Retinal detachment

etiology, types and management of retinal detachment

1. RETINAL DETACHMENT 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. Indications for pars plana vitrectomy Giant retinal tear large posterior tear severe PVR

34. Pneumatic retinopexy 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