest
its highest border
 When the SRF crosses the vertical midline above, the
primary break is near to 12 o’clock, the lower edge of the
RD corresponding to the side of the break

58. Signs
 Relative afferent pupillary defect
 Intraocular pressure (IOP) is often lower by about 5 mmHg
compared with the normal eye
 Iritis
 ‘Tobacco dust’ consisting of pigment cells is commonly seen
in the anterior vitreous substantial vitreous blood or
inflammatory cells are also highly specific

59. A Shafer sign
present in
the anterior
vitreous

60.  Retinal breaks appear as discontinuities in the retinal surface
 They are usually red because of the color contrast between the
sensory retina and underlying choroid
 Retinal signs depend on the duration of RD and the
presence or absence of proliferative vitreoretinopathy (PVR)

61. Management of rhegmatogenous retinal detachment
The principles of surgery for retinal detachment are as follows:
Find all retinal breaks
Create a chorioretinal irritation around each break.
Close the retinal breaks

62.  In 90%–95% of RRDs, a definite retinal break can be found,
often with the help of Lincoff rules
 An occult break is presumed to be present
 Patients with RRD have photopsias, or floaters and flashes of
light

63.  Retina detaches progressively from the periphery to the optic
nerve head
 Convex borders and contours and a corrugated appearance,
especially in recent retinal detachments, and undulates with
eye movements
 Long-standing RRD,the retina may appear smooth and thin
 Fixed folds resulting from proliferative vitreoretinopathy (PVR) a
lmost always indicate an RRD
 Shifting fluid may occur, is uncommon and more typical of
serous retinal detachments

64. Fresh retinal detachment
 The RD has a convex configuration and a slightly opaque
and corrugated
 Appearance as a result of retinal oedema
 There is loss of the underlying choroidal pattern and retinal
blood vessels appear darker than in flat retina

65. Fresh retinal detachment.
(A) U-tear with superotemporal detachment, threatening the central macula;
note that substantially elevated retina appears dark on
the wide-field image (B) autofluorescence demonstrating
extent of fluid spread

66. (C) superior bullous detachment
(D) typical corrugated appearance of detached retina
(E) macular hole surrounded by shallow subretinal fluid confined to the posterior pole

67. Long-standing retinal detachment
Retinal thinning secondary to atrophy is a characteristic
finding, and should not lead to a misdiagnosis of retinoschisis
Intraretinal cysts may develop if the RD has
been present for about 1 year; these tend to disappear after
retinal reattachment
Subretinal demarcation lines (‘high water’ or ‘tide’ marks)
caused by proliferation of RPE cells at the junction of flat
Retinal cysts

68. (B) multiple cysts in chronic total detachment (red-free
wide-field image) (C) B-scan ultrasonogram demonstrating
cyst

69. (D) demarcation line (E) demarcation line surrounding
localized fluid associated with a small round asymptomatic
hole (wide-field image)

70. A.RRD with bullous configuration B.TRD with the cancave surface

71. .

72. .

73. REFERENCES
Albert’s Principles and practice of Ophthalmology-Retina
and Vitreous
Skuta,G.L. et. al. American Academy of Ophthalmology
Retina and Vitreous 2020 Edition. USA
Sihota, R. et al. Parsons’ Diseases of the Eye, 22nd Ed.,
2015
Bowling , B. Kanski’s Clinical Ophthalmology: A Systemic
Approach, 8th Ed. 2016. Australia.

74. Thank you!
Excellence Equity Efficiency
L V Prasad Eye Institute