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Management of retinal detachment
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.
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Management of retinal detachment
- 1. MANAGEMENT OF RETINAL DETACHMENT DR. AMREENH. DESHMUKH
- 2. OUTLINE Classification ofRD 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 ScleralOutflow Nanophthalmos Uveal effusion syndrome Posterior scleritis
- 6. Breakdown ofRPE & 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 Multiplemyeloma 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 ofRetinal 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 ClinicalExamination 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 withScleral 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 Duboischart Junction of P Plicata & P Plana The Ora The Equator
- 14.
- 15. Fundus drawing Tipsfor 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 • RightEye – Localized RD with HST at 11° clock and Lattice at 1° clock
- 17. FUNDUS DRAWING Draw asyou 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 portionof 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/INTERRUPTEDLINES • Cystoid degeneration • Outline of change in area or folds of detached retina because of shifting fluid
- 25. FUNDUS DRAWING- GREENSOLID • 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- BROWNSOLID • 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- YELLOWSOLID • Post cryo retinal edema • Substance of long & short ciliary N • Retinoblastoma Yellow – stippled- • Drusen Yellow Crossed • Chorioretinal coloboma
- 33. FUNDUS DRAWING- BLACKSOLID • Hyperpigmentation as a result of previous Rx with cryo/Diathermy • Completely Sheathed vessels • Pigment within detached retina (Lattice, HST)
- 34. FUNDUS DRAWING- BLACKSOLID • 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 PrimaryBreak 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- SCANis a two dimensional imaging system which utilises high frequency sound waves ranging from 8-10 MHz. B stands for bright echoes.
- 39. Physics It isan 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 Echoesare 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: Opaqueocular 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. Opaqueocular 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 patientis 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 NormalOcular 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 -highlyreflective 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.
- 49. VITREOUS HAEMORRHAGE To detectextent, density, location and cause Fresh haemorrhage shows dots or lines Old haemorrhage the dots gets brighter
- 50. POSTERIOR VITREOUS DETACHMENT membranouslesion with no/some attachments to the optic disc
- 51. POSTERIOR VITREOUS DETACHMENT Mobilityof 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 producesa 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.
- 54.
- 55.
- 56. CLOSED FUNNEL RDWITH RETINAL CYST Retinal Tear
- 57. Appears as RDbut 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 Theretina 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 approachto selection of appropriate retinal reattachment procedure
- 64.
- 65. How scleral buckleworks??? 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 Radialexplants- 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.
- 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 Buckleinfection, 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 inducedby 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 Canbe 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 Failureof 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.
- 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 gasexchange- 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 Indicatedin 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 Inferiorretinal 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 inVR 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 invitreoretinal surgery Non-expansile Expansile Air SF6 Nitrogen C4F10 Helium CF4 Oxygen C2F6 Argon C3F8 Xenon C4F10 Krypton C5F12
- 90. Properties of intraoculargases 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 ofintraocular 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 inRD 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 Prolongedtamponading 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 varioussurgical 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 Factorsto 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 chancesof 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 retinalbreak- 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 LASERused- 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/tpatient 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- transconjunctivalapplication- 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/subconjunctivalinjection 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 offailure 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 LASERRetinopexy 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 RetinalBreaks 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 TractionalRetinal 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- toclear 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 techniqueis 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.