DR WANI'S TALK ON RETINAL DETACHMENT LECTURE FOR RESIDENTS [DR WANI TALK.pptx

Dr Wani talks on RD for residents in KLE hospital
This is a detailed talk that deals with all aspects fo RH RD
This talk aims to clear the concepts about RD
It deals the incidence of RH Rd, pathogenesis, cliinical features , diagnosis , treatment options prognosis etc

1. Retinal Detachment Definition Classification Epidemiology Patho -physiology Clinical features Diagnosis Treatment and its complications Prognosis

2. RETINAL DETACHMENT DR VIVEK B WANI MS FRCSED

3. A. DEFINITION OF RD Retinal detachment is the separation of the neuro -sensory retina (NSR) from the underlying retinal pigment epithelium (RPE)

4. Retinal anatomy

5. The potential space of- SRS

6. B. Classification of Retinal Detachment Rhegmatogenous RD- a full thickness neurosensory retinal break allows the fluid from vitreous to enter the sub-retinal space and cause detachment Tractional RD- the NSR is lifted by pull/traction exerted by bands or membranes that are present on the surface of retina or sub- retinaly or trans- vitrealy Exudative RD-NSR separates from RPE by entry of fluid production usually by choroid in absence of retinal break or traction Combined- separation of NSR with tractional component being present first and a break caused by traction causing further separation

7. RRD-Clinical and subclinical Subclinical RD- sub-retinal fluid more than 1 DD beyond the posterior margin of the hole or tear but less than 2DD from the equator and does not cause visual field defect Clinical retinal detachment-A RD that impairs any portion of the visual field or extends 2 DD posterior to the equator

8. C. Epidemiology- Rh RD Rh RD occurs among 10 to 18 persons per 100,000 population per year(1-1.8 per ten thousand) Of these cases 40% will myopia, 20-40% will have h/o cataract surgery and 10% will have h/o trauma Estimates reveal that 10% of people with retinal detachments in one eye develop detachment in the other eye over five years

9. D. Patho -physiology Forces that keep the retina attached Risk factors for Rh RD How does RD develop? PVD Retinal break formation Entering of fluid under retina Rh RD

10. D. Pathophysiology a) Forces that keep the NSR apposed to the RPE are i ) Mechanical Fluid pressure of vitreous and the IOP Interphotoreceptor substance which acts as a glue between RPE and NSR Formed vitreous acts a glue for breaks closing them Interdigitations between photoreceptors and microvilli of RPE Oncotic pressure of choroid which facilitates movement of fluid from subretinal space in to the choroid ii) Metabolic The RPE acts as a pump to transport fluid from the SRS to the choroid

11. b) Risk factors for Rh RD Myopia -up to 40% with RH RD have myopia Cataract surgery 20-40 % are pseudophakic or aphakics Lattice degeneration 30% of patients with Rh RD have lattice degeneration Trauma -10% of Rh RD have h/o trauma YAG laser capsulotomy h/o RD in the other eye h/o RD in family member Genetic disorders-Stickler’s, Marfan’s , Wagners Infections and inflammations - CMV retinitis, endophthalmitis , Acute retinal necrosis

12. c) How does the Rh RD develop PVD Retinal break Entering of fluid in to the SRS There are exceptions to the above chronology

13. i ) POSTERIOR VITREOUS DETACHMENT- PVD PVD is separation of the posterior vitreous cortex from the ILM This usually occurs after substantial liquefaction of the vitreous ( syneresis ) The loculi or areas of liquefaction in the vitreous coalesce A break occurs in the posterior vitreous surface through which the fluid escapes The escaped fluid dissects the vitreous cortex from the retina in all quadrants up to posterior border of the vitreous base where it is firmly attached to the retina

14. PVD

15. PVD Usually occurs between 45-65 YRS Increases with ageing Early in myopes, uveitis and trauma cases

16. Normal strong adhesion of vitreous is seen Margin of disc Macula Major retinal vessels Vitreous base-it does not detach spontaneously from this site May detach after severe blunt trauma –Vitreous base avulsion

17. Abnormal strong adhesions of vitreous to retina Margins of lattice degeneration Chorioretinal scars Posterior extensions of vitreous base-not visible WWP and white with pressure areas Abnormal strong adhesions between vitreous and retina and retinal vessels will result in retinal breaks or avulsed vessels with vitreous and retinal hgs when PVD occurs

18. Symptoms of PVD Flashes are due to traction on the retina at the vitreous base Most noticeable during dark Have no localizing value Floaters are due to Weiss ring, vitreous hemorrhage, condensed collagen fibers in vitreous and pigments DV –– condensed vitreous fibrils, vitreous hemorrhage of varying degrees Many patients are asymptomatic

19. PVD PVD is diagnosed by visualizing the posterior vitreous face and the Weiss ring –a glial ring detached from the edge of the ONH

20. PVD

21. Sequel of PVD Retinal tears Vitreous hemorrhage Vitreous haze or clouding Retinal tears occur at Posterior border of the vitreous base where there may be localized posterior extension of the base Posterior margin or side of lattice degeneration Abnormal vitreo-retinal adhesions that may or may not be visible pre PVD

22. Sequel of PVD PVD may also cause avulsion of superficial retinal blood vessels, pre-papillary vessels and vessels crossing the torn retina causing retinal and vitreous hemorrhages

23. ii) RETINAL BREAKS Retinal break-is a full thickness defect in the neurosensory retina I) Those caused by traction are called tears Flap tear or HST-horse shoe tear -A retinal tear caused by vitreoretinal traction on the retina The tear is horse shoe shaped because a flap of retina is attached to the detached vitreous The tip of the flap is always pointing posteriorly Giant retinal tear (GRT) -a tear>3 clock hrs in circumference

24. HST shape

25. Different types of retinal breaks

26. HST

27. GRT GRT-a tear that is >3 clock hours in circumference The vitreous is attached to the anterior margin of the tear always and the posterior border is free of vitreous

28. GRT treated by laser!

29. RETINAL BREAKS II) Those that are round and not associated with traction are called holes They occur due to atrophy of retina They can occur in lattice degeneration or in an otherwise normal appearing retina A special type is operculated hole which is caused by traction but the resultant hole is free of traction

30. Atrophic holes

31. Operculated retinal hole Operculated retinal hole-a full thickness defect in the retina caused by vitreoretinal traction at the site of the lesion with a piece of retina torn apart completely by traction The piece of retina torn apart is attached to the posterior hyaloid and is called operculum If this occurs during PVD then all traction surrounding the tear is eliminated

32. Operculated hole

33. Retinal dialysis Retinal dialysis- crescent shaped retinal break at the ora serrata –disinsertion of retina from the ora serrata-usually due to blunt trauma

34. Retinal dialysis

35. iii) Entry Of Sub-retinal Fluid Traction on the retina Ocular movements –effects on liquid vitreous Comparative retinal density Choridal leakage RPE pump failure

36. Traction On Retina Gravitational force of gel vitreous on the retina In standing position with a superior break the attached vitreous at the break causes traction because of the gravitational pull on the gel

37. Traction On Retina- Ocular Movement Rotational eye movement – retina and eye wall move but vitreous lags behind because of its inertia This causes the vitreous to cause traction on the retina at break and opens the break

38. Traction On Retina When the eye movement stops the vitreous gel is continuing to move and this causes traction to be applied at the opposite side

39. Liquid Vitreous Movement Rotatory eye movement causes flow currents in liquid and gel vitreous in a direction opposite to that of the eye movement The liquid vitreous dissects beneath the edge of retinal break

40. Liquid Vitreous Movement Rotatory eye movement also has inertial effect on the subretinal fluid This leads to extension of RD

41. Comparative Retinal Density In superior breaks when the retina is detached the detached retina being heavier(1.0174) detaches further due to gravitational effect as the liquid vitreous ( 1.0033) is lighter

42. Choroidal Leakage Some eyes with RD have uveitis and this may cause choroidal exudation and choroidal detachment and this may add to RD

43. Failure Of RPE Pump High myopia Old age Aphakic patients Failure of the pump may cause development of RD even with atrophic holes without any vitreous traction

44. Summary Of Pathogenesis Of RD PVD Retinal break formation Traction on retina- by gel vitreous by gravitational forces, by rotational movements of the eye Separation of retina- by liquid vitreous and subretinal fluid by rotational eye movements Overpowering of forces which keep the retina in place Development of retinal detachment

45. Retinal Detachment Definition Classification Epidemiology Pathophysiology Clinical features Diagnosis Treatment and its complications Prognosis

46. E) Rh RD Clinical features Symptoms b) signs Symptoms-symptoms of PVD may precede the development of Rh RD Flashes- Usually patients give h/o flashes as the first symptom More appreciated in the dark Their cessation may indicate that the traction has stopped Flashes indicate presence of fresh PVD or continuing traction Does not have localizing value

47. a) Symptoms Floaters – is due to PVD –Weiss ring, collagen fibrils condensation or vitreous hg Field defect - If the RD develops slowly then the patient may appreciate a part of field becoming dark and then slowly spreading Usually upper field defects are not reported Field defects have great localizing value

48. a)Symptoms Failure of vision Sudden painless loss of vision is the hallmark of RH RD though it may be gradual in slowly developing inferior RDs When the fovea is involved then the patient may complain of decreased vision It may also be due to a bullous RD covering the flat macula Redness –sometimes uveitis may be present in cases of RH RD causing redness Pain – only when complications occur in chronic cases when IOP may increase or rarely NVG Sometimes inferior Rh RD may be detected during routine clinical examination

49. b) Signs AC reaction –mild to moderate may be present sometimes leading to post synechiae especially in chronic cases RAPD+ Cataract - in chronic Rh RD cases IOP - usually lower than opposite eye Very low IOP indicate choroidal detachment High IOP indicates a chronic RD causing Shultz syndrome or secondary to uveitis Anterior vitreous -may show pigments indicating presence of tears-Tobacco dust sign or Schaffer sign If PVD has caused vitreous hemorrhage it may obscure fundus view to varying extent

50. b)Signs-fundus Detached retina –Early A recently detached retina obviously is elevated and has broad folds and has lost transparency and assumes a gray, translucent appearance The vessels appear dark Eye movements typically cause the detached retina to undulate in a characteristic manner Fine, irregular corrugations are usually present and are the result of intra-retinal edema The fine details of the choroidal vasculature are somewhat obscured by the overlying detached retina Macula stands out as red spot as it is thinner and lacks layers that get edematous so it may be confused as macular hole Of course there will be one or more retinal break/s

51. b)Signs Detached retina late changes The retina undergoes atrophy and becomes semitransparent The corrugated appearance is gone Cystic spaces may develop in the retina in chronic cases-6 mo Pigmentary changes take place at the border of detachment if it is more of three months duration –demarcation lines In very long standing cases extensive capillary non perfusion can lead to NVE formation NVG can also occur in very chronic cases Choroidal detachment and chronic hypotony and phthisis bulbi in untreated cases

52. Demarcation lines

53. b)Signs-localization of breaks

54. Lincoff and Geiser rules In superior nasal or temporal detachments, the hole lies within 1.5 clock hours of the highest border 98% of the time. In total detachment or superior detachments that cross the midline, the primary hole is at the 12-o'clock position or in a triangle, the apex of which is at the ora serrata and the sides of which intersect the equator 1 hour to either side of the 12-o'clock position. This occurs 93% of the time. In inferior detachments, the higher side indicates to which side of the disc an inferior hole lies 95% of the time. When an inferior detachment is bullous, the primary hole lies above the horizontal meridian

55. Retinal Detachment Definition Classification Epidemiology Pathophysiology Clinical features Diagnosis Treatment and its complications Prognosis

56. F. Diagnosis The fundus examination by indirect ophthalmoscope or by slit lamp biomicroscopy is conclusive in cases where the media is clear In cases where the media is hazy then USB is indicated to confirm the diagnosis Media may be hazy due to vitreous hg due to PVD, vitreous haze due to vitritis and PVD, cataract in chronic cases or concurrent RD with cataract cases

57. Character Rh RD TRD Exudative RD Retinoschisis Symptoms 4Fs DV+,NO Flashes/float No flashes floaters + None or DV Retina Convex configuration Grayish corrugated Concave Semitransparent Convex bullous Grayish smooth surface Tense, transparent, convex Mobility Mobile , makes undulating movements Not mobile Mobile shifting fluid Not mobile Break Yes Nil Nil Inner and outer +/- Height of RD High Shallow more at Traction Highest reaching lens High Cause Break Traction membranes Inflammation or tumors etc Degeneration or genetic Field defect Relative Relative Relative Absolute

58. Retinal Detachment Definition Classification Epidemiology Pathophysiology Clinical features Diagnosis Treatment, success rates and complications Prognosis

59. G. Treatment Spontaneous resolution of Rh RD is rare and surgical treatment is needed in all cases SURGICAL TREATMENT Scleral buckle Pars plana vitrectomy Pneumoretinopexy Temporary Balloon buckle

60. History of treatment of Rh RD Jules Gonin was the first to propose that the retinal break is the cause of the Rh RD and demonstrated for the first time (1919)that the Rh Rd can be cured by closing the break – ignipuncture Reported 50% success rate with his technique Gonin J (1930) The treatment of detached retina by sealing the retinal tears. Arch Ophthalmol 4:621

61. Jules Gonin

62. H/O treatment of RH RD 1949 Custodis introduced scleral buckling in addition to the treatment of the retinal break by diathermy- polyviol material Reported 83% success rate and did not believe that drainage was necessary Custodis E (1956) Klin Monatsbl Augenheilkd 129:476

63. Custodis

64. H/O treatment of RH RD Schepens -1950 lamellar scleral dissection with scleral implant-polyethylene tube + diathermy+ SRF drainage Was the first to use binocular indirect ophthalmoscope for RD surgery

65. Charles Schepens

66. H/O treatment of RH RD Brockhurst in 1956 introduced lamellar dissection+diathermy+silicone implant of various shapes and sizes+ encircling band Lincoff –explants + cryotherapy + better suturing material +non drainage

67. Harvey Lincoff

68. Vitrectomy Von Hippel cut vitreous membrane and treated successfully the TRD 1915 Kasner 1962 open sky vitrectomy showed that the vitreous can be cut with scissors after holding with cotton wicks Machemer introduced closed system vitrectomy PPV –VISC First PPV done in 1971 Machemer R, Buettner H, Norton EWD, Parel JM (1971) Vitrectomy : a pars plana approach. Trans Am Acad Ophthalmol Otolaryngol 75:813

69. Robert Machemer

70. Which treatment to chose? Depends upon Characteristics of the Rh RD Status of PVD Media Patient –age n preferences Instruments available Experience and expertise of the surgeon

71. However the trend now is PPV for most cases of Rh RD though there are few exceptions

72. a) Scleral buckling In which cases of Rh RD? RD in phakic eyes and young patients with attached posterior hyaloid Detachments due to dialysis Detachments due to atrophic holes RHRD due to breaks anterior to the equator: easy to place a buckle in the right position and hard access to the periphery with PPV in a phakic eye (lens touch) Inferior retinal detachments As a supplement to PPV in pseudophakic , aphakic and RD with severe PVR

73. Where is the SB not suitable option Posterior retinal breaks not easy to reach including Rh RD due to macular hole MYOPES Hazy media due to vitreous hemorrhage Rh RD with significant vitreo-retinal traction Rh RD with PVR worse than c1 Giant retinal tear Rh RD Combined TRD with Rh RD Patients with sickle cell anemia to avoid ant segment ischemia due to buckle effect Very thin sclera Had filtering surgery for glaucoma

74. Advantages of SB Extraocular procedure if no SRF done More forgiving than vitrectomy It does not induce cataract, which occurs in almost 80% of vitrectomized phakic eyes within 1 year to 2 years Cheap -with minimal instrumentation needed A high percentage of success is achieved with a single procedure (up to 90%) Does not need positioning Less often needed to use tamponade so air travel possible

75. Disadvantages of SB May alter the shape of the globe and induce refractive changes Induce muscle imbalance, ocular motility disturbance More painful A difficult technique that requires skill and experience at every step, from localizing the tears to indenting the sclera and draining the subretinal fluid

76. Preparation for surgery Investigate for his/her fitness for surgery Anesthesia – LA/ GA -age, duration of surgery and patient preferences Urgent surgery- macula sparing Rh Rd specially the superior Rh RDs Macula off RDs can be posted 1-3 weeks Patients are advised bed rest to reduce the SRF

77. Scleral buckling Aim is to produce localized indentation of the sclera, choroid and RPE under the retinal break to close it functionally

78. SB of retinal break results in Decrease in Vitreoretinal traction by displacing the eye wall and retina centrally Displacement of SRF away from the retinal break Approximation of retinal break and vitreous formed gel Alteration in the concave shape of the inner eye wall resulting in change in currents of intraocular fluid that facilitates entry of fluid through the break Cryotherapy of the breaks results in a chorioretinal scar resulting in closure of the break permanently

79. Scleral buckling Explant or Implant? Explant is sutured on the scleral surface Implant is placed in scleral tunnels or under flaps of partial thickness sclera made over the breaks, implant placed and scleral flaps sutured to cover the implant Implants give better height and chances of extrusion are less but difficult and risky in thin sclera- patients like myopes Explants are made of sponge or hard silicone

80. Scleral Explant Orientation - Radial-vertical to the limbus Circumferential- parallel to the limbus Segmental or Encirclage Some include radial under segmental

81. Radial buckle In cases of single HST between recti muscles Radial buckles are placed vertical to the limbus covering the break adequately Usually sponge material is used Useful in posterior breaks too

82. Radial Buckle Faster Less refractive changes May not need gas injection thus no restrictions on air travel or positioning But-Accurate positioning is needed for success

83. Circumferential Segmental- limbus parallel but usually 1-2 quadrants Multiple tears at different levels in one or two quadrants, anterior breaks or dialysis Are easy to place Less refractive error post op They can be placed posteriorly too The segmental element should extend 30d beyond the vitreoretinal pathology Less chances of compromising vortex veins Effect fades with time so retinopexy is important

84. When do we use encircling procedures? (1) Multiple breaks in different quadrants (2)Aphakia and Pseudophakia- there is concern about potentially unidentified and untreated breaks (3)Diffuse vitreoretinal pathology, such as extensive lattice degeneration or vitreoretinal degenerations usually in high myopes (4) proliferative vitreoretinopathy of grade B or greater It supports the vitreous base preventing effect of anterior contraction An encircling band can be placed over a segmental or 360 tire The ends are tied in a Watzke sleeve and shortening the band length by pulling the ends in opposite directions- causes more indentation

85. Extent of the encirclage antero -posteriorly If the encircling element is supporting pathologic conditions in attached retina, such as a retinal break, lattice degeneration, or prominent vitreoretinal adhesions, the most posterior aspect of the condition needs to be supported by the encircling element If no specific pathologic factor is to be supported, the encircling element should support the posterior margin of the vitreous base

86. Segmental with encirclage

87. How much area should the explant cover The explant should be large enough to cover the break and around 2 mm beyond the break The buckle effect should extend to the vitreous base anteriorly The height should be adequate to close the break on the table

88. How to increase the height of the buckle –refers to degree of indentation To increase the height of the tire buckle the sutures are taken wider to tie the explant –axial length may shorten Usually the distance between the sutures in segmental buckle is 2-3 mm more than the width of the buckle material or tire 220 buckle which has 7 mm width needs sutures 9 mm apart In encircling buckle the encircling element is shortened by pulling the ends and tied to increase the height of the buckle –axial length increases

89. Disadvantages of the encirclage Fish-mouthing of HST- relative circumferential shortening of the sclera and choroid induced by the buckle in relation to the retina The relative excess of retinal surface causes the retina to lie in radial folds over the buckle with HST opening up like fish mouth resulting in failure of break to close and failure of SB Anterior segment necrosis –if tight encirclage Refractive changes Mobility disorders

90. Suture material used A spatula needle with a 5-0 non-absorbable suture such as polyester, nylon, or polypropylene is used

91. Steps of SB Anesthesia –LA or GA -Clean and prep the eye. Drape, speculum, 360 conj peritomy if encirclage is planned all Recti held with 4-0 silk sutures Indirect ophthalmoscope examination Cryotherapy to all the breaks and other pathologies like LATTICE DEGENERATION AND retinal traction tufts Accurate marking of the retinal breaks on the surface of the sclera Passing of 5-0 ethilon sutures in chosen quadrants, passing of the SB material under sutures and temporary tying Inspection of retina -check for position of buckle and closure of breaks and arterial pulsations disc circulation If the retinal breaks settle on the buckle no SRF draining is necessary The sutures are tied and trimmed

92. Cryo marks

93. Drainage of SRF The rationale for drainage of sub-retinal fluid is two fold: to allow the retinal break to settle on the elevated buckle by removing fluid from the sub-retinal space –close the break to diminish intraocular volume so as to allow elevation of the buckle without difficulties with elevated IOP

94. When to drain the SRF Bullous detachments : to place the retinal break on the buckle and to facilitate cryo treatment of the break Inferior breaks : Inferior breaks tend to settle less readily on the buckle than do superior breaks, perhaps because of gravity. Also gas injection will not work Proliferative vitreoretinopathy : Proliferative vitreoretinopathy may prevent the retina from settling, resulting in prevention of closure of retinal breaks Highly myopic detachments and aphakic detachments : The syneresis of the vitreous that occurs in myopia and aphakia may be a factor in the failure of these retinas to settle on the buckle without drainage. Sick RPE another cause

95. Chronic detachments : Subretinal fluid in chronic detachments becomes viscous, assuming the biochemical profile of plasma Poor retinal pigment epithelium function : Detachments in patients with age-related macular degeneration Eyes intolerant of sustained intraocular pressure rises, such as those with known glaucoma or recent cataract surgery(especially ECCE) When to drain the SRF

96. How to drain the SRF The most dependent and safe position is chosen after the examination is done Usually away from the break Usually below or above the horizontal meridian to avoid injury to long ciliary vessels and nerves Many drain under the scleral buckle before tying it up a) Direct puncturing of sclera 27 g needle attached to a 2 ml syringe with plunger removed is used to make a full thickness scleral perforation

97. How to drain the SRF b) to do a scleral cut down 1 mm long vertical to limbus deep to expose the choroid Usually a preplaced suture is taken if the cut down is not in the bed of the buckle Mild cautery applied to the knuckle of choroid A needle puncture is made and apply gentle pressure on the globe to express the SRF The fundus is examined for adequacy of drainage, bleeding, incarceration or perforation of retina

98. SRF DRAINAGE BY CUT DOWN

99. SB -end of surgery Ensure that the breaks are on the buckle If the drainage is adequate and the break now lies on the buckle Rule out complications of SRF drainage like choroidal hg, subretinal hg, retinal injury or retinal incarceration The SB sutures are tied and knots are rotated posteriorly, the excess of band or buckle in encirclage elements is cut Examine the ON to rule out increased IOP If the globe is soft after drainage inj of gas or BSS done SOS Remove the sutures of recti Close the conjunctiva

100. Complications of SB During surgery Corneal clouding due to compression of the eye for cryo , scleral buckle and traction on eye Cryo Suture placement SRF drainage

101. During Cryo Wrong area cryo due to indentation by the shaft the tip may cryo the macula

102. Cryo complications Sudden removal of the probe before it thaws can cause choroidal bleed, scleral tear The ice ball should be allowed to melt before trying to remove the probe from the scleral surface

103. Suture placement SB

104. Suture placement Scleral perforation during placement of scleral sutures is a potentially serious complication May result only in SRF drainage Retinal break- try to cover this break by new position of buckle Subretinal hemorrhage-mild or massive –depends upon the quantity

105. During SRF drainage A dry tap -this can be avoided by steadily advancing the needle until fluid is present around the needle Choose an area where there is high RD SRF The possibility of subretinal fluid shifting away from the drainage site can be minimized by visualizing the subretinal fluid immediately before drainage

106. Complications-SRF drainage Retinal perforation - when the needle strikes the retina because there is shallow subretinal fluid or excessive entry of the needle Treatment- If the drainage site is in the bed of the buckle, usually no treatment is required, with the possible exception of cryotherapy If the perforation occurs outside the bed of the buckle, a new unsupported retinal break has been created, and this requires cryotherapy and adjustment of the buckle for adequate support

107. Retinal incarceration at the drainage site IOP fluctuation may cause it Characteristic dimpled appearance of the retina over the drainage site Treatment Minimal degrees of incarceration may be ignored, but large amounts of incarceration require support If incarceration occurs outside the bed of the buckle, the buckle should be modified to support the incarceration site

108. Choroidal hemorrhage The choroidal hemorrhage is due to puncture of choroidal vessels As there is no autoregulation of choroidal vessels –increase the IOP by applying pressure Position the patient so that it does not percolate to sub- foveal area Usually subsides with time If massive with involvement of fovea-external drainage or PPV is needed

109. Post op complications Glaucoma Choroidal detachment Exudative detachment Endophthalmitis -SRF drainage cases Failure of SB Infection and exposure of buckle Macular pucker Cystoid macular edema Strabismus Post op refractive changes

110. Post op complications Glaucoma causes --high buckle, angle closure glaucoma due to AC shallowing due to buckle effect, Anterior segment ischemia Ant segment ischemia-tight encirclage -presents with corneal edema, AC reaction, high IOP, iris atrophy , cataract -pts with sickle cell hemoglobinopathy type SC are more susceptible

111. Post op complications Choroidal detachment Extensive cryotherapy Encirclage that are large and posterior Blockage of venous drainage through vortex veins due to compression SRF drainage that resulted in hypotony Can occur in up to 40% starts in 2-4 days of surgery Mostly good prognosis May lead to angle closure , retinal apposition with extensive choroidals

112. Exudative retinal detachment The configuration of RD does not explain the RD The breaks are seen to be adequately closed Usually due to inflammation of excessive cryo treatment Usually develops after48-72 hours and may go on to become more extensive than preop Conservative treatment is usually effective Oral steroids are effective

113. Post op complications Infection and extrusion of the buckle – sponges are more susceptible for infection The material has to be removed Re RD chances are 4-30% after removal of the SB

114. CME Cystoid macular edema-due to inflammation associated with surgery Occurs in 20% Cryotherapy more than diathermy use Aphakia and Age are risk factors

115. Macular pucker/ERM Develops in 3-15% More common in vitreous loss during SRF dr , total RD, preoperative PVR

116. Post operative diplopia Uncommon 3% More common in resurgeries , large buckles, encirclage Treated conservatively

117. Post op refractive changes Radial buckles usually do not cause changes unless and until they are large –astigmatism Segmental buckles induce less change Encircling elements- usually cause myopia The myopia is usually of 2-3D in band buckles Very high buckles may cause hyperopic shifts

118. Failure to reattach PVR is the most common cause of failure Appearance of new breaks or missed breaks Inadequate coverage of the retinal breaks by the buckle

119. Prognostic factors for SB Initial VA Macula on detachment Quadrants of RD Presence of large tear PVR and its grade Pre operative hypotony and choroidal detachment SRF drainage Aphakia or pseudophakia High myopia

120. PPV for Rh RD PPV is being used by more and more surgeons for treating the Rh RD The main reasons have been advances in instrumentation with higher cutting rates with least injury to retina, wide angle viewing systems, less and less invasive surgeries, experience with PPV Some choose to place a buckle in addition to the PPV in selected cases

121. Advantages of PPV Removes all media opacities Removes all traction on retina-ideal for severe PVR Intraoperative visualization of retinal breaks even in periphery so all breaks are treated Controlled drainage of SRF under direct view with less risks vs SB Preferable in thin sclera, glaucoma filtration surgeries, strabismus surgery Does not cause refractive changes Less pain

122. Disadvantages of PPV Need for a tamponade -gas bubble and Postoperative positioning and inability to travel by air post op Cataract formation in 80% in 1-2 years especially when gas tamponade is used Formation of new retinal tears Costly instrumentation needing expensive packs

123. PPV disadvantages Injected gas may make IOL to shift and move, and IOL subluxation may occur as a consequence Retention of PFCL if used in some cases PPV less forgiving, and failure will turn your case into a more severe case compared to buckling The major drawback of primary vitrectomy is that it is still associated with significant rates of anatomical and functional failures

124. What cases are suitable for PPV? Primary PPV for Rh RD is definitely indicated in Rh RD with hazy media- significant capsular opacities, vitr hg, vitritis etc Rh RD with PVR C1 or worse Pseudophakic / aphakic RDs GRT Rh RD with posterior breaks where buckle cannot be placed Cases of RD with macular hole Superior retinal breaks wit Rh RDs

125. AIMS OF PPV Remove all media opacities Remove all traction on retina including membranes both on retina and under the retina Identify all breaks and treat them Flatten the retina on table and inject tamponade gas/silicone oil

126. PPV 23 g or 25 g 20 g has become obsolete in most institutions 27 g is a new entrant The 23g and smaller versions are less invasive and have less chances of creating tears in periphery 25 g and 27 g have less chances of hypotony

127. STEPS of PPV Counsel patient, Prepare the patient for surgery –fitness LA or GA, Drape Trocars placed Infusion canula fixed, verify it is in vitreous and infusion started CORE vitreous removed Post hyaloid detached if already not detached and trimmed to periphery

128. Fix trocars

129. Post hyaloid s

130. Remove all membranes on the retina and traction Use triamcinolone to stain residual vitreous or post hyaloid Fluid air exchange through the primary tear or a retinotomy Endolaser to retinotomy , tears, degenerations and many times 360 d periphery Tamponade with gas or silicone injection STEPS of PPV

131. Complete vitreous removal is needed for successful PPV Posteriorly Peripherally vitreous base shaving Anterior vitreous behind the crystalline lens or IOL

132. PPV

133. Vitreous removal strategy Perform a core vitrectomy If posterior hyaloid is not off as seen during PPV A blind suction is done at disc area to hold the post hyaloid by suction Once the posterior hyaloid is seen to be getting engaged in to the vitrector port it is slowly lifted A circular wave of detachment is seen Then this post hyaloid is cut and removed with vitrector till the vitreous base We always cut the flap of retinal tear to make it a hole and remove all traction on retina

134. Where the blind suction does not work Inject triamcinolone acetonoide over the posterior retina If the post hyaloid is still present the particles will adhere to the post hyaloid and indicate its presence Then you can hold the edge of the Weiss ring of the post hyaloid with vitrector and apply suction only and lift

135. Removal of the PVD

136. Peripheral vitreous removal Peripheral vitreous is removed as much as it is possible without causing retinal tears The post hyaloid is lifted and carried to periphery with gentle pulling till it cannot be detached further -vitreous base has been reached The vitreous base is dissected with shave function of the vitrector

137. Removal of peripheral vitreous Removal of peripheral vitreous may be difficult due to a mobile retina RD Depressing the periphery by an assistant will aid in this procedure Some use PFCL to flatten the retina posteriorly and stabilize it while shaving but it will entail cost and removal of it thoroughly which sometimes may be difficult One can also do vitreous shaving after fluid air exchange

138. Anterior vitreous The removal of vitreous behind an IOL is easy as there is no fear of injury to lens However in phakic eyes a careful approach is needed A bubble of air may be injected in anterior vitreous which will escape in to the space behind phakic lens and separate the vitreous behind it

139. After removal of vitreous Any membranes on the retina are removed again assisted by dyes like kenalog or Trypan blue Once the vitreous and membranes are removed and all traction removed on the retina we flatten the retina by removing the SRF It is done by either FAE or inj of PFCL liquid When we start FAE –air starts entering the eye instead of irrigating solution, the irrigating solution in the eye and subretinal fluid are aspirated with back flush instrument

140. SRF drainage The SRF is aspirated with original tear if it is posterior and reachable If it is anterior then a retinotomy is done with cautery usually above the disc nasally PFCL injection prevents the retinotomy making as the heavy liquid pushes the SRF out through the original tear in periphery Complete removal of SRF and fluid in vitreous cavity is desirable

141. After the retina is flattened Endolaser to all tears, degenerations, periphery 360 d is done A final aspiration is done to remove all fluid collected on the disc and the residual SRF Now we have to think of tamponade Usually gas SF6 or C3F8 are used Silicone oil in PVR cases , pts who are young, pts who want to travel

142. How to inject the tamponade gas? SF6 25% or C3F8 14% are usually used They are loaded in 50 cc syring with a 27 g needle The gas injected through the pars plana while the intraocular air/gas mixture is allowed to go out through a 27g needle attached to 2 cc syringe with piston removed is inserted through the pars plana

143. Ports of trocars Are usually not sutured if 23 g onwards Silicone oil inj ---usually sutured Patch with antibiotic and corticosteroid combination ointment instillation

144. Post op care Strict head positioning is important If it is a superior break a sitting up position If temporal break lateral position Aim is to keep the tear at the highest position so that the gas closes the tear More posterior tear a face down position is needed Usually for 10 days

145. Follow ups Post op 1,8,21 and then sos Earlier and more often if there are complications like high IOP

146. Complications of PPV Intra-operative While inserting the trocars /infusion cannula - injury to lens, subretinal or sub-choroidal placement of irrigation canula While doing the core vitrectomy - injury to the crystalline lens, injury to the moving retina and bleeding While doing the PVD – tears in retina at the periphery while stripping of the PVD, bleeding Corneal clouding –especially in diabetics

147. 5. While removing the membranes- hgs , retinal tears 6. While doing FAE- failure to settle the retina, retinal folds, entry in to the AC, fogging of posterior surface of lens IOL or crystalline 7. While doing laser- retinal injury and hgs 8. Choroidal detachments, expulsive hemorrhage 9. Gas/ silcione injection- low or extra fill, entry in to the AC, movement of IOL Complications of PPV-Intra-operative

148. Post operative High IOP- gas expansion, silicone overfill, inflammation, AC shallowing , pupillary block Low IOP- leaking wounds that have not been sutured 23 g Choroidals –rare unless and until there is hypotony Cataract- most common complication-gas cataract, lens injury, silicone induced 80% DEVELOP cataract within two years Movement of IOL due to gas overfill Re-detachment –PVR, tears at pars plana due to entry trocars , untreated tears, gas under fill or silicone under fill , non compliance regarding head positioning Complications of PPV

149. Anatomical and visual results of SB AND PPV Anatomical success is defined variously- Single surgery success Final success after many procedures Visual success depends upon various criteria-macula off or on improvement from pre-op vision VA of 20/40 or better etc

150. Anatomical success SB and PPV Results depend upon complexity of the retinal detachment These include- phakic / pseudophakic , PVR?, size of tear, location of tear, duration of RD, extent of RD, preop hypotony n choroidal detachment Final success varies from 65-95% for both SB and PPV

151. SPR trial 2007 of moderate complexity RDs

152. SPR STUDY

153. Excluded eyes Uncomplicated Rh RDs Preop characteristics-Excluded eyes -PVR worse than grade B or C -choroidal detachment or hyoptony - Large tear(>1 and <3 clock hours) or giant retinal tear (3 clock hrs or more ) -macular hole associated Rh RD or posterior breaks with RH RD( bcs PPV is must in such cases)

154. European Vitreoretina Society Report 1 Regardless of lens status, eyes undergoing vitrectomy had a higher single-surgery reattachment rate than those treated with scleral buckle alone

155. Pnuemoretinopexy In 1985 Dominguez in Spain and in 1986 Hilton and Grizzard in US independently introduced the technique of Pneumoretinopexy It is not universally popular technique Practiced mostly in North America and certain European countries If proper case selection is done the technique has high chances of success with one surgery Hilton GF, Grizzard WS: Pneumatic retinopexy : a two-step outpatient operation without conjunctival incision. Ophthalmol 93:626--41, 1986

156. Pneumoretinopexy -Principles Inject an expanding gas bubble in the vitreous-SF6 or C3F8 Position the patient to close the hole by gas bubble -close the break Treat the break by cryo/laser

157. How does it work The intraocular gas bubble has high surface tension which is the main mechanism for closing retinal break Once the break is closed SRF absorption takes place fast, as no more fluid is entering the subretinal space Treat the break by cryo or laser to permanently close the break

158. Gas bubble and surface tension A gas bubble induces an interfacial tension of 70 dynes per cm on the retinal surface, whereas silicone oil creates a surface tension of only 21.3 dynes per cm For an average eye *0.3 ml of gas - 60 degrees of the retinal surface *1.2 ml of intraocular gas to cover 90 degrees of the retinal surface

159. Amount of gas More gas is required to cover an equivalent arc of retinal surface for a highly myopic eye with a large globe A large gas bubble may cause unwanted vitreoretinal traction, resulting in new retinal breaks

160. Intravitreal gas and duration and expansion Gas Average duration Largest at size Average expansion Air 3 days Immediate No expansion SF6 12 days 36 hours Doubles C3F8 38 days 3 days Quadruples

161. Why does the gas bubble used in eye expand?

162. Pre-op counseling Importance of proper positioning Chances of success and need for further surgeries Explain the advantages- simple and less costly with a reasonable rate of success An office procedure

163. Inclusion criteria RD with no PVR Clear media One or more breaks occupying not more than one clock hour of retinal arc Tear(s) are located in upper two-thirds of fundus Patient able to maintain desired head posture for 16 hour per day for five days

164. Other considerations May have lattice degeneration (not exceeding three clock hours) Pseudophakia May have retinal detachment of any size Amount of subretinal fluid is not a consideration, but detachment must extend at least three disc diameters from break(s)

165. Which cases are suitable for the procedure?- Clinical Trial group

166. Contraindications for pneumoretinopexy Tears in inferior 4 clock hours of retina Tears in more than 1 clock hour area superiorly PVR C or worse Hazy media Extensive lattice degeneration and vitreous traction Severe glaucoma

167. Prerequisites for the procedure Rule out any other tear in the detached retina by thorough examination by indirect ophthalmoscope A missed tear is one of the commonest causes of failure A tear in the flat retina may be acceptable if it is treated at the time of procedure

168. Procedure of the pneumoretinopexy Anesthesia-Usually done under sub-conj infiltration of xylocaine 2% or PB/RB or sub- tenon inj of Xylocaine 2% Office or O T procedure Prep the eye Single sitting treatment consists of -- Cryo treatment of tear -- Laser treatment of 360d retinal periphery posterior to ora serrata in the attached parts --- Laser treatment of retinal degenerations and flat retinal tears

169. Retinopexy For cryotherapy - there is weakening of the adhesion in the first week possibly due to local tissue edema By second week similar strength of adhesion to photocoagulation develops More pigment dispersion while treating with cryo advantages of cryo The cryo can be used to treat a tear in detached retina-so single sitting The peripheral teas are easy to treat with cryo than laser

170. Laser- Retinopexy -two sittings procedure Laser retinopexy produces normal adhesive strength by 24 hours This adhesive strength further increases to two fold by 2-3 weeks of photocoagulation However laser can not be used to treat the tear when there is fluid So usually gas is injected and when the retina is flattened in the area of tear then laser is done the next day or so– so two sittings needed Laser suitable to treat more posterior tears Less pigment dispersion at the time of treatment with laser vs cryo

171. After the retinopexy is done -Procedure Betadine povidone 5% instillation Sterile speculum Gas injection 0.5 ml of SF6 or 0.3 ml of C3F8 pure gas Pre injection paracentesis is done if the high IOP is a concern Injection is made through the pars plana away from the break The injection is made at an upper position of the globe

172. Injection of gas Point the needle perpendicular to the sclera and advance the needle in the direction of center of the eye Once the needle is half way in the vitreous -withdraw it till only one mm is in the eye and then inject rapidly This will prevent fish egg formation of bubbles

173. Choice of gas and size of gas bubble 1ml bubble will cover 3 clock hours of retinal surface SF6 expands to twice the size in 24-36 hours usually 0,5 ml is injected C3F8 only 0.3 ml needs to be injected and it expands to four times in 48 hours But it lasts longer preventing air travel or mountain traveling

174. Steps of Pneumoretinopexy

175. After the gas injection Following gas-bubble injection, eye is inspected digitally first to see if it has become tense Indirect ophthalmoscopy is done to rule out CRA closure If the eye ball is not tense a paracentesis is not necessary If it is hard or CRAO closure is suspected a AC tap is done The antibiotic drops and steroid drops placed and a circular level with clock hours is attached to the eye patch

176. After care The patient is positioned so that the bubble is opposed to the break for 24 to 48 hours. As the remainder of the retina attaches, peripheral laser photocoagulation is completed for 360° if not done already Positioning is continued for 3 to 5 days for 16 hours per day. Activity, including reading, is restricted until the bubble has resorbed

177. When laser is used initially

178. Follow ups Next day, one week then 2-3 weeks and then monthly for a year

179. Advantages of PR Simple office based Relatively noninvasive and short procedure Less cost vs SB or PPV Less equipment is needed Less painful than SB May be suitable for pts with glaucoma filtration surgeries, thin sclera, sick patients who are not able to undergo SB or PPV, patients on anticoagulants

180. Disadvantages A thorough exam is must Any missed break is cause of failure A very compliant patient must for success Air travel affected Failure rate higher than SB or PPV but in highly selected cases it may be equal to them

181. Complications of Pneumoretinopexy New or missed breaks are seen in significant number The rate varies from 13 to 34% If the new breaks or missed breaks are seen more cryo/laser may be done and additional gas injection may be done if the tears in the superior retina Otherwise SB or PPV needed

182. Complications Cataract progression –very rare less than 4% Vitreous loss at the time of gas injection Subretinal gas –Fish egg bubbles may enter especially large breaks and go under the retina and expand preventing the surgical success Avoid this by injecting gas in a correct manner If happens pt positioned supine and allow the gas to come out and then position patient Or SB or PPV and drainage of gas

183. Donut sign or sausage sign

184. Complications of Pneumo Entry of gas in to Petit space-sausage sign Entry of gas in to AC PVR 4-10% Endophthalmitis Macular hole formation GRT CME ERM Choroidal detachment rare IOP rise

185. Thanks for your attention

186. Group Scleral buckle Vitrectomy P value Phakic 0.33 0.48 0.0005 SB BETTER Psuedophakic / aphakic 0.46 0.38 0.1033 Primary Anatomical success Phakic 133/209(63.6%) 132/207(63.8%) 0.97 Psuedo aphakic 71/133(53.4%) 95/132(72%) 0.002

187. PPV VS SB in uncomplicated Rh RDs Four thousand one hundred seventy-nine uncomplicated cases of RRD were included. Combining phakic , pseudophakic , and aphakic groups, those treated with scleral buckle alone (n = 1341) had a significantly lower final failure rate than those treated with vitrectomy , with or without a supplemental buckle (n =2723; P =0.04). In phakic patients, final failure rate was lower in the scleral buckle group compared with those who had vitrectomy , with or without a supplemental buckle (P = 0.028). In pseudophakic patients, the failure rate of the initial procedure was lower in the vitrectomy group compared with the scleral buckle group (P = 3x10 -8 ). There was no statistically significant difference in failure rate between segmental (n = 721) and encircling (n =351) buckles (P = 0.5). Those who underwent vitrectomy with a supplemental scleral buckle (n ¼ 488) had an increased failure rate compared with those who underwent vitrectomy alone (n =2235; P= 0.048) Pneumatic retinopexy was found to be comparable with scleral buckle when a retinal hole was present (P =0.65), but not in cases with a flap tear (P =0.034) Ophthalmology 2013;120:1804-1808