RHEGMATOGENOUS Retinal detachment

RRD PPT by Dr Sidesh Hendavitharana

1. RHEGMATOGENOUS RETINAL DETACHMENT Dr.Sidesh Hendavitharana (Registrar in Ophthalmology )

2. . RD is seperation of neurosensary retina from RPE. FOUR types, Rhegmatogenous RD Tractional RD Exudative RD Combined rhegmatogenous and tractional RD

3. Rhegmatogenous RD Also called primary RD Greek,rhegma =break Usually due to break in retina in form of hole or tear through which vitreous gains access into subretinal space and seperates sensary retina from pigment epithelium.

4. Predisposing(risk) factors Age-most common in 40-60yrs of age Sex-more common in male(3:2 compared to females) Myopia-account for 30% of RD(more common in myope over -3.0D Aphakia Peripheral retinal degeneration-S-W-A-F-L, S-snail track degeneration White with or without pressure Acquired retinoschisis Focal retinal clumps Lattice degeneration Trauma-commonest in young adults Cataract surgery-more in ICCE Senile posterior vitreous detachment

5. Typical lattice degeneration Present in about 8% of general population Present in about 40% of eyes with RD Spindle-shaped islands of retinal thinning Network of white lines within islands Variable associated RPE changes Small round holes within lesions are common Overlying vitreous liquefaction Exaggerated attachments around margin of lesion Retina Vitreous

6. Complications of lattice degeneration Indications for prophylaxis No complications - in most cases RD associated with atropic holes, particularly in young myopes RD associated with tractional tears in eyes with acute PVD RD in fellow eye Extensive lattice in high myopia

7. Snailtrack degeneration Indications for prophylaxis - presence of holes Sharply demarcated, frost-like bands which are longer than lattice Large round holes which carry high risk of RD

8. White-without-pressure Indications for prophylaxis - giant tear in other eye Translucent grey appearance of retina Occasional giant tear formation along posterior margin of lesion

9. Pathogenesis

10. Clinical features Symptoms Dark spot in front of eye(floaters)-due to rapid vitreous degeneration. Transient light flashes( photopsia )-due to irritation of retina by vitreous movements. Muscae volitantes and distortion of objects Shadow or clouds in front of eye,percieved as black curtain Localized profound dimness of vision(in cases of large and central retinal hole)

11. signs Pupillary reflex- marcus Gunn pupil in eyes with extensive RD IOP-usually slightly lower or may be normal. Fundus examination ( indirect ophthalmology - investigation of choice)

12. Fresh retinal detachment Grayish white,opaque,raised detached retina(convex configuration) and corrugated appppearance (due to intraretinal edema) with loss of underlying choroidal pattern Dark retinal vessels with no central light reflex. No shifting of fliud Oscillation of multiple retinal folds with movement of eye One or more retinal breaks or holes in upper temporal region Vitreous show pigment in anterior vitreous(tobacco dusting or shafer sign)with posterior detachmnet . Associated degeneration,pigmentation and haemorrhage in retina.

13. Old retinal detachment Retinal thining (due to atrophy) Fixed retinal folds(absence of retinal undulation) Subretinal demarcation lines(due to proliferation of RPE cells at junction of flat detachment) secondary intraretinal cysts(in very old RD) Multiple opaque strands of subretinal fibrosis. Proliferative vitreoretinopathy .

14. Classification Of PVR The term "proliferative vitreoretinopathy" was coined in 1983 by the Retina Society Terminology Committee. In 1989, the classification was amended by the Silicone Study Group before being most recently modified in 1991 to its current classification. Currently, PVR is divided into grades A, B, and C. Grade A is limited to the presence of vitreous cells or haze. Grade B is defined by the presence of rolled or irregular edges of a tear or inner retinal surface wrinkling, denoting subclinical contraction. Grade C is recognized by the presence of preretinal or subretinal membranes. Grade C is further delineated as being anterior to the equator (grade Ca) or posterior to the equator (grade Cp) and by the number of clock hours involved (1 to 12).

15. Proliferative vitreoretinopathy Vitreous haze and tobacco dust Grade A (minimal) Rigid retinal folds Vitreous condensations and strands Grade C (severe) Retinal wrinkling and stiffness Rolled edges of tears Grade B (moderate)

16. Retinal breaks,

17. Primary retinal break It is responsible for RD and determines configuration of SRF Quadratic distribution of breaks in eyes with RD Configuration of SRF in relation to primary break

18. Fundus drawing,

19. Investigations Visual fields- scotomas corresponding to areas of RDs Slit lamp examination with 3 mirror gonioscope -helps detect breaks and evaluate vitreous condition. ERG-subnormal or absent US-A scan and B scan Confirm the diagnosis Particularly used in pts with hazy media or dense cataract.

20. Differential diagnosis Senile retinoschisis Splitting of retina at the level of inner nuclear layer and outer plexiform layer Commonly occur in lower temporal quadrant. Progresses slowly Presence of absolute field defect Presence of transparent and immobile inner retinal layer.

21. Treatment Aims, To find retinal break and seal it. To relieve vitreoretinal traction To drain SRF

22. Operative Sealing the retinal breaks Involves the detection,accurate localization and sealing by producing aseptic chorioretinitis with cryoretinopexy at -70 c ,laser photocoagualation or diathermy to sclera. SRF drainage Involve drainage of subretinal fluid by inserting a fine needle through sclera and choroid into subretinal space Allow immediate apposition between sensary retina and RPE.

23. Mainain chorioretinal apposition Chorioretinal apposition to be maintained for atleast couple of weeks Sclera buckling or encirclage Procedure Involves inward indentation of sclera by inserting an explants(radial explants for isolated hole and circumferential explants for breaks involving 3 or more quadrants)with help of matresses suturing of sclera. Indications Uncomplicated primary detschment

24. Pneumatic retinopexy Indication Fresh superior RD with1-2 small holes extending over less than 2 o’clock hours in upper temporal quadrant in peripheral retina. Procedure Involves sealing breaks with cryopexy followed by injection of expanding gas bubble into vitreous to remain in contact with tear for 5-7 days.

25. Parsplana vitrectomy , endolaser photocoagulation and internal tamponade Indication Complicated RD TRD Procedure Multistep procedure involving 3 port pars plana vitrectomy to remove all membranes and vitreous Internal drainage of SRF through existing retinal breaks using fine needle or through a posterior retinotomy Flaterning of retina by injecting silicone oil or perfluorocarbon liquid Creation of chorioretinal adhesions by endolaser around area of retinal tear and holes. Maintain retinal tamponade by retaining silicone oil inside or exchange long acting gas.

26. Configuration of scleral buckles Radial Segmental circumferential Encircling augmented by radial sponge Encircling augmented by solid silicone tyre

27. Preliminary steps Peritomy Insertion of squint hook under rectus muscle Insertion of bridle suture Inspection of sclera for thinning or anomalous vortex veins

28. Localization of breaks Insert 5/0 Dacron scleral suture at site of apex of break Grasp cut suture with curved mosquito forceps close to knot While viewing with indirect ophthalmoscope check position of indentation in relation to break

29. While viewing with indirect ophthalmoscope indent sclera gently with tip of cryoprobe Freeze break until sensory retina just turns white Cryotherapy

30. Insertion of local explant Distance separating sutures measured and marked Ends trimmed Sutures tightened over explant Insertion of mattress-type suture

31. Encircling procedure Strap fed under four recti Ends secured with Watzke sleeve Strap slid posteriorly and secured in each quadrant Strap tightened to produce required amount of internal indentation

32. Drainage of subretinal fluid Indications Haemorrhage Difficulty in localizing break Immobile retina Longstanding RD Inferior RD Retinal incarceration Complications Technique

33. Causes of early failure May be associated with communicating radial retinal fold Insert additional radial buckle Buckle failure ‘ Fishmouthing ’ of retinal tear Buckle inadequate size or height Buckle incorrectly positioned

34. Technique (a) Cryotherapy Pneumatic retinopexy Indications RD with superior breaks (b) Gas injection (c) Postoperative positioning (d) Flat retina

35. Vitrectomy for giant tears Unrolling of flap with light pipe and probe Completion of unrolling Injection of silicone oil or heavy liquid

36. Vitrectomy for PVR Dissection of star folds and peeling of membranes Injection of expanding gas or silicone oil

37. Vitrectomy for diabetic tractional RD Release of circumferential traction Release of antero- posterior traction Endophotocoagulation

38. Thank you