This document discusses the classification, natural history, preoperative evaluation, and management of various types of retinal detachments. It covers rhegmatogenous retinal detachment, tractional retinal detachment, exudative retinal detachment, and classifications such as primary versus secondary detachments. Preoperative evaluation includes clinical examination techniques like binocular indirect ophthalmoscopy, fundus drawing and ultrasound. Management principles and techniques like scleral buckling surgery, pneumatic retinopexy and vitrectomy are outlined.

1. MANAGEMENT OF
RETINAL
DETACHMENT
DR. AMREEN H. DESHMUKH

2. OUTLINE
 Classification of RD
 Natural History of RD
 Preoperative Evaluation
 Principles of management
 Management of Rhegmatogenous RD
 Management of Retinal Breaks
 Management of TRD
 Conclusion

3. Classification of RD
 Primary RD- Rhegmatogenous RD
 Secondary RD
 Tractional RD
 Exudative/Serous RD
 Combined Mechanism RD

4. Serous Retinal Detachment
 Alterations in choroidal flow
 Tumours
 Choroidal melanoma
 Nevi
 Haemangioma
 Metastasis
 Retinoblastoma
 Idiopathic CSCR
 Chronic diffuse retinal epitheliopathy
 Bullous inferior RD
 Vasculitis & autoimmune diseases
 SLE
 Wegener’s granulomatosis
 PAN
 Relapsing polychondritis
 Dermatomyositis
 Goodpasture’s syndrome
 Systemic Diseases
 Malignant hypertension
 DIC
 TTP
 Preeclampsia
 Renal failure

5.  Poor Scleral Outflow
 Nanophthalmos
 Uveal effusion syndrome
 Posterior scleritis

6.  Breakdown of RPE & retina
 VKH disease
 Retinal Vascular Disease
 Coat’s disease
 Familial exudative vitreoretinopathy
 Retinal angiomatosis
 Sarcoidosis
 Infectious diseases
 Toxoplasmosis
 Syphilis
 Lyme disease
 Tuberculosis
 Histoplasmosis
 Coccidiomycosis
 Cryptococcus
 Cat scratch disease

7.  Miscellaneous
 Multiple myeloma
 Immunogammopathies
 Paraproteinemias
 Post-surgical
 Medications- Interferon, Ribavirin
 Congenital anomalies of optic nerve- pit/ coloboma/ morning glory syndrome
 Bilat. Diffuse uveal melanocytic proliferation

8. Natural History of Retinal Detachment
 Progress to near total or total RD
 A subtotal RD with stable borders and demarcation lines
 SRF d/t superior retinal break settles inferiorly away from the retinal break,
and the site of original break flattens
 Spontaneous attachment occurs, associated with a very small break or
closure of the break by scar tissue

9. Pre-operative Evaluation
 Clinical Examination
 Slit Lamp Examination to rule out anterior segment pathology
 Binocular Indirect Ophthalmoscopy with scleral indentation
 Goldmann Three-mirror Examination
 Fundus drawing with Localisation of Primary Break
 Ultrasonography
 OCT- to detect SRF, other pathologies
 Haematological Investigations
 CT and MRI

10. Binocular Indirect Ophthalmoscopy
with Scleral Indentation
 Stereoscopic view of fundus
 Inverted and laterally reversed image
 View upto Equator
 With Scleral Indentation
 Visualization of peripheral retina anterior to equator upto Ora serrata
 Kinetic evaluation of the retina

12. 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

13. Fundus drawing-Amsler Dubois chart
Junction of
P Plicata &
P Plana
The Ora
The Equator

14. Fundus drawing

15. Fundus drawing
 Tips for drawing
 Disregard Sup/Inf and Temp/Nasal while drawing
 What ever appears closer to the observer in the condensing lens is
peripheral (anterior)
 Observe the disc and follow a vessel to the periphery
 Observe the macula at the end for best patient co-operation

16. Fundus drawing
• Right Eye – Localized RD with HST at 11° clock and Lattice at 1° clock

17. FUNDUS DRAWING
Draw as you see the lesion in the
condensing lens

18. FUNDUS DRAWING – RED SOLID
• Retinal arterioles
• Neovascularization
• Vascular anomalies
• Attached retina
• Vascular tumors

19. FUNDUS DRAWING – RED SOLID
• Hemorrhages
( Pre and retinal)
• Open interior of
retinal breaks
(tears, holes)
• Open interior of
outer layer holes in
retinoschisis

20. • Open portion of GRT
or large dialyses
• Inner portion of CRA
• Inner portion of thin
areas of retina
• Open portion of
retinal holes in inner
layer of retinoschisis
FUNDUS DRAWING- RED CROSSED

21. FUNDUS DRAWING – BLUE SOLID
• Detached retina
• Retinal veins
• Outlines of retinal
breaks
• Outlines of ora
serrata

22. FUNDUS DRAWING – BLUE SOLID
• VR traction tuft
• Outline of lattice
degeneration (inner X)
• Outline of thin area of
Retina

23. FUNDUS DRAWING – BLUE CROSSLINES
•Inner layer of retinoschisis
•White with or without
pressure (label)
•Detached parsplana
epithelium anterior to
separation of ora serrata
•Rolled edges of retinal tears
/ inverted flap in GRT
(curved lines)

24. FUNDUS DRAWING
BLUE CIRCLE/INTERRUPTED LINES
• Cystoid degeneration
• Outline of change in
area or folds of
detached retina
because of shifting
fluid

25. FUNDUS DRAWING- GREEN SOLID
• Opacities in the media
• Vitreous hemorrhage
• Vitreous membranes
• Hyaloid ring
• IOFB

26. FUNDUS DRAWING – GREEN SOLID
• Retinal operculum
• Outline of elevated
Neovascularisation
• Vitreous Substitute –
Silicone Oil, Gas

27. FUNDUS DRAWING – GREEN DOTTED
• Asteroid hyalosis
• Frosting or
snowflakes on
Retinoschisis or
lattice degeneration

28. FUNDUS DRAWING – BROWN SOLID
• Uveal tissue
• Pigment beneath
detached retina

29. FUNDUS DRAWING- BROWN SOLID
• Pigment epithelial
Detachment
• Choroidal
melanomas
• Nevus
• Choroidal
detachment

30. FUNDUS DRAWING – BROWN OUTLINE
• Edge of buckle
beneath detached
retina
• Outline of
Posterior
Staphyloma

31. FUNDUS DRAWING – YELLOW SOLID
• I/R, S/R hard
exudate
• S/R gliosis
• Deposits in the
RPE

32. FUNDUS DRAWING- YELLOW SOLID
• Post cryo
retinal edema
• Substance of long
& short ciliary N
• Retinoblastoma
Yellow – stippled-
• Drusen
Yellow Crossed
• Chorioretinal
coloboma

33. FUNDUS DRAWING- BLACK SOLID
• Hyperpigmentation as a
result of previous Rx
with cryo/Diathermy
• Completely Sheathed
vessels
• Pigment within detached
retina (Lattice, HST)

34. FUNDUS DRAWING- BLACK SOLID
• Pigment within choroid or
pigment epithelial
hyperplasia within
attached retina (e.g. RP)
• Pigment demarcation line
at margin of attached
and detached retina

35. FUNDUS DRAWING – BLACK OUTLINE
• Edge of buckle
beneath attached
retina
• Outline of CRA

36. Localization of Primary Break
 Configuration of SRF
 Gravitational shift
 Anatomical Barriers- optic disc, ora serrata
 Location of primary breaks
 Lincoff’s rule
 Location of break
 ST>IT>SN>IN quadrants

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

39. Physics
 It is an acoustic wave that consists of particles within the medium
 Frequencies used in diagnostic ophthalmic ultrasound are in the range of
8-10 MHz
 These high frequencies produce shorter wave lengths which allow good
resolution of minute ocular and orbital structures
 Multiple short pulses are produced with a brief interval that allows the
returning echos to be detected, processed and displayed.
 The basis of the echo system is piezoelectric element which is a quartz or
ceramic crystal located near the face of the probe

40. sound waves from
transmitter
Echoes are received
by receiver
Amplification
Oscilloscope screen
Target tissue

41. Types of frequency
 Low frequency: orbital tissue
 Medium frequency: ( 7 – 10 mhz ) Retinal , vitreous , optic nerve
 High frequency: ( 30 – 50 mhz) : ant chamber upto 5 mm

42. Indications
Anterior segment:
 Opaque ocular media (i.e. corneal opacities)
1. Pupillary membrane
2. Dislocation / Subluxation lens
3. Cataract / after cataract
4. Posterior capsular tear
5. Pupillary size / reaction
 Clear ocular media
Diagnosis of iris and ciliary body tumors

43. Posterior segment:
1. Opaque ocular media
 Vitreous haemorrhage
 Vitreous exudation
 Retinal detachment
(type / extent)
 Posterior vitreous
detachment (extent)
 Intraocular foreign
body (size/ site/ type)
2. Clear ocular media
 Tumour (size/ site/ post
treatment follow up)
 Retinal detachment
(solid / exudative)
 Optic disc anomalies
3. ocular trauma

44. Examination technique
The patient is either
reclining on a chair
or lying on a couch.
The probe can be
placed directly over
the conjunctiva or
the lids.

45. Probe positions
 Transverse : most common
Lateral extent, 6 clock hours
 Longitudinal : radial ,1 clock hours, AP diameter in
Retinal tumors and tears
 Axial : lesion in relation to lens and optic nerve .

46. Appearance of Normal Ocular
Structures
 LENS: oval highly reflective structure with intralesional echoes with
none to highly reflective echoes.
 Vitreous is echolucent.
 Retina, choroid and sclera: single reflective high structure.
 OPTIC NERVE : Wedge shaped acoustic void in the retrobulbar region.
 EXTRA OCULAR MUSCLES : Echolucent
to low reflective fusiform structures. The SR- LPS complex is the thickest.
IR is the thinnest. IO is generally not seen except in pathological
conditions.

47.  ORBIT -highly reflective due to orbital
fat.
 Always examine the other eye before
coming to a conclusion regarding the
lesion .
 Opacities produce dots or short lines
 Membranous lesions produce an
echogenic line

48. ULTRASONOGRAPHIC
CHARACTERISTICS

49. VITREOUS HAEMORRHAGE
To detect extent,
density, location and
cause
Fresh haemorrhage
shows dots or lines
Old haemorrhage
the dots gets
brighter

50. POSTERIOR VITREOUS DETACHMENT
membranous lesion
with no/some
attachments to the
optic disc

51. POSTERIOR VITREOUS DETACHMENT
Mobility of PVD is
more than RD.
The spike of RD is
more than PVD.
PVD becomes more
prominent in higher
gain settings

52. RETINAL DETACHMENT
The detachment
produces a bright
continuous, folded
appearance with
insertion into the disc
and ora serrata.
It is to determine the
configuration of the
detachment as
shallow, flat or bullous

53. EXUDATIVE RETINAL DETACHMENT

54. RHEGMATOGENOUS RD

55. RHEGMATOGENOUS RETINAL DETACHMENT

56. CLOSED FUNNEL RD WITH
RETINAL CYST
Retinal Tear

57. Appears as RD but it is a PVD
Clues: non uniform thickness of membrane
very thin attachment to the disc.

58. Retinal Reattachment Surgery
 Scleral Buckling Surgery with or without drainage
 Encircling
 Segmental
 Temporary scleral buckle
 Lincoff balloon
 Absorbable material
 Vitrectomy
 Classical
 Sutureless
 Pneumoretinopexy
 Routine
 With drainage of SRF/intravitreal liquid

59. Aim of Surgery
 To counter the factors & forces that cause retinal detachment
 Re-establish physiological conditions that maintain contact between NSR
& RPE

60. Principles of Treatment
 Sealing of all retinal breaks
 Relief of vitreo-retinal traction
 Scleral buckling
 Pneumatic retinopexy
 Vitrectomy
 Adjuncts

61. Gonin’s principle
 The retina has to be brought back into firm contact with the underlying
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.

62. Classic Schepens Technique
 Localisation of break/s
 Lamellar scleral dissection
 Intrascleral buckle
 Encirclage
 SRF drainage
DACE procedure
 Drainage of SRF
 Air injection
 Cryotherapy
 Encirclage

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

64. Scleral Buckling
Surgery

65. 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 SRF away from the break
& alters the shape of eyewall, thus
reducing the effects of the intraocular
fluid currents

66. Scleral Buckles
 Permanent
 Solid Silicone
 Sponge
 Hydrogel
 Absorbable
 Gelatin
 Synthetic suture
 Donor tissue
 Effect depends upon
 Type of material
 Location & tension of scleral sutures
 Circumferential tightening of
encircling buckle

67. Buckle configuration
 Radial explants- right angle to limbus-
to seal U tears/posterior breaks
 Segmental circumferential- parallel to
limbus
 Encircling- entire circumference of
globe for 360˚ buckle

68.  Relative contraindications
 Thin sclera
 Glaucoma filtering blebs/valve implants
 Previous strabismus surgery
 Very posterior retinal breaks
 Giant retinal tears
 PVR grade C
 Significant vitreous opacities

69. Scleral Buckling Surgery
 Procedure
 Under LA or 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
 SRF drainage
 Saline/Air injection
 Retinopexy- cryotherapy
 Buckle sutures finalized

70.  Video

71.  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

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

73.  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, ocular rigidity

74. Lincoff’s balloon
 Can be inserted under LA
 Minimal surgical trauma
 No scleral suturing
 No changes in refractive status of the eye

75. SRF Drainage-
 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

76.  Technique
 Cut-down
 Radial Sclerotomy, beneath the area of deepest SRF, 4mm long, sufficient 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 G hypodermic needle bent at 2mm from tip, full thickness perforation
 Air injection after drainage of SRF

77.  Complications
 Failure of drainage- dry tap
 Retinal perforation
 Intraocular haemorrhage
 Vitreous loss
 Retinal incarceration
 Endophthalmitis

78. Pars Plana Vitrectomy
 Indicated in
 Media opacities- cataract , VH & advanced PVR
 Posteriorly located breaks
 RD with giant retinal tear or macular hole
 Pseudophakia
 Tractional RD
 Relative contraindications
 Relatively simple phakic RD
 Inferior retinal dialysis

79.  Video

80. Procedure
 LA/GA
 360˚/ Limited Conjunctival peritomy
 3 Sclerotomies- ST, SN & IT quadrants
 PVD induction and thorough PPV
 Preretinal membranes peeled off
 Retinal breaks are marked with light cautery burns

81.  Fluid gas exchange- endodrainage of SRF through pre-existing breaks/
Drainage retinotomy
 Endophotocoagulation, Cryo for peripheral breaks
 Endotamponade- silicone oil/ Long acting gases
 Inferior PI in aphakic cases if silicone oil used

82. Sutureless Microincision Vitrectomy
 Transconjunctival sutureless MIVS using 23G/ 25G instrumentation
 Advantages
 Shorter surgical time
 Less surgically 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- MVR blade
 Wide angle viewing systems

83. Scleral Buckling+ PPV
Indicated in peripheral retinal involvement in
 Proliferative vitreoretinopathy
 Giant retinal tears
 Peripheral uveitis
 Viral retinitis
 Retinopathy of Prematurity
 Proliferative retinopathies

84. Pneumatic Retinopexy
 Short, minimally invasive, OPD procedure
 Intravitreal injection of an expansile gas bubble, cryopexy, postoperative
patient positioning
 Indications
 Fresh uncomplicated RRD
 Retinal break smaller than one clock hour
 Multiple breaks within one clock hour
 All breaks in superior 8 clock hours

85.  Contraindications
 Inferior retinal breaks
 PVR
 Media opacities impairing proper assessment
 Uncontrolled glaucoma
 Air travel
 Patient unable to maintain postoperative positioning

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

88. 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

89. Gases tried in vitreoretinal surgery
Non-expansile Expansile
Air SF6
Nitrogen C4F10
Helium CF4
Oxygen C2F6
Argon C3F8
Xenon C4F10
Krypton C5F12

90. 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

91.  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

92. Silicone Oil in RD Repair
 FDA approved for VR surgery in 1994
 Highly viscous, transparent liquid with high surface tension, lighter than
water
 Viscosity 1000-5000 centistokes
 Indications
 Detachment with inferior breaks
 Extensive PVR
 One eyed patient with need of early visual recovery
 Giant retinal tears
 Traumatic detachments

93.  Advantages
 Prolonged tamponading effect
 Less strict 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, BSK
 Inadequate tamponading for inferior
breaks
 Post-operative change in refraction
 Perisilicone oil membrane & macular
pucker
 Redetachment after oil removal (15-
20%)

94. 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,
iatrogenic breaks
In-office procedure,
minimally invasive,
↓ Recovery time, better
post-op VA

95. Retinal Breaks
 Factors to consider for treatment of retinal breaks
 Symptoms
 Age of patient
 Systemic status of the patient
 Refractive error (>6D myopia)
 Break- Location, age, type, size
 Status of fellow eye
 Aphakic/PCIOL/ needs cataract surgery

96.  Increased chances of RD, needs T/t
 Phakic patients with symptomatic breaks
 Superotemporal breaks- macula off RD
 Larger breaks
 HST/ retinal dialysis
 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

97. Management
 Acute retinal break- new floaters and flashes- d/t acute PVD
 Presence or absence of symptoms with onset of break- most important
prognostic criterion for progression to retinal detachment
 Anterior breaks--Cryotherapy/ LASER
 Posterior breaks--Slit Lamp/ Indirect Ophthalmoscopic LASER delivery
 Large breaks--Anterior part- Cryotherapy
Posterior part- LASER

98. LASER Photocoagulation
 LASER used- Argon Green, Krypton Red, Diode Laser
 Delivery system- slit lamp/ indirect ophthalmoscopic
 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 moderate intensity
 No more than half spot size untreated retina between burns
 Patching, re-examine at 5-7 days

99.  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
 Failure depends upon- failure rate 0-
22%
 Type of break
 Indication of treatment
 Length of follow-up
 Complications
 Macular pucker
 Epiretinal membrane formation
 Adie’s pupil
 Subretinal and vitreous haemorrhage
 Breaks in Bruch’s membrane
 Scleral rupture- staphylomatous sclera,
cryo done

101. 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
 Extensive cataract
 Anterior/posterior capsular opacity
 Vitreous haemorrhage

102. Cryotherapy
 Under topical
anaesthesia/subconjunctival injection
 Check cryoprobe for correct freezing
and defrosting, rubber sleeve does
not cover the slip
 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
 Not to remove the probe until it has
defrosted completely as premature
removal may crack the choroid-
leading to choroidal haemorrhage
 Pad eye for 4 hours
 At 5 days, pigmentation begins to
appear
 Initially fine, then coarser, a/w
chorioretinal atrophy

104.  Causes of failure
 Failure to surround the entire lesion
 Failure to apply contiguous treatment
 Failure to use an explant or gas tamponade
 New break formation

105. Cryotherapy vs LASER Retinopexy
Cryotherapy
 Use of external probe & IDO
 Can be used with moderate media
opacities
 Promotes dispersion of viable RPE
cells & breakdown of BRB
 CME, wrinkling of ILM
 Increased Postoperative flare,
extensive retinal oedema, necrosis
LASER Retinopexy
 Endolaser/ IDO with laser
 Difficult in moderate media opacities/
shallow SRF
 Ideal for posteriorly located breaks

106. Management of Retinal Breaks
Treatment guidelines for retinal breaks
Type of break Phakic High Myopia Fellow eye Aphakia/
Pseudophakia
HST symptomatic Treat Treat Treat Treat
HST Asymptomatic Observe Treat some Treat Treat 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 Observe

107. Management of Tractional Retinal
Detachment
 TRD progresses very slowly, may reattach spontaneously
 Localized TRD away from macula- observation
 Indications for surgery
 Macular threatened or detached
 Vitreous haemorrhage
 Retinal holes
 Surgical Principles
 To relax the vitreoretinal traction
 Closure of retinal holes
 Drainage of SRF

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

109. Conclusion
 Scleral buckling : Standardized, predictable & successful
 Complications
 Alternative techniques : Limitations, selective
 Pneumoretinopexy- most popular
 Primary vitrectomy : more popular these days – 23 G or 25 G

110.  No technique is the “ Best”
 Fundamental goal : Identify and functionally close all retinal breaks
 Skill with Indirect Ophthalmoscopes - the Dying art of localization
 Choice of surgery :
 Individual experience
 Training
 Equipment available
 Changing contemporary practices

111. References
 Clinical Ophthalmology, Kanski
 Ophthalmology, Myron Yanoff & Duker
 Retina , Stephen J. Ryan

112. THANK YOU!!!