A comprehensive review about retinal detachment for 4th year medical students Dr. Mahmoud Farouk, Assistant Professor Sohag University 2020

1. Retinal Detachment
for 4th year medical students
2020
Mahmoud Farouk, MD, FRCS
Assistant Professor of Ophthalmology
Sohag University

2. Normal Fundus

4. How to examine the
fundus ??

5. How to examine the fundus
1) Direct ophthalmoscope
2) Indirect ophthalmoscope
3) Slit lamp

6. Direct ophthalmoscope

7. Indirect ophthalmoscope

8. Slit lamp

9. Special investigation for fundus
examination
1) Fluorescein Angiography (FA)
2) Optical coherence tomography (OCT)
3) Ultrasonography
4) Electrophysiology (ERG – VEP)

10. Fluorescein Angiography (FA)

11. Optical coherence tomography
(OCT)

12. Ultrasonography

13. Electrophysiology
1) Electro-retinogram (ERG)

14. Electrophysiology
2) Visual Evoked Potential (VEP)

15. Retinal Detachment
Definition
Separation of the sensory retina from the RPE by SRF.

16. Types (according to Etiology):
1) Rhegmatogenous (1ry) RD
(Rhegma=break=tear):
Due to defect in the sensory retina (tear).
2) Non-rhegmatogenous (2ry) RD
A) Tractional: the sensory retina is pulled away from RPE.
B) Exudative: SRF derived from choriocapillaris, gains
access to SR space through damaged RPE

17. Rhegmatogenous (1ry) RD
Pathogenesis
 Due to defect in the sensory retina (tear or break) which
allows the SRF derived from liquified vitreous gel
(syneresis) to gain access to SR space.

18. Pathogenesis
How the tear is formed ?
 The tear (or break) occurs due to interaction
between 2 factors:
1) V-R traction.
2) Predisposing degenerations in the peripheral
retina.

19. 1) V-R traction.
 Vitreous liquefaction →
 Posterior vitreous
detachment (PVD) →
 Reach an area of V-R
adhesion →
1) Break or
2) Vit. Hge
3) Complete PVD

20. 2) Predisposing peripheral retinal
degenerations:
1) Lattice degeneration: (8% population & 40% of RD).
2) Snail-track degeneration
3) Degenerative retinoschisis
4) White without pressure

21. Retinal tears (Full-thickness defects of the sensory retina)
Types according to Morphology:
1) Horse-shoe tears (U-tears).
2) Incomplete U-tears (linear, L-shaped, or J-shaped).
3) Operculated tears.
4) Dialysis.
5) Giant tears.
6) Holes: caused by chronic atrophy
Types according to the site: oral – post oral – equatorial –
postequatorial – macular.

22. Retinal tears

23. High myopia & RD:
 10% of the general population.
 40% of all RDs.
Significance of myopia:
1) Peripheral retinal degenerations are commoner
2) Vitreous degeneration & PVD are more common.
3) Vitreous loss during cataract surgery
4) Posterior capsulotomy increases the risk of RD

24. Symptoms
Early:
1) Photopsia: due to traction on the retina. Cessation of
photopsia may be due to PVD or Separation of operculum
2) Floaters (Musca) : solitary ring-shaped, cobwebs, sudden
shower of minute red or dark spots.
Later symptoms:
1) VF defect: dark curtain in opposite VF to RD.
2) Loss of central vision: macular detachment or obscuration.
Clinical Picture of rRD

25. Signs:
1) Decreased VA
2) Marcus-Gunn pupil (APD).
3) IOP is lowered
4) Iridocyclitis
5) Red reflex: greyish in color
6) Tobacco dust in the vitreous
7) Retina (Fundus): According to the duration of RD:
A) Early (Fresh) RD
B) Long standing RD

27. 1) Early (Fresh) RD
 The retina has a convex configuration and a slightly
opaque and corrugated appearance.
 B-scan ultrasonography shows good mobility of the
retina and vitreous

28. 2) Long standing RD
1. Retinal thinning
2. Secondary intraretinal cysts
3. Subretinal demarcation lines (‘high water marks’)
4. Proliferative vitreoretinopathy (PVR) is caused by epiretinal and
subretinal membrane formation. contraction of these membranes
causes tangential retinal traction and fixed retinal folds
5. B-scan ultrasonography shows reduction of retinal mobility

30. Investigations
1) Ultrasonography (B-Scan)

31. Investigations
2) OCT (may be needed)

32. Prophylaxis (Prevention) of rRD
= Treatment of retinal breaks
Indications:
1) The characteristics of the break:
What are the Retinal breaks needing prophylaxis:
1) Type: Tears (not holes). 2) Size: Large tears.
3) Symptomatic. 4) Site: Superior
2) The characteristics of the patient
Aphakia, pseudophakia, myopia, other eye RD, family history.
Methods:
1) Argon Laser photocoagulation
2) Cryotherapy
To induce sterile chorio-retinitis

33. Argon Laser photocoagulation

34. Treatment of rRD
1) Pneumatic retinopexy.
2) Scleral buckling.
3) Pars Plana Vitrectomy (PPV).

35. 1) Pneumatic retinopexy.
Principle
 An intravitreal expanding
gas (SF6,C3F8) is used
to seal the break.
 Cryotherapy
Indications
1. Uncomplicated RDs,
2. small retinal break in the
upper 2/3 of the
peripheral retina.

36. 2) Scleral buckling (Standard or
conventional retinal surgery)
 Principle:
1) SB involves the creation of inward indentation of the
sclera in order to:
a) Close the retinal breaks by apposing the RPE to the
sensory retina.
B) Reduce dynamic V-R traction.
2) Drainage of SRF: Creates immediate apposition
between the sensory retina & RPE.
3) Intravitreal air injection.

37. 2) Scleral buckling (Standard or
conventional retinal surgery)

39. 2) Scleral buckling (Standard or
conventional retinal surgery)
 Types of SB:
1) Radial buckles.
2) Circumferential: Segmental or Encircling

40. 3) Pars Plana Vitrectomy (PPV).
 A procedure designed to remove vitreous gel to gain access to a
diseased retina
 Principle:
1) Removal of the vitreous gel.
2) Relief of V-R traction.
3) Retinal reattachment.
4) Endolaser photocoagulation of the break
5) Injection of tamponading agent (Silicon oil or Gas)
 Indications: Usually in complicated RDs when retinal breaks cannot
be closed by conventional SB (large size, posterior location, PVR).

41. Three Ports Pars Plana
Vitrectomy (PPV).

42. Remember
Prophylaxis (Prevention) of rRD
= Treatment of retinal breaks
1) Argon Laser photocoagulation
2) Cryotherapy
Treatment of rRD
1) Pneumatic retinopexy.
2) Scleral buckling.
3) Pars Plana Vitrectomy (PPV).

43. 2) Non-rhegmatogenous (2ry) RD
 A) Tractional: the sensory retina is
pulled away from RPE.
 B) Exudative: SRF derived from
choriocapillaris, gains access to SR space
through damaged RPE

44. Tractional RD
The sensory retina is pulled away from the RPE by contracting V-R
membranes
 Symptoms:
1. No Photopsia & floaters (why ?)
2. VF defect develops slowly, may become stationary for months or
years.
 Signs:
1. Detached retina is concave.
2. No Breaks.
3. SRF is shallow.
4. Retinal mobility is severely reduced.

45. Tractional RD
 Causes:
1. PDR
2. ROP
3. Penetrating trauma.
 Treatment:
PPV

46. Exudative RD
SRF derived from the choriocapillaris gains access to SRS
through damaged RPE
Causes:
1. Tumors: Choroidal or 2ry
2. Inflammations: VKH disease, post. Scleritis
3. Severe hypertension
Symptoms:
- No Photopsia is absent
- VF defect may develop suddenly
& progresses rapidly.
- May be bilat. (systemic disease).

47. Exudative RD
Signs:
- Detached retina is convex.
- Breaks are absent.
- SRF is deep (the retina may be seen behind the
crystalline lens).
- The retina is very mobile (shifting fluid)
Treatment:
of the cause.

48. Thank You