This document provides an overview of retinal detachment, including its definition, types, signs, symptoms, and management. It discusses the four main types - rhegmatogenous, tractional, exudative, and combined tractional-rhegmatogenous. Rhegmatogenous retinal detachment is the most common type, characterized by a retinal break allowing fluid accumulation under the retina. The document describes treatments like scleral buckling, pneumatic retinopexy, and vitrectomy. It also reviews complications of various surgical procedures and use of tamponading agents like gases and silicone oil.

1. Presenting author-Dr Priyanka (DNB RESIDENT)
DEPARTMENT OF OPHTHALMOLOGY

2. Definition
Retinal detachment (RD) refers to separation of
the neurosensory layer of retina from the pigment
epithelial layer, to which it is normally loosely
attached.

3. Layers of retina-
inside out
1) Internal limiting membrane
2) Nerve fibre layer
3) Ganglion cell layer
4) Inner plexiform layer
5) Inner nuclear layer
6) Outer plexiform layer
7) Outer nuclear layer
8) External limiting membrane
9) Photoreceptors
10) Retinal Pigment epithelium

4. Types of RD
Four types-
1) Rhegmatogenous Retinal detachment (RRD)
2) Tractional retinal detachment
3) Exudative / serous retinal detachment
4) Combined tractional-rhegmatogenous retinal
detachment

5. RHEGMATOGENOUS RD
 Most common type, affects 1 in 10,000 of population ,
with BE affected in about 10%. M>F, 40-70 yrs
 Greek: rhegma , meaning a rent or a fissure or a break
 Characterized by the presence of a retinal break in
concert with vitreoretinal traction that allows
accumulation of liquified vitreous under the
neurosensory retina , separating it from the RPE.

6.  Predisposing factors in pathogenesis of RD- Over
40% of RRD occur in myopic eyes(>-6.0D/ AL
26mm). Presence of PVD, H/O trauma ,
predisposing peripheral retinal lesions, Vitreous loss
during cataract surgery and laser capsulotomy carry
a higher risk
 SYMPTOMS- flashing lights and floaters reported
in about 60% of pts., Curtain like relative peripheral
visual field defect
 SIGNS- RAPD (Marcus Gunn pupil) in extensive RD,
low IOP, mild iritis, tobacco dust like pigments cells
seen in anterior chamber

7. Fresh rhegmatogenous RD
Macular hole
Surrounded by
sub-retinal
fluid

8. Fresh RRD signs- convex
configuration
U tear with ST detachment
Typical corrugated appearance
of detached retina

9. Tobacco dust in anterior vitreous(
shaffer’s sign)- pathognomic of a
retinal tear

10. Long standing RRD signs-
Retinal cysts multiple cysts B-scan

11. Demarcation line
Demarcation line surrounding
localized fluid with a small hole

12. Proliferative vitreoretinopathy-
sign of RRD
 Usually, PVR occurs following surgery for
rhegmatogenous RD or penetrating injury , though
may occur in eyes with RRD without previous
retinal surgery
 Main features- retinal folds and rigidity, causing
decreased retinal mobility following eye movements

13. Staging of PVR-
GRADE A- early retinal
wrinkling
GRADE B- Rolled retinal
break edges

14. Staging of PVR
GRADE C with prominent
star fold
Advanced disease with characteristic
funnel shaped detachment

15. Tractional RD
Neurosensory retina is pulled away from the RPE by
contracting vitreoretinal membranes in the absence of
a retinal break
MAIN CAUSES: Proliferative retinopathy like DM,
ROP and penetrating posterior segment trauma

16. SYMPTOMS- slowly progressive visual field defect,
Photopsia and floaters usually absent.
SIGNS- retinal mobility severely reduced, shifting
fluid absent,
If Tractional RD develops a break, it assumes
characteristics of rhegmatogenous RD and progresses
rapidly, known as combined tractional-
rhegmatogenous RD
Diagnosis of TRD –

17. Tractional RD – concave
configuration
Secondary to Proliferative
Diabetic retinopathy
 Severe TRD

18. OCT showing concave
configuration of Tractional RD

19. Tractional RD USG B-scan:
incomplete posterior vitreous detachment
and relatively immobile retina

20. Exudative retinal detachment
• characterized by accumulation of SRF in
the absence of retinal breaks or traction
• May occur in a variety of vascular,
inflammatory, and neoplastic diseases
involving the retina, RPE and the choroid in
which fluid leaks outside the vessel and
accumulate under the retina

21. CAUSES OF Exudative RD-
 Choroidal tm like melanomas, haemangiomas ,
metastases.
 Inflammation such as harada ds , posterior scleritis.
 Bullous central serous chorioretinopathy – rare cause
 Iatrogenic causes- RD surgery, PRP
 Choroidal neovascularization – may leak to give rise to
ERD
 Hypertensive choroidopathy as in toxemia of pregnancy
 Idiopathic ,such as uveal effusion syndrome

22. Exudative RD – convex configuration,
choroidal melanoma

23. Exudative RD- Diagnosis
 SYMPTOMS : Floaters may be present if a/s vitritis,
visual field defects may develop suddenly and
progress rapidly.
No vitreoretinal traction , so photopsia absent
SIGNS : convex configuration like RRD but its surface
are smooth and not corrugated, detached retina is
very mobile and exhibits the phenomenon of
‘shifting fluid’ .

24. ERD WITH SHIFTING FLUID
Inferior collection of SRF
with pt. sitting
Shifting of SRF upwards
when the pt. is supine

25. Resolution of exudative RD- ‘leopard
spot’ pigmentation

26. Differential diagnosis of RD-
 Degenerative retinoschisis- present in about 5% of
population over age 20 years, prevalent in
hypermetropia. Elevation is convex, smooth, thin and
relatively immobile
 Choroidal detachment- include low IOP, elevations
are brown, smooth , relatively immobile and do not
extend to the posterior pole
 Uveal effusion syndrome- MC in middle aged
hypermetropes
 Vascularized vitreous membranes( d/t PDR, Vos etc)
 Old organized vitreous hemorrhage

27. Management of RD-
 Identification of the causative retinal break
 Selection of surgical procedure with least
morbidity
 Evaluation of the fellow eye to plan for any
prophylaxis (laser, cryotherapy)
 Medical evaluation for presurgical fitness

28. Lincoff’s for finding the primary
break in RD

29. Selection of surgical procedure
 Scleral buckling (minimal invasive/ classical)- gold
standard for most cases of uncomplicated RRD
 Vitrectomy (classical/ sutureless; using gas/ silicone oil
and if needed, an encircling silicone band)- PPV is
required in cases which are complicated by significant
media opacities like cataract, VH, or advanced PVR
 Pneumoretinopexy- out patient procedure in which an
intravitreal gas bubble together with cryotherapy or
laser are used to seal a retinal break

30. Scleral buckling
 Reattachment rate- 94%
 Limitations/ complications- morbidity, infection,
buckle extrusion, ocular motility distubances
 Benefits- excellent long term anatomic success

31. Scleral buckling
Circumferential explant
Buckle induced
circumferential explant

32. Pars plana vitrectomy
 Reattachment rate- 71-92%
 Limitations/ complications- iatrogenic retinal
breaks, PVR, lens trauma, cataract progression
 Benefits- visualization of all breaks, removal of
opacities/ synechiae, anatomic success in
complicated detachment

33. Giant retinal tear large posterior tear severe PVR

34. • Reattachment rate- 64%
•Limitations/ complications- limited to uncomplicated RRD
with superior breaks, need for post operative positioning,
creation of iatrogenic breaks.
•Benefits- in-office procedure, minimally invasive, reduced
recovery time, better post operative VA

35. Pneumatic retinopexy
Gas bubble in vitreous
cavity
‘Fish eggs’ due to gas
bubble break up

36. Exudative RD t/t
 Some cases resolve
spontaneously
 Others treated with
systemic corticosteroids(
harada ds, posterior
scleritis)
 Laser photocoagulation- in
bullous central serous
chorioretinopathy

37. Gases tried in vitreoretinal surgery
Nonexpansile gases( after
PPV) Expansile gases in
pneumoretinopexy
 Air - avg duration 3 days
 Nitrogen
 Helium
 Oxygen
 Argon
 Xenon
 krypton
 SF6 - avg duration 12 days
 C3F8- Longer acting
perfluoropropane, avg
duration 38 days
 C4F10
 CF4
 C2F6
 C4F10
 C5F12

38. Tamponading agents/ vitreous
subtitute used in vitreoretinal
surgery
 Intraocular gases
 Silicone oil
 Perfluorocarbons (PFCL)

39. Post operative complications-
 Raised IOP - due to overexpansion of intraocular
gas, silicone oil associated glaucoma
 Cataract- gas induced, silicone induced, following
vitrectomy
 Band keratopathy- due to extended silicone oil
tamponade

40. Complications of scleral buckling
Buckle extrusion
Buckle intrusion
subretinally

41. Complications of silicone oil
injection
Cataract with an inverted
pseudo-hypopyon
(hyperoleon)
Band keratopathy

42. Complications of silicon oil
injection
Pupillary block glaucoma
caused by oil in AC
Glaucoma d/t emulsified oil
in AC , hyperoleon seen

43. Thank You