Retinal detachment new

A CLASS PRESENTATION ON RETINAL DETACHMENT

1. RETINAL DETACHMENT Presented by: Yogesh kumar tiwari MSc.Nsg.1 st year CON,AIIMS Moderator:Mrs . Ujjwal Dahiya Lecturer,CON,AIIMS

2. Introduction The role of vision in our lives is difficult to define, because it is so deeply personal and intimate Whenever there is a failure in the vision, its not only the eyes, that are said to be in darkness but the whole life is in darkness. Loss of vision means loss of independence. Among the various causes of blindness ,retinal detachment is one which is an ocular emergency.

3. Definition Retinal detachment is a disorder of the eye in which the retina peels away from its underlying layer of support tissue. A detached retina is a serious and sight-threatening event. And unless the retina is reattached soon, permanent vision loss may result.

4. Anatomy of eyeball

5. Retina The retina is the inner most layer of the eye. It is composed of nerve tissue. The optical system of the eye focuses light on the retina much like light is focused on the film in a camera.

6. Layers of retina The retina is composed of 10 layers Pigmented epithelium Photoreceptors; bacillary layer (outer and inner segments photoreceptors) External (outer) limiting membrane Outer nuclear

7. Layers of retina Outer plexiform Inner nuclear Internal limiting membrane Inner plexiform layer Ganglion cell layer Nerve fiber layer

8. Layers of retina

9. How does retina forms images ?

10. Vitreous Humour Comprises a large portion of the eyeball It is a clear gel that occupies the space behind the lens and the retina

11. Epidemiology The incidence of retinal detachment in otherwise normal eyes is around 5 new cases in 100,000 persons per year Detachment is more frequent in middle­aged or elderly populations, with rates of around 20 in 100,000 per year The lifetime risk in normal individuals is about 1 in 300 Retinal detachment is more common in people with severe myopia (above 5–6 diopters ), in whom the retina is more thinly stretched. In such patients, life time risk rises to 1 in 20. About two thirds of cases of retinal detachment occur in myopics . Myopic retinal detachment patients tend to be younger than non­myopic ones.

12. Type There are three types of retinal detachment: rhegmatogenous tractional exudative

13. Types Rhegmatogenous retinal detachment –It occurs due to a break in the retina (called a retinal tear ) Retinal breaks are divided into three types – holes, tears and dialyses.

14. Types Exudative , serous, or secondary retinal detachment –It occurs due to inflammation, injury or vascular abnormalities Fluid accumulating underneath the retina without the presence of a hole, tear, or break. Rare

15. Types Tractional retinal detachment –It occurs when fibrous or fibrovascular tissue, pulls the sensory retina from the retinal pigment epithelium.

16. Risk factors Severe myopia Retinal tear Family history Other eye diseases or disorders, such as retinoschisis , uveitis, degenerative myopia, or lattice degeneration

17. Risk Factors … Eye injury Tumors Systemic diseases such as diabetes & sickle cell disease Complications from cataract surgery

18. Sign and symptims Warning signs Flashes of light ( photopsia ) A sudden increase in the number of floaters Blurred vision Seeing a shadow or a curtain descending from the top of the eye or across

19. Diagnosis Elicit history for any of the following: History of trauma Previous ophthalmologic surgery Previous eye conditions ( eg , uveitis and vitreous hemorrhage ) Duration of visual symptoms and visual loss

20. Diagnosis Physical examination should include the following: Checking of visual acuity External examination for signs of trauma and checking of the visual field Assessment of pupil reaction Measurement of intraocular pressure in both eyes Slit-lamp examination Examination of the vitreous for signs of pigment or tobacco dust

21. Diagnosis Fundus photography or ophthalmoscopy . Fundus photography : larger instrument than the ophthalmoscope Ultrasound

22. Significance of timely treatment Visual improvement is much greater when the retina is repaired before the macula is detached. Once the retina is reattached, vision usually improves and then stabilizes.

23. Treatment General principles of treatment : 1. Find all retinal breaks 2. Seal all retinal breaks 3. Relieve present (and future) vitreo retinal traction

24. Surgical Methods Cryopexy and laser photocoagulation Scleral buckle surgery Pneumatic retinopexy Vitrectomy

25. Cryopexy Cryotherapy (freezing) is used to wall off a small area of retinal detachment Uses nitrous oxide to freeze the tissue behind the retinal tear This prevents fluid passing through the hole.

26. Laser Photocoagulation If the retina is torn or the detachment is slight Laser burn the edges of the tear and halt progression. Stimulates the scar tissue formation to seal the edges of the tear

27. Scleral buckle surgery Surgeon sews silicone bands to the sclera (the white outer coat ofthe eyeball) The bands push the wall of the eye inward against the retinal hole Cryotherapy (freezing) is applied around retinal breaks prior to placing the buckle

28. Scleral buckle surgery Subretinal fluid is drained as part of the buckling procedure The buckle remains in situ The most common side effect of a scleral operation is myopic shift. Myopic shift: the operated eye will be more short sighted after the operation

29. Scleral buckle surgery Types of scleral buckling: Radial scleral buckle Circumferential scleral buckle Encircling buckles

30. Pneumatic retinopexy Generally under local anesthesia Gas bubble (SF6 or C3F8 gas) is injected into the eye after which laser or freezing treatment The patient's head is then positioned Have to keep their heads tilted for several days

31. Reseach input Problem statement- Outcome of surgery after macula-off retinal detachment – results from MUSTARD, one of the largest databases on buckling surgery in Europe ABSTRACT. Purpose: To evaluate the anatomical success rate of scleral buckling surgery in the treatment of rhegmatogenous retinal detachment and to evaluate the differences in outcome between patients suffering macula-off retinal detachment and those without a macular involvement. Methods: As a retrospective interventional case series, Munster Study on Therapy Achievements in Retinal Detachment (MUSTARD) is one of the largest ever established of retinal detachment patients and their outcome after buckling surgery, with 4325 patients who underwent surgery between 1980 and 2001. In 53.94% (n = 2134) of 3956 patients with nontraumatic retinal detachment, the macula was involved. The main outcome measure was the achievement of dry anatomical attachment of the retina. Results: The success rate in patients with macula-off retinal detachment is 80.46% and thus 7.78% lower (p < 0.01) than that in those patients with their macula intact whose success rate amounted to 88.24%. The overall success rate of all 4325 MUSTARD patients was 83.98%. Conclusions: Scleral buckling is an established and mostly successful method for the treatment of retinal detachment. As our case series has demonstrated, even eyes with macula-off can be treated successfully by this procedure, thereby avoiding the complications of primary vitrectomy.

32. Pneumatic retinopexy The surface tension of the gas/water interface seals the hole in the retina Combined with cryopexy or laser photocoagulation

33. Vitrectomy Tiny incision in the sclera Remove vitreous Gas is often injected to into the eye During the healing process, the eye makes fluid that gradually replaces the gas and fills the eye.

34. Vitrectomy Using gas in this operation : no myopic shift after the operation Silicon oil (PDMS), if filled needs to be removed after a period of 2–8 months

35. COMPLICATIONS AFTER SURGERY Discomfort Watering Redness Swelling Itching Blurred vision

36. Prognosis 85 percent of cases will be successfully treated with one operation 15 percent requiring 2 or more operations After treatment patients gradually regain their vision over a period of a few weeks, although the visual acuity may not be as good as it was prior to the detachment, particularly if the macula was involved in the area of the detachment. Currently, about 95 percent of cases of retinal detachment can be repaired successfully

37. Pre operative management Assess the visual acuity of the client’s non-operative eye prior to surgery Assess the client’s support systems and the possible effect of impaired vision on lifestyle and ability to perform ADLs in the post- operative period Safety measures such as installing hand rails,especially if the client has limited vision in the unaffected eye Remove all eye makeup and contact lenses or glasses prior to surgery Mydriatic (pupil-dilating) or cycloplegic ( ciliary - paralytic) drops and drops to lower intraocular pressure may be prescribed preoperatively.

38. POST – OPERATIVE MANAGEMENT Monitor status of the eye dressing following surgery. Assess dressings for the presence of bleeding or drainage Maintain the eye patch or eye shield in place. The eye patch or shield helps prevent inadvertent injury to the operative site Place the client in a semi-Fowler’s or Fowler’s position , having the client lie on the unaffected side.These positions reduce intraocular pressure in the affected eye. Assess the client and medicate or assist to avoid vomiting coughing , sneezing or straining as needed. These activities increase intraocular pressure

39. Contd … After surgery for a detached retina,the client is positioned so that the detachment is dependent or inferior. For example , if the outer portion of the left retina is detached , the client is positioned on the left side . Positioning so that the detachment is inferior maintains pressure on that area of the retina, improving its contact with the choroid. Assess comfort and medicate as necessary for complaints of an aching or scratchy sensation in affected eye . Immediately report any complaint of sudden, sharp eye pain to the physician.

40. Contd … Assess for potential surgical complications: a. Pain in or drainage from the affected eye b. Hemorrhage with blood in the anterior chamber eye c. Flashes of light, floaters, or the sensation of a curtain being drawn over the eye (indicators of retinal detachment) d. Cloudy appearance to the cornea (corneal edema ) Evidence of any of the above manifestations or unusual complaints by the client should be reported to the physician at once Approach the client on the unaffected side.This approach facilitates eye contact and communication.

41. Contd … Place all personal articles and the call bell within easy reach . These measures prevent stretching and straining by the client Assist with ambulation and personal care activities as needed. Assistance may be necessary to maintain safety Antibiotic ,anti-inflammatory and other systemic and eye medications as prescribed . Medications are prescribed post operatively to prevent infection or inflammation of the operative site, maintain pupil constriction , and control intraocular pressure Administer antiemetic medication as needed. It is important to prevent vomiting to maintain normal intraocular pressures

42. Home care Adequate lighting Promote unrestricted ambulation Removal of hazards like rugs, clutters, unnecessary furnitures Provision of hand rails in hallways, bathrooms Access to radio and television Voice activated switches Pill organizers Large print newspapers, magazines

43. Contd … Double vision Glaucoma Bleeding into the vitreous, within the retina, or behind the retina Cataract Drooping of the eyelid Infection around the scleral buckle Endophthalmitis

44. Prognosis Treatment failures usually involve either the failure to recognize all sites of detachment, the formation of new retinal breaks,or proliferative vitreo retinopathy Involvement of the macula portends a worse prognosis Damage to vision may occur during reattachment Surgery 10 percent of patients with normal vision experience some vision loss after a successful reattachment surgery.

45. Conclusion Visual impairment is more than a physiologic deficit. It is a loss that has physical and emotional effects on the person afflicted. So as far as possible prevent those causes of blindness.