This document provides an overview of the classification, evaluation, and management of various types of retinal detachment. It discusses pre-operative evaluation including clinical examination techniques. It then covers principles of management for different retinal break types including laser photocoagulation, cryotherapy, drainage of subretinal fluid, and various tamponade agents. Scleral buckling surgery techniques and complications are explained. Silicone oil usage indications and complications are also summarized.

1. MANAGEMENT OF
RETINAL
DETACHMENT
Dr.ANUPAMAMANOHARAN
JUNIORRESIDENT
DEPTOFOPHTHAL
UGMCH OOTY (TN)

2. Classification of RD
Primary RD - Rhegmatogenous RD
Secondary RD
TractionalRD
Exudative/Serous RD
Combined MechanismRD

3. OUTLINE
Preoperative Evaluation
Principles of management
Management of Retinal breaks
Management of Rhegmatogenous RD
Management of TractionalRD
Management of ExudativeRD

4. Pre-operative Evaluation
Clinical Examination
Slit Lamp Examination to rule out anterior segment
pathology
Binocular Indirect Ophthalmoscopy with scleral
indentation
Goldmann Three-mirrorExamination
Localization of Primary Break
Ultrasonography
OCT
CTand MRI

5. Binocular Indirect Ophthalmoscopy
with Scleral Indentation
Stereoscopic view of fundus
Inverted and laterally reversed image
View upto Ora Serrata
With Scleral Indentation
Visualization of peripheral retina anterior to equator upto Ora serrata

7. Goldmann Three-mirror Examination
Central lens and three mirrors
Central lens- 30˚ upright view of Posterior
pole
Equatorial mirror (largest and oblong)- 30˚ to
equator
Peripheral mirror (medium and square) -
between equator and ora serrata
Gonioscopy mirror (smallest and dome
shaped)- extreme periphery and pars plana
Image-
Vertical meridian-inverted, not laterally
reversed
Horizontal Meridian- Laterally reversed

8. Localization of Primary Break
Configuration of SRF
Gravitationalshift
Anatomical Barriers- optic disc, ora serrata
Location of primary breaks
Lincoff’srule
Location of break
ST>IT>SN>INquadrants

9. Ultrasonography
B- SCANis a two dimensional imaging system which utilises high
frequency sound waves ranging from 8-10 MHz.
B stands for bright echoes.

10. RHEGMATOGENOUS RETINAL DETACHMENT
A.On B-Scan Retinal
detachment appears highly
reflective,Corrugaed V-
Shaped membrane
attached to the Optic disc
B.In case of Long standing
RD Some patient develop
cyst which is usually
visualized in BScan

11. TRACTIONAL RETINAL DETACHMENT
A.Tangential, caused by the
contraction of epiretinal
fibrovascular membranes with
puckering of the retina and
distortion of blood vessels
Small area of
vitreoretinal adherence
produces tentlike RD.
B. Traction retinal detachments
(RD) with bridging membrane.
This bridging membrane is the
posterior hyaloid, which extends
from one traction detachment to
another

12. EXUDATIVERETINALDETACHMENT
The detached retina is very
mobile and exhibits the
phenomenon of ‘shifting fluid’
in which SRF detaches the area
of retina under which it
accumulates
For example, in the upright
position the SRF collects under
the inferior retina, but on
assuming the supine position
for several minutes, the inferior
retina flattens and SRF shifts
posteriorly, detaching the
superior retina

13. POSTERIORVITREOUSDETACHMENT
Mobility of PVD is
more than RD.
The spike of RDis
more than PVD.

14. MRI/CT in RD
Folded membranes with
subretinal space fluid
(which is usually
hyperdense on CT)
the detachment is
limited anteriorly by
the ora serrata
posteriorly the
detachment converges
on the optic disk

15. Aim of Surgery
To counter the factors & forces that cause retinaldetachment
Re-establish physiological conditions that maintain contact between NSR
& RPE

16. Principles of Treatment
Locate the Hole
Seal the Hole
SRF Drainage
External Tamponade
Tamponade
Internal Tamponade
Pars Plana Vitrectomy

17. Gonin’s principle
The retina has to be brought back into firm contact with theunderlying
pigment epithelium and choroid, at least in the area of the holes;and
The contact must be maintained whilst an inflammatory reaction causes
the formation of a scar which involves both, retina and choroid and by this
seals the retinal holes.

18. Algorithm for approach to selection of appropriate retinal
reattachment procedure

19. Retinal Breaks
Factors to consider for treatment of retinalbreaks
Symptoms
Age of patient
Systemic status of thepatient
Refractive error (>6Dmyopia)
Break- Location, age, type, size
Status of fellow eye
Aphakic/ PCIOL / needs cataractsurgery

20. Increased chances of RD,needsT/t
Phakic patients with symptomaticbreaks
Superotemporal breaks- macula offRD
Largerbreaks
Symptomatic HST/ retinaldialysis
Retinal tear at margin of lattice with symptoms
No treatment, observation
Phakic patients- no prev H/O retinal disease, No high myopia
With asymptomatic HST/Atrophic holes / with operculum

21. Management
Anterior breaks--Cryotherapy/ LASER
Posteriorbreaks--Slit Lamp/ Indirect OphthalmoscopicLASERdelivery
Large breaks--Anterior part- Cryotherapy
Posterior part- LASER

22. LASER Photocoagulation
LASER used- Argon Green, Krypton Red, Diode Laser
Delivery system- slit lamp(Mid periphery and posterior)
Indirect ophthalmoscopic (Periphery)
Spot size 200µm Duration 0.1-0.2sec
Goldmann Triple-mirror contact lens or wide-field lenses 2.2
panfundoscopic lens
Surround the lesion with 3-4 rows of confluent burns of moderateintensity
No more than half spot size untreated retina between burns
Patching, re-examine at 5-7 days
Especially indicated in
•Prophylactically to prevent progression of RD
•chronic inferior RD
•systemic illness contraindicate to surgery

23. Post t/t patient should avoid
strenuous physical exertion for
upto 7 days until adequate
adhesion has formed and lesion
is securely sealed
Firm adhesion achieved at 3
weeks
Complications
Epiretinal membrane formation
Adie’s pupil
Subretinal and vitreous haemorrhage
Breaks in Bruch’s membrane
Scleral rupture- staphylomatous sclera,

25. Cryotherapy
Mechanism- transconjunctival application- destroys choriocapillaris, RPE
and outer retina- Adhesion between tear and adjacent retina
Partial adhesion at 1 week, Complete at 3 weeks
Indications- media opacities
Extensivecataract
Anterior/posterior capsularopacity
Vitreoushaemorrhage

26. Cryotherapy
Under topical
anaesthesia/subconjunctival injection
Check cryoprobe for correct freezing
and defrosting
While viewing with IDO, gently indent
sclera with tip of probe, start at ora
serrata and move posteriorly
Surround the lesion with single row of
application, terminate freezing as
retina whitens, 2mm around entire
break
Pad eye for 4 hours
appear
Not toremove the probe until it has
defrosted completely aspremature
removal may crack the choroid-
leading to choroidal haemorrhage
At 5 days, pigmentation begins to
Initially fine, then coarser, a/w
chorioretinal atrophy

28. Causesof failure
Failure to surround the entire lesion
Failure to apply contiguous treatment
Failure to use an explant or gas tamponade
New breakformation

29. Management of Retinal Breaks
Treatment guidelinesfor retinal breaks
Type of break Phakic High Myopia Fellow eye Aphakia/
Pseudophakia
HST symptomatic Treat Treat Treat Treat
HST Asymptomatic Observe Treat in some Treat Treat in some
Operculated
symptomatic
Treat some Treat Treat Treat
Operculated
asymptomatic
Observe Treat few Observe Observe
Round hole
asymptomatic
Observe Observe Treat some Observe
Lattice without holes Observe Observe Treat some unless
lattice >6clock hours
Observe
Lattice with round holes Observe Observe Treat some Observe

30. SRFDrainage-
Indications
Long standing RD
Bullous elevated detachments
No visible breaks
Coexistent glaucoma
Highly myopic detachments
Aphakic & pseudophakic
eyes
Multiple breaks
Significant vitreous traction
Giant tears
Inferior breaks
Thin sclera

31. Technique
Cut-down
Radial Sclerotomy, beneath the area of deepest SRF
,4mm long,
depth to allow herniation of small dark knuckle of choroid
Gentle low-heat cautery to the knuckle/ puncture with
25G hypodermic needle
Prang
Digital pressure applied on globe to occlude CRA&
complete occlusion of choroidal vasculature
27 Ghypodermic needle bent at 2mm from tip, full thickness perforation
Air injection after drainage of SRF

32. Complications
Failure of drainage - dry tap
Retinal perforation
Intraocularhaemorrhage
Vitreousloss
Retinal incarceration
Endophthalmitis

33. External
Tamponade

34. How scleral buckle works???
Gold standard for uncomplicated RD
Relieves vitreous traction along the
surface of the buckle
The buckle displaces the retinal break
centrally, where the break becomes
tamponaded by cortical vitreous
It displaces SRFaway from the break
& alters the shape of eyewall, thus
reducing the effects of the intraocular
fluid currents
Scleral Buckling Surgery

35. Buckle configuration
Radial explants- right angle to limbus-
(seal U tears / posterior breaks)
Segmental circumferential- parallel to
limbus
A.detachments with single or closely
spaced retinal breaks less than one clock
hour in total extent or with posterior
breaks
B. The primary advantage of segmental
buckles is the relative ease of placement
and minimal change in the refractive error
c. For posterior breaks, segmental
elements allow closure of the break while
avoiding the side effects of large posterior
encircling elements

36. Encircling Buckles
A. Although segmental buckles effectively close isolated tears,
they do not provide retinal support elsewhere
B. Specifically, other areas of vitreoretinal traction away from the segmental
element are not supported, which may result in the formation of new
retinal breaks
Indications
(1) Cases with multiple breaks in different quadrants;
(2) Aphakia;
(3) Pseudophakia;
(4) Myopia;
(5) Diffuse vitreoretinal pathologic conditions, such as extensive lattice
degeneration or vitreoretinal degenerations; and
(6) proliferative vitreoretinopathy

37. Scleral Buckles
Permanent
Solid silicone tires of various sizes and profiles (A–C)
are trimmed to the desired size (D–F). Silicone sponges
also come in various sizes (G,H) and may have a circular or
oval cross-section (I). Watzke sleeves (J) are used with
bands (K) and silicone tires to create encirclements (L)
Sponge
Hydrogel
Absorbable
Gelatin
Synthetic suture
Donor tissue (fascia lata, preserved human
Sclera)

38. Relative contraindications
Thinsclera
Glaucoma filtering blebs / valve implants
Previous strabismus surgery
Very posterior retinalbreaks
Giant retinaltears
PVRgrade C
Significant vitreousopacities

39. Scleral Buckling Surgery
Procedure
Under LAor GA
360˚ Conjunctival Peritomy with horizontal relaxing incisions
Tractional sutures inserted beneath four recti
Localisation of breaks and marking on scleral surface
Mattress type buckle sutures
Appropriate buckle selected, inserted & temporarily tightened
SRFdrainage
Saline/Air injection
Retinopexy- cryotherapy
Buckle sutures finalized

40. Complications
Intraoperative
Scleral perforation
Choroidal Haemorrhage
Subretinal Bleed, Retinal Incarceration and perforation
Impaired visibility- corneal haze, hyphema, miosis, air/gas injection
Damage to vortex veins
Vitreous loss

41. Postoperative
Buckle infection, migration, extrusion
Failed retinal reattachment
Redetachment
Anterior segment ischemia
Choroidal edema, detachment
Secondary Glaucoma
Suboptimal visual recovery- CME, persistent
subfoveal SRF
Ptosis, diplopia and motility disturbances

42. Changes induced by scleral buckles in the eye
Axial length of the eye-
Encircling- Increased/decreased axial length depending upon material, location,
height of buckle
Induced spherical equivalent & astigmatic refractive error
segmental- hyperopic shift
Volume of the eye
Altered compliance, ocularrigidity

43. Tamponading Agents in VR Surgery
Tamponading agents/ vitreous substitutes
Materials used
Intraocular gases
Silicone oil
Perfluorocarbon liquid (PFCL)
Characteristics of gases
High surface tension (occludes retinal break)
Buoyancy (Force to push retina)
Used as
Non-expansile mixture with air after PPV
100% concentration in pneumoretinopexy
Internal Tamponade

44. Pneumatic Retinopexy
Short, minimally invasive, OPD procedure
Indications
Fresh uncomplicated RRD
Retinal break smaller than one clockhour
Multiple breaks within one clock hour
All breaks in superior 8 clockhours
Low pressure environments, typically air travel, and nitrous oxide
anaesthesia must be avoided until gas absorption is complete as these will
increase the intraocular gas pressure

45. Procedure
Anaesthesia-Topical/LA
Cryopexy around retinal breaks
Single, expansile gas bubble injected in vitreous cavity through pars plana
using sterile 30 G needle
Positioning- to ensure max. tamponade, retinal break should remain at the top

47. Contraindications
Inferior retinalbreaks
PVR
Media opacities impairing properassessment
Uncontrolled glaucoma
Airtravel
Patient unable to maintain postoperative positioning

48. Gasestried in vitreoretinalsurgery
Non-expansile Expansile
Air SF6
Nitrogen C4F10
Helium CF4
Oxygen C2F6
Argon C3F8
Xenon C4F10
Krypton C5F12

49. Properties of intraocular gases
Gas Average
Duration
Largest size
of the
bubble
(duration)
Average
expansion
Nonexpansil
e
concentratio
n
Typical Dose
Air 3 days Immediate No
expansion
-- 0.8ml
SF6 12 days 36 hours 2 times 18% 0.5ml
C3F8 38 days 72 hours 4 times 14% 0.3ml

50. Advantages of intraocular gases vs use of silicon oil
No need of repeat surgery for removal
Absence of complications related to long-term presence of silicone oil
Disadvantages of intraocular gases
Requirement of strict postoperative positioning
Risk of postoperative rise in IOP
Restriction of air travel
Development of lens opacity
Delayed visual rehabilitation
Short duration of tamponading effect
Recurrent detachment from severe proliferation

51. Silicone Oil in RD Repair
FDAapproved for VRsurgery in 1994
Silicone oils have low specific gravity – they are lighter than
water and thus buoyant
Viscosity 1000-5000 centistokes
Indications
Detachment with inferior breaks
ExtensivePVR
One eyed patient with need of early visual recovery
Giant retinaltears
Traumaticdetachments

52. Advantages
Prolonged tamponading effect
Lessstrict requirement of post-
operative positioning
Early visual rehabilitation
No restriction on air travel
Hypotony less common
Disadvantages
Needs repeat surgery for removal
Cataract, raised IOP,
Post-operative change in refraction
Perisilicone oil membrane & macular
Pucker 20 %
Redetachment after oil removal (15-

53. Complication
A. Suprachoroidal silicone oil injection is a rare but devastating complication
that occurs with incomplete penetration of the choroids
B. Subretinal silicone oil- Subretinal silicone oil injection occurs because of
unrelieved traction on the retina or because of excess manipulation of the
retina under silicone oil
C.Intraocular bleeding
D. Anterior-chamber silicone oil
E. Recurrent retinal detachment
F. Band Keratopathy
F. Glaucoma
G.Chronic Hypotony
H.Refractive changes
I.Macular epiretinal membranes
J.Cataract formation

54. Removal of Silicone Oil
A.As a general principle, silicone oil should be removed once the
objectives of the tamponade have been achieved and the retinal
status is stable in order to minimize the long-term complications
associated with its use
B. In most cases, we generally remove the silicone oil between 6 weeks
and 6 months if the retina remains attached and the intraocular pressure is
normal
C. If partial recurrent retinal detachment is present, we will generally
reoperate to repair the detachment and leave the oil in place
until the retina is entirely attached
D.Even if the retina is attached, we will avoid silicone oil removal if the
eye is chronically hypotonous, as we have seen rapid progression
to phthisis when oil is removed in this situation

55. Comparison of various surgical techniques
Method Reattachment Rate Limitations/Complications Benefits
Scleral Buckling 94% Morbidity, infection, buckle
extrusion, ocular motility
disturbances
Excellent long term
anatomic success, good
visual outcome
Pars Plana Vitrectomy 71-92% (1˚ success
rate)
94% (2˚ success
rate)
Iatrogenic retinal breaks,
PVR,lens trauma, cataract
progression
Visualization of all
breaks, removal of
opacities/synechiae,
anatomic success in
complicated
detachments
Pneumatic Retinopexy 64% (1˚ success
rate)
91% (2˚ success
rate)
Limited use only in
uncomplicated RRD with
superior breaks
Post-op positioning,
In-office procedure,
minimally invasive,
↓ Recovery time, better
post-op VA

56. Pars Plana Vitrectomy
Indicated in
Media opacities- cataract , Vitreous hemorrhage
& advanced P
V
R
Posteriorly locatedbreaks
RD with giant retinal tear or macular hole
Pseudophakia
TractionalRD
Relative contraindications
Relatively simple phakicRD
Inferior retinaldialysis

57. Procedure
LA/GA
360˚/ Limited Conjunctival peritomy
3 Sclerotomies- ST
,SN & ITquadrants
A cross-sectional view of a
vitrectomy, showing an vitrectomy cutting
Probe ,endoillumination probe and Infusion
cannula probe
PVD induction and thorough PPV
Preretinal membranes peeled off
Retinal breaks are marked with light cautery burns

58. Fluid gas exchange- endodrainage of SRFthrough pre-existing breaks/
Drainage retinotomy
Endophotocoagulation, Cryo for peripheral breaks
Endotamponade- silicone oil/ Long acting gases
Inferior PI in aphakic casesif silicone oil used

59. Sutureless Microincision Vitrectomy
Transconjunctival sutureless MIVS using 23G/ 25G instrumentation
Advantages
Shorter surgicaltime
Lesssurgically induced astigmatism
Reduced risk of post-operative corneal astigmatism
Greater rigidity, better illumination, improved fluidics with 23 G
Pneumatic dual drive cutter with ultrahigh cut rate 5000 cpm
IOP compensation via direct control of infusion pressure
Direct control of duty cycle
New scleral entry system- MVRblade
Wide angle viewingsystems

60. Management of Tractional Retinal
Detachment
TRDprogresses very slowly, may reattach spontaneously
Localized TRDaway from macula-observation
Indications for surgery
Macular threatened ordetached
Vitreoushaemorrhage
Retinalholes
Surgical Principles
To relax the vitreoretinaltraction
Closure of retinal holes
Drainage ofSRF

61. PPV- to clear media, release of AP & tangentialtraction
ERM- peeling/ segmentation/ delamination
Enblock excision of traction membranes
Retinotomy with internal drainage of SRF
,internal tamponade withLA
gases/silicone oil injection
Endodiathermy & endophotocoagulation- new vessels & retinopexy

62. Management of Exudative Retinal
Detachment
Exudative RD is characterized by the accumulation
of SRF in the absence of retinal breaks or traction
Treatment depends on the cause
Some cases resolve spontaneously,
whilst others are treated with systemic corticosteroids
(Harada disease and posterior scleritis)
In some eyes with bullous
central serous chorioretinopathy, the leak in the RPE can
be sealed by laser photocoagulation

63. T
H
A
N
KYOU!!!