retinal detachment and surgeries

1. Rhegmatogenous
Retinal
Detachment
Nawat Watanachai
2012

2. Little QUIZ (10min)





1. how to differentiate RRD/TRD/ERD
from fundus findings?
2. risk of PVR
3. contraindication for pneumatic
retinopexy
4. compare PPV vs SBP for RRD
5. compare laser vs cryo retinopexy

3. Retinal Detachment: Definition

separation of the inner layers of the
retina from the underlying retinal
pigment epithelium (RPE, choroid)

4. RD: Pathophysiology
3 basic mechanisms:
1. Rhegmatogenous retinal detachment (RRD)
2. Exudative retinal detachment (ERD)
3. Traction retinal detachments (TRD)

5. The Vitreous


Water 98-99% water
1-2%
 collagen type II fibres*
 salts, sugars
 glycosaminoglycan, hyaluronic acid

very few cells
 mostly phagocytes
 hyalocytes of Balazs (surface/ hyaluronate)

refractive index of 1.336

6. The Vitreous *

Condense and attach more at
Optic disc rim
Along blood vessels
Macula
Peripheral retinal abnormalities
○ Chorioretinal scar
○ Lattice degeneration and others
Ora serrata (Vitreous base: 2mmA, 4mmP)

7. Vitreous degeneration/ syneresis

8. Posterior Vitreous Detachment

9. Posterior Vitreous detachment
Weiss ring

10. Posterior vitreous detachment

Prevalence increase with
AXL
age
○ < 10% at < 50 yrs
○ 30% at 50-70 yrs
○ >60% at > 70 yrs

Other associate
Cataract Sx, within 2 yrs after surgery
○ ICCE 84% = ECCE c PC tear76%
○ ECCE c intact PC40%
○ PE 30%
 inflammation / uveitis
 trauma
 syndromes

11. Posterior vitreous detachment

Symptoms
most asymptomatic
photopsia
○ physical stimulate of vitreoretinal traction
floaters
○ Weiss ring and V.condensation in the posterior
hyaloid surface
○ vitreous opacity eg. blood , glia cell
VH rupture of retinal vessel

12. Vitreo-retinal adhesion
-Chronic traction  hyperpigmented area
-Acute traction  retinal break/ tear

13. Retinal Break/ tear

14. Rhegmatogenous retinal
detachment
-
A hole, tear, or break
in the neuronal layer
allowing fluid from the
vitreous cavity to
seep in between and
separate sensory and
RPE layers

15. RB and PVD*

acute symptomatic PVD
15% retinal tear

PVD with VH
50-70 % retinal tear

PVD without VH
10-12 % retinal tear

16. Risks of RRD 1 *


Posterior vitreous detachment
Peripheral retinal lesions
enclosed oral bays
meridional folds
cystic retinal tuft
lattice degeneration




Myopia
Senile retinoschisis
Cataract extraction
Trauma

17. Risks of RRD 2 *

Intraocular inflammation/infection
-Acute retinal necrosis syndrome
-Cytomegalovirus retinitis
-Ocular toxocariasis
-Ocular toxoplasmosis
-Pars planitis

18. Risks of RRD 3 *







Choiroid/ retinal coloboma
Lens coloboma
Stickler syndrome
Goldmann-Favre syndrome
Marfan syndrome
Homocystinuria
Ehlers-Danlos syndrome

19. Mortality/Morbidity*


1: 10,000 population : yr
15% of people with RD in one eye
 develop RD in the other eye. (lifetime)

Risk of bilateral RD is increased
(25-30%) in patients who have had bilat
eral cataract extraction.

20. History




Floaters
Flashing light (photopsia)
Shadow in the peripheral visual field
Decreased visual acuity and a wavy
distortion of objects (metamorphopsia)

21. History




Detachments anterior to the equator are
very unlikely to affect the VF
Detachment posterior to the equator can
be isolated with visual field testing, but
many patients aware of a defect only when
it involved the posterior pole and macula.
Photopsia and floaters  not helpful in
locating the position of the retinal tear or
detachment
visual field defect  very specific for
locating the detachment.

22. History



FHx of RRD
History of trauma
previous surgery
cataract extraction/ esp c cpx (-L-’)
intraocular foreign body removal
retinal procedures

23. Physical examination



VA/ VF
IOP : hypotony of >4-5 mm Hg less than
the fellow eye is common
Vitreous
tobacco dust (Shafer’s sign), pathognomonic for
a retinal tear in 70% of cases with no previous
eye disease or surgery.

24. Physical examination

Indirect ophthalmoscopy
with scleral depression

A 3-mirror contact lens
examination with a slitlamp

25. Physical examination

marked elevation of the retina, which
appears gray with dark blood vessels that
may lie in folds.

26. Retinal detachment
Which one is this case?
1. Rhegmatogenous retinal detachment (RRD)
2. Exudative retinal detachment (ERD)
3. Traction retinal detachments (TRD)

27. Is this RRD/ TRD or ERD *
symptoms
RRD
TRD
ERD
floaters
++
+/-
+/-
flashing
++
-
-
Progressio
n of VA
loss
acute
chronic
Subacute/
chronic
Fluctuation
of vision
-
+/-
+

28. Is this RRD/ TRD or ERD *
signs
RRD
TRD
ERD
Shaffer’s
sign
+
-
-
PVD
++
-
+/-
VH
+/-
+/-
-
RD contour
convex
concave
bullous
RD surface
corrugate
Ridge/ wavy
smooth
shifting
+/-
-
++
associated
Myopia/
trauma/ Sx
DM
CTD

29. Workup for diagnosis


Lab study – unhelpful
Imaging – not necessary in most cases
Poor visualization  B-scan
Weird cases
○ IOFB/parasite

30. CLINICAL FEATURES

Early

Long standing

31. CLINICAL FEATURES:early

Early
retina lost transparency and assumes a
gray, translucent appearance
fine, irregular corrugations usually present
○ result of intraretinal edema

32. Recent rhegmatogenous retinal detachment showing loss of the
normal retinal transparency and irregular corrugations

33. CLINICAL FEATURES : early


fine details of the choroidal vasculature
obscured by overlying detached retina
within days of RRD
outer retinal degeneration starts to occur
photoreceptor damage related to height and
duration
circulation of inner retina not affected

34. CLINICAL FEATURES : early

If retina reattached within a week
most of cellular changes reversible

RPE cells underlying RRD released
into SRF and may pass through RB into
vitreous cavity
tobacco dust 70% of case

35. CLINICAL FEATURES :early

Lincoff and Geiser reported 4 guidelines
for locating RB causing RRD *
determined by
○ location of causative break
○ anatomic barriers (optic n.,ora serrata,
existing chorioretinal adhesions)
○ effect gravity on SRF in upright
position

Note : only for fresh RD with 1 RB

36. ป๋า harvey lincoff
ณ NEI

37. Lincoff rule

total or superior RD
that cross midline
primary hole usually
within 1 clock hr. of
o'clock meridian

12-
If detachment extends
more inferiorly on
either nasal or
temporal side
RB usually on same
side of 12-o'clock
meridian

38. Lincoff rule

superotemporal RD
RB lies near superior edge of detached retina

superior nasal or temporal RD
RB lies within 1.5 clock hr. of the highest border 98%

39. Lincoff rule

inferior RD
higher side indicates
which side of the disc
an inferior hole lies
95% of the time

inferior detachment
is bullous
primary hole lies
above horizontal
meridian

40. CLINICAL FEATURES:long standing

LONG-STANDING
progressive atrophy of all retinal layers
smooth contour and semitransparent
some cases, cystic spaces
atrophy and depigmentation of underlying
RPE

41. CLINICAL FEATURES :LONG-STANDING

RRD ≥ 3 mo.
RPE metaplasia at border of detachment

Most RRD surrounded by demarcation line
eventually progress; nonetheless, surgical
repair of these eyes has an excellent
prognosis

42. CLINICAL FEATURES :LONGSTANDING

RRD > 6 mo.
Subretinal fibrosis

43. CLINICAL FEATURES :LONGSTANDING

RRD > 1 year
intraretinal cyst
can resolve if retinal reattach

44. CLINICAL FEATURES :LONGSTANDING

very long-standing
extensive capillary nonperfusion lead to
peripheral retinal NV
IOP can rise
○ TM impeded by pigment clumps or the outer
segments of photoreceptors

45. PROLIFERATIVE
VITREORETINOPATHY



occurs ~ 10% of all RRD which ¼ require
additional surgical intervention
most common cause of failure to repair
risk factor
aphakia , preop PVR , extensive RD , uveitis ,
excessive cryo, GRT, massive VH

46. Classification
RD with vitreoretinopathy1983*
Grade
Name
Signs
A
Minimal
vitreous haze ,pigment clump
B
Moderate
wrinkling inner retinal surface,roll edge RB ,
retinal stiffness , vessel tortous
C
Marked
full thickness fix retinal fold
C1,C2,C3
D
Massive
full thickness fix retinal fold 4 quadrants
D1 wide ,D2 narrow
D3 close not seen optic disc

47. Classification of PVR 1991*
grade
features
A
vitreous haze ,pigment clump,pigment cluster inferior
retina
B
wrinkling inner retinal surface,roll and irregular edge RB ,
retinal stiffness , vessel tortous ,vitreous mobility ,
CP1-12
posterior to equator : focal , diffuse ,or circumferential full
thickness fold , subretinal strands
CA1-12
anterior to equator : focal ,diffuse ,or circumferential full
thickness fold , subretinal strands

48. Management RRD

Retinal repositioning
Push the retina-eyewall
○ Pneumatic retinopexy
○ Scleral buckle procedure
○ vitrectomy
Remove SRF/ perfluorocarbon liquid
Remove fibrous membrane/traction

Seal the break(s)
Cryoretinopexy
Laser retinopexy

Temponade the retina
Gas/ silicone oil

49. Retinal Repositioning
○ Pneumatic retinopexy
○ Scleral buckle procedure
Scleral balloon
○ vitrectomy

50. Pneumatic retinopexy *

intravitreal gas tamponade RB temporary
100%C3F8


4X at 72 hrs
SRF will resolve
Need laser / cryo to permanently close the
RB

51. Pneumatic retinopexy*

Contraindications
Break > 1 clock hr
Break inferior 4 clock hr
PVR grade C,D
Cloudy ocular media
Uncontrolled or severe glaucoma
Can’t maintain position

52. Pneumatic retinopexy

Relative contraindications
Extensive lattice degeneration
Aphakia or pseudophakia

53. Results PR


50-80% reattach with single PR
60-98% reattach with reoperation

54. Scleral buckle


Indent sclera with solid silicone
Segmental versus Encircling Buckles

55. Scleral buckle : Segmental *

usually reserved for
RRD < 1 clock hour
posterior breaks

primary advantage
easy of placement
minimal refractive error change
avoid effects of large encircling elements

however, for most large posterior breaks ,
all MH prefer closure with gas and
vitrectomy

56. Scleral buckle : Segmental



not provide retinal support elsewhere
vitreoretinal traction away from
segmental element not supported,
which may result in formation of new RB
because of limited support , some
surgeon prefer encircling when possible

57. Scleral buckle :encircling

particularly indicated in *
multiple breaks in different quadrants
Aphakia/ pseudophakia
High/pathologic myopia
diffuse vitreoretinal pathologic eg. extensive
lattice degeneration or vitreoretinal
degenerations
PVR ≥ grade B

58. Scleral buckle

Intraoperative complications
Corneal clouding
○ epithelial edema from IOP rising
Miosis
○ hypotony , inflammation
Scleral perforate
Drainage complications
○ retinal incarcerate/perforate
○ choroidal hemorrhage

59. Scleral buckle

Post-op complications
Glaucoma
Anterior segment ischemia
Infection/extrusion
CD
○ vortex vein obstrution
○ drainage procedure
CME

60. Scleral buckle

Post-op complications
Macular pucker
Motility disturbance
Change refractive error
○ greater in phakic eye
○ Myopic or hyperopic?
ERD
○ cause unknown

61. Scleral buckle


macula off VA ≥ 20/50 ~ 40-60%
duration of macula detachment relate
with final VA
VA ≥ 20/40
71% if detach < 10 days
VA ≥ 20/40 27% if detach 11days-6 weeks
VA ≥ 20/40
14% if detach > 6 weeks

62. Temporary balloon



Lincoff’s balloon
external device indent
sclera to allow
cryotherapy or laser
induce choriorertinal
adhesion
especial useful in
inferior RD when PR not
possible

63. Vitrectomy

Remove vitreous
Remove vitreoretinal traction on RB


FAX
Injection of gas or liquid silicone



Avoid complication from SB
Complete tamponade of vitreous cavity

64. Vitrectomy

Advantages
better intraoperative control in difficult
situation
improve visualization of peripheral break
Internal drainage avoid complication of
external drainage

65. Vitrectomy

Advantages
high intraoperative reattach rate
remove of vitreous opacity
remove capsular opacity
internal photocoagulation / cryotherapy RB
drainage suprachoroidal fluid if present

66. Vitrectomy

Advantages
less post-op change refractive error
lower incidence of post-op double vision
lower incidence of ERD
avoid hazard of scleral perferation

67. Vitrectomy

Disadvantages
delay visual restitution from gas tamponade
position after operation
air travel avoid

68. Vitrectomy

Disadvantages
higher rate of cataract in phakic eye
higher rate of iatrogenic break
higher rate of post-op IOP rising
higher rate of post-op new/miss break
special equipment
higher cost

69. Vitrectomy



Results
Anatomical reattach 64-100%
Functional results
VA ≥ 20/50 63%
Compare with SB VA ≥ 20/50
39-56%

70. Seal the break(s)



Diathermy (obsolete)
Laser
cryo

71. Laser photocoagulation



usually cannot seal RB if presence SRF
may be use to create barrier to prevent
progression of RD
esp. useful in
chronic inferior RD
systemic illness contraindicate to surgery

72. Laser photocoagulation



slit-lamp
biomicroscope with
contact lens
laser indirect
ophthalmoscope
(LIO)
endolaser

73. Laser photocoagulation*


Slit-lamp
 better magnified
 Safer in inexpertise
operator
 Less need of corneal
care during laser
 Less pain
LIO
 significant cataracts,
PCO, mild VH more
easily treated with
LIO
 indentation
 Need more skill
 not be readily
available
 Any patient position

74. A.posteriorly located retinal tear
B.treat by laser photocoagulation

75. Laser photocoagulation *

Compared with diathermy and cryopexy
less breakdown of blood–ocular barrier
thermal effect confined predominantly to
retina and pigment epithelium
little or no effect on choroid or sclera
induces adhesive effect between retina &
pigment epithelium within 24hr

76. Cryoretinopexy



RD with very shallow fluid can be cure by
cryoretinopexy alone
using cryoprobe and indirect ophthalmoscope
testing cryoprobe prior to make sure probe is
freezing

77. Cryoretinopexy


freezing or whitening of RPE will noticed first,
followed by delineation of edges of retinal tear
and whitening of retina
excessive freezing or ice crystal formation
should be avoided

78. Cryoretinopexy

histologic response depends on whether
RPE alone or RPE and overlying detached
retina together are frozen
only RPE froze once retina reattached
○ pigment epithelial hyperplasia
○ loss of retinal outer segments
○ normal microvillous interdigitations seen between
retina and RPE are missing

79. Cryoretinopexy

If both RPE and overlying retina frozen
cellular connections between retina and RPE
consisting of desmosome formation between
retinal glia and pigment epithelium or direct
contact between retinal glia and Bruch's
membrane

81. Cryoretinopexy

Disadvantage
dispersion of pigment epithelial cells, which can
result in subretinal pigmentary changes after
reattachment
dispersion of viable pigment epithelial cells
capable of causing PVR following cryopexy

82. Cryoretinopexy

Some study suggest cryopexy is risk factor of
post-op PVR whereas others not show an
association
minimize cryotherapy-induced pigment epithelial cell
dispersion by
○ not over treating
○ avoiding unnecessary scleral depression of treated
areas

localization and examination with scleral
depression should be performed before
cryopexy

83. Cryoretinopexy : disadvantage

induce choroidal congestion &hyperemia
although not permanent
may complicate drainage of SRF through
treated areas

breakdown of BRB
cause post-op CME and ERD