Evolution of retinal detachment surgery

1. EVOLUTION OF RETINAL DETACHMENT SURGERY

2. • Retinal detachment occurs when the neurosensory retina (NSR) separates
from the retinal pigment epithelium (RPE) and fluid accumulates within
this potential space.
• Types of RD:
o Rhegmatogenous or Primary R.D
o Nonrhegmatous or Secondary R.D
• Tractional R.D.
• Exudative (Serous) R.D

3. • Three pre-requisites for the development of RRD are:
i) liquefaction of the vitreous,
ii) tractional forces that produce a retinal break, and
iii) a retinal break through which fluid gains access into the subretinal
space.

4. • Horseshoe tear (HST)- This type of tear is predisposed by posterior
vitreous detachment(PVD) with the narrow edge mostly directs
posteriorly. They are mostly seen in the superotemporal quadrant and can
be associated with vitreous haemorrhage.

5. • Giant retinal tear (GRT)- PVD causing retinal tear extending 3 or more clock
hours ( 90) with vitreous attached to the anterior edge. Due to large area of
exposed RPE there is early onset of PVR so surgery is indicated early.
• Operculated tear – continuous vitreous traction on a flap of a tear.

6. • Dialysis – circumferential tear along the ora with vitreous attached to both
anterior and posterior margins of the tear. Usually seen in the
inferotemporal quadrant but may occur in superonasal quadrant mostly
because of trauma.
• Holes – atrophic holes are full thickness retinal defect without vitreous
traction.
Retinal holeRetinal dialysis

7. • Lattice degeneration – These are elongated areas of retinal thinning with
arborizing network of criss-cross white lines with underlying RPE changes.
Lattices aremostly seen between equator and vitreous base and usually are
bilateral. Inferotemporal quadrant is the most common site.
• Degenerative retinoschisis – In typical cases there is split of retina in outer
plexiform layer and most commonly seen in inferotemporal quadrant with a
smooth dome shaped elevation of retina. Symptomatic progressive RD occurs
when there is break in both inner and outer layer of retinoschisis, in presence
of PVD.
Lattice with posterior tearMacula off RRD with inferotemporal lattice with early peripheral proliferative
vitreoretinopathy (PVR). Note the other lattices at the end of superotemporal
vessels

8. Clinical examination
Anterior segment examination
• Cornea-clear (descemet's folds if hypotony)
• Mild flare and cells
• Relative afferent pupillary defect in extensive R.D
Posterior segment
• Tobacco dust in retrolental space (Shaffer’s sign)
• Vitreous haemorrhages
Fundus Examination
• Loss of normal fundal glow
• Retinal breaks
• demarcation line
• Intraretinal cyst and subretinal gliotic changes

9. Clinical presentation
• Photopsia
• floaters
• Flashes
• Visual field defect
• Concave/convex configuration
• Retinal breaks
• SRF
• Highest elevation at sites of vitreo-retinal traction.
• shifting fluid.

10. RETINAL BREAKS & DETACHMENT

12. Lincoff rule

13. • Albrecht von Grafe: was first to notice and document a retinal tear
• Coccius first described retinal breaks in 1853 before the development of
indirect ophthalmoscope.
• James Ware: First attempt in treating retinal detachment in 1805

14. Pre gonin era
chemical retinopexy
• The first theory talked about RD as being spontaneous with the main culprit being
abnormal leakage from choroid.
• Treatments in the form of scleral and retinal puncture to relieve the pressure.
• SRF drainage along with the idea to induce retinopexy was introduced for the first time
by Fano in 1866.
• Induced chemical retinopexy in the form of injection of iodine solution into the
subretinal space to achieve a chemical reaction.

15. • Galvanocautery was pioneered by Deutschmann.
• Role of hypotony and associated circulatory alterations as the cause of RD was put
forth.
• Injection of materials like rabbit vitreous and gelatin to increase the intraocular
pressure were attempted
• Lagrange introduced a procedure known as ‘colmatage’ whereby intraocular pressure
was increased by applying three rows of scleral cautery in a circumferential manner in
order to increase hydrostatic pressure in the retina.
• Osmotic agents were also injected into the subconjunctival space in the hope of
reduction of SRF. These included saline, gelatin, cane sugar, glycerine and mercury salts.

16. • Leber and Nordenson put forward their theory of vitreous traction in the
genesis of RD.
• Unfortunately met with criticism.
• Samelsohn insisted on bilateral compression bandages with bed rest with
idea of increasing intraocular pressure.
• Dietary modifications with salt restriction were another treatment on
offer.

17. Jules Gonin (1870–1935)
• Proved the role of retinal break in the pathogenesis of RD
• ‘Ignipuncture’ whereby retinal breaks were localized,subretinal space was
entered after making a radial scleral incision near the causative break and
SRF was drained.
Various methods of retinopexy:
• Thermocautery was then introduced to create a retinopexy.
• The use of chemical cauterization for retinopexy in the form of potassium
hydroxide introduced by Guist and Lindne in 1931.
• Diathermy was introduced by Larsson, Weve and Safar.

18. • Electrolysis was reintroduced by Imre in 1932
• cryotherapy was introduced by Deutschmann and Bietti in 1933.
• The credit for its current use goes to Harvey Lincoff and Amoils who made
its use easy by creating a specially designed cryo-probe with use of liquid
nitrogen.
• Ruby laser and then argon laser use in 1969 by L’Esperance.

19. Scleral buckling
• Gold standard surgery for uncomplicated RRD with success rate reaching 94%
in studies
• The first scleral buckling procedure using an episcleral exoplant was performed
by Ernst Custodis in 1949.
• Charles Schepens gets the credit for doing the first scleral buckling surgery in
the USA in 1951.

20. • Schepens introduced the silicone rubber implants in 1960.
• The first use of nonabsorbable sutures for scleral buckling was devised by
Arruga in 1958.
• Harvey Lincoff in 1965 who modified the original procedure by Custodis.
-included use of silicone sponge, use of improved scleral needles and
cryotherapy instead of diathermy for retinopexy.

21. Vitrectomy era
• With improved instruments and surgical techniques PPV has become a more
common surgery to treat any type of RRD nowadays.
• David Kashner with help of cellulose sponge and scissors performed the first
vitrectomy (open sky) in a child with trauma on 1961
• Robert Machemer, performed the first pars plana vitrectomy (17G VISC) in a
patient of vitreous haemorrhage on 1970.

22. • Gholam Peyman introduced the electric
solenoid-driven guillotine cutter and a separate
endoillumination probe
Endoilluminator
• Connor O’ Malley and Ralph Heinz introduced 20G vitrectomy system
called Ocutome 800 working on principle of pneumatic cutting.
Gholam Peyman

23. • Chen (1996)- self-sealing sutureless sclerotomy for the 20-gauge.
• Steve Charles led the way in developing the linear or proportional mode. He
is also credited for developing fluid air exchange, flute needle, internal
drainage of SRF and endophotocoagulation techniques.
• Eckardt developed a 23-gauge system
• OHM: first use of intravitreal gas (air) in 1911.
23G trocar Accurus

24. • Eugene de Juan (1990) invented the 25-gauge with transconjunctival
sutureless vitrectomy (TSV)Itrectomy system
25G instruments
Constellation vitrectomy system

25. • Edward Norton: first to use iso-expansile gas (SF6) with retinal detachment surgery.
• Haidt: first to introduce perfluorocarbon liquids as vitreous substitute in 1982. Use
of perfluorocarbon (PFCL) brought the major breakthrough in the management of
giant retinal tear and complicated RD with proliferative vitreoretinopathy. (PVR
• Perfluoropropane gases like SF6,C3F8 are better
tamponading agents and after intravitreal injection
expands and stays for longer period.
• Oshima et al developed a 27-gauge system

28. • A meta-analysis concluded that scleral buckling was associated with better
final visual acuity and less postoperative cataract in phakic eyes, whereas
PPV was associated with better anatomic re-attachment rates in
pseudophakic eyes.
• Advancement in VR surgeries have made RD surgeries much more
predictable.
• The choice of procedure depends number, size and position of retinal
breaks, lens status, patients ability to maintain prone position and
surgeon’s expertise and preference.
• The principle though remains same, ‘Find the break, treat the break and
close the break permanently’

29. Thank you