MANAGEMENT OF RETINAL DETACHMENTDR. AMREEN H. DESHMUKH
OUTLINE
Classification of RD Natural History of RD Preoperative Evaluation Principles of management Management of Rhegmatogenous RD Management of Retinal Breaks Management of TRD Conclusion
Classification of RD
Primary RD- Rhegmatogenous RD Secondary RD
Tractional RD Exudative/Serous RD Combined Mechanism RD
Serous Retinal Detachment
Alterations in choroidal flow Tumours
Choroidal melanoma Nevi Haemangioma Metastasis Retinoblastoma
Idiopathic CSCR Chronic diffuse retinal
epitheliopathy Bullous inferior RD
Vasculitis & autoimmune diseases SLE Wegener’s granulomatosis PAN Relapsing polychondritis Dermatomyositis Goodpasture’s syndrome
Systemic Diseases Malignant hypertension DIC TTP Preeclampsia Renal failure
Poor Scleral Outflow Nanophthalmos Uveal effusion syndrome Posterior scleritis
Breakdown of RPE & retina VKH disease Retinal Vascular Disease
Coat’s disease Familial exudative
vitreoretinopathy Retinal angiomatosis
Sarcoidosis
Infectious diseases Toxoplasmosis Syphilis Lyme disease Tuberculosis Histoplasmosis Coccidiomycosis Cryptococcus Cat scratch disease
Miscellaneous Multiple myeloma Immunogammopathies Paraproteinemias Post-surgical Medications- Interferon, Ribavirin Congenital anomalies of optic nerve- pit/ coloboma/ morning glory
syndrome Bilat. Diffuse uveal melanocytic proliferation
Natural History of Retinal Detachment
Progress to near total or total RD A subtotal RD with stable borders and demarcation lines SRF d/t superior retinal break settles inferiorly away from the
retinal break, and the site of original break flattens Spontaneous attachment occurs, associated with a very small
break or closure of the break by scar tissue
Pre-operative Evaluation
Clinical Examination Slit Lamp Examination to rule out anterior segment pathology Binocular Indirect Ophthalmoscopy with scleral indentation Goldmann Three-mirror Examination Fundus drawing with Localisation of Primary Break
Ultrasonography OCT- to detect SRF, other pathologies Haematological Investigations CT and MRI
Binocular Indirect Ophthalmoscopy with Scleral Indentation Stereoscopic view of fundus
Inverted and laterally reversed image View upto Equator With Scleral Indentation
Visualization of peripheral retina anterior to equator upto Ora serrata Kinetic evaluation of the retina
Goldmann Three-mirror Examination
Central lens and three mirrors Central lens- 30˚ upright view of
Posterior pole Equatorial mirror (largest and oblong)-
30˚ to equator Peripheral mirror (medium and square)
- between equator and ora serrata Gonioscopy mirror (smallest and dome
shaped)- extreme periphery and pars plana
Image- Vertical meridian-inverted, not laterally
reversed Horizontal Meridian- Laterally reversed
Fundus drawing-Amsler Dubois chart
Junction of P Plicata &
P Plana
The Ora
The Equator
Fundus drawing
Fundus drawing
Tips for drawing
Disregard Sup/Inf and Temp/Nasal while drawing
What ever appears closer to the observer in the condensing lens is peripheral (anterior)
Observe the disc and follow a vessel to the periphery
Observe the macula at the end for best patient co-operation
Fundus drawing
• Right Eye – Localized RD with HST at 11° clock and Lattice at 1° clock
FUNDUS DRAWINGDraw as you see the lesion in the condensing lens
FUNDUS DRAWING – RED SOLID
• Retinal arterioles
• Neovascularization
• Vascular anomalies
• Attached retina
• Vascular tumors
FUNDUS DRAWING – RED SOLID
• Hemorrhages ( Pre and retinal)
• Open interior of retinal breaks (tears, holes)
• Open interior of outer layer holes in retinoschisis
• Open portion of GRT or large dialyses
• Inner portion of CRA
• Inner portion of thin areas of retina
• Open portion of retinal holes in inner layer of retinoschisis
FUNDUS DRAWING- RED CROSSED
FUNDUS DRAWING – BLUE SOLID
• Detached retina
• Retinal veins
• Outlines of retinal breaks
• Outlines of ora serrata
FUNDUS DRAWING – BLUE SOLID
• VR traction tuft
• Outline of lattice
degeneration (inner X)
• Outline of thin area of
Retina
FUNDUS DRAWING – BLUE CROSSLINES
•Inner layer of retinoschisis
•White with or without pressure (label)
•Detached parsplana epithelium anterior to separation of ora serrata
•Rolled edges of retinal tears / inverted flap in GRT (curved lines)
FUNDUS DRAWING BLUE CIRCLE/INTERRUPTED LINES
• Cystoid degeneration
• Outline of change in area or folds of detached retina because of shifting fluid
FUNDUS DRAWING- GREEN SOLID
• Opacities in the media
• Vitreous hemorrhage
• Vitreous membranes
• Hyaloid ring
• IOFB
FUNDUS DRAWING – GREEN SOLID
• Retinal operculum
• Outline of elevated Neovascularisation
• Vitreous Substitute – Silicone Oil, Gas
FUNDUS DRAWING – GREEN DOTTED
• Asteroid hyalosis
• Frosting or snowflakes on Retinoschisis or lattice degeneration
FUNDUS DRAWING – BROWN SOLID
• Uveal tissue
• Pigment beneath detached retina
FUNDUS DRAWING- BROWN SOLID
• Pigment epithelial Detachment
• Choroidal melanomas
• Nevus
• Choroidal detachment
FUNDUS DRAWING – BROWN OUTLINE
• Edge of buckle beneath detached retina
• Outline of Posterior Staphyloma
FUNDUS DRAWING – YELLOW SOLID
• I/R, S/R hard exudate
• S/R gliosis
• Deposits in the RPE
FUNDUS DRAWING- YELLOW SOLID
• Post cryo retinal edema
• Substance of long & short ciliary N
• Retinoblastoma Yellow – stippled-• Drusen Yellow Crossed• Chorioretinal coloboma
FUNDUS DRAWING- BLACK SOLID
• Hyperpigmentation as a result of previous Rx with cryo/Diathermy
• Completely Sheathed vessels
• Pigment within detached retina (Lattice, HST)
FUNDUS DRAWING- BLACK SOLID
• Pigment within choroid or pigment epithelial hyperplasia within attached retina (e.g. RP)
• Pigment demarcation line at margin of attached
and detached retina
FUNDUS DRAWING – BLACK OUTLINE
• Edge of buckle beneath attached retina
• Outline of CRA
Localization of Primary Break
Configuration of SRF Gravitational shift Anatomical Barriers- optic disc, ora serrata Location of primary breaks Lincoff’s rule
Location of break ST>IT>SN>IN quadrants
Ultrasonography
B- SCAN is a two dimensional imaging system which utilises high frequency sound waves ranging from 8-10 MHz.
B stands for bright echoes.
Physics
It is an acoustic wave that consists of particles within the medium Frequencies used in diagnostic ophthalmic ultrasound are in the
range of 8-10 MHz These high frequencies produce shorter wave lengths which
allow good resolution of minute ocular and orbital structures Multiple short pulses are produced with a brief interval that
allows the returning echos to be detected, processed and displayed.
The basis of the echo system is piezoelectric element which is a quartz or ceramic crystal located near the face of the probe
sound waves from transmitter
Echoes are received by receiver
Amplification
Oscilloscope screen
Target tissue
Types of frequency
Low frequency: orbital tissue Medium frequency: ( 7 – 10 mhz ) Retinal , vitreous ,
optic nerve High frequency: ( 30 – 50 mhz) : ant chamber upto 5
mm
IndicationsAnterior segment: Opaque ocular media (i.e. corneal opacities)
1. Pupillary membrane2. Dislocation / Subluxation lens3. Cataract / after cataract4. Posterior capsular tear5. Pupillary size / reaction
Clear ocular media Diagnosis of iris and ciliary body tumors
Posterior segment:1. Opaque ocular media
Vitreous haemorrhage Vitreous exudation Retinal detachment
(type / extent) Posterior vitreous
detachment (extent) Intraocular foreign
body (size/ site/ type)
2. Clear ocular media Tumour (size/ site/
post treatment follow up)
Retinal detachment (solid / exudative)
Optic disc anomalies 3. ocular trauma
Examination technique
The patient is either reclining on a chair or lying on a couch.The probe can be placed directly over the conjunctiva or the lids.
Probe positions
Transverse : most common Lateral extent, 6 clock hours
Longitudinal : radial ,1 clock hours, AP diameter in Retinal tumors and tears
Axial : lesion in relation to lens and optic nerve .
Appearance of Normal Ocular Structures
LENS: oval highly reflective structure with intralesional echoes with none to highly reflective echoes.
Vitreous is echolucent. Retina, choroid and sclera: single reflective high structure. OPTIC NERVE : Wedge shaped acoustic void in the retrobulbar
region. EXTRA OCULAR MUSCLES : Echolucent
to low reflective fusiform structures. The SR- LPS complex is the thickest. IR is the thinnest. IO is generally not seen except in pathological conditions.
ORBIT -highly reflective due to orbital fat.
Always examine the other eye before coming to a conclusion regarding the lesion .
Opacities produce dots or short lines
Membranous lesions produce an echogenic line
ULTRASONOGRAPHIC CHARACTERISTICS
VITREOUS HAEMORRHAGETo detect extent, density, location and cause
Fresh haemorrhage shows dots or lines
Old haemorrhage the dots gets brighter
POSTERIOR VITREOUS DETACHMENT
membranous lesion with no/some attachments to the optic disc
POSTERIOR VITREOUS DETACHMENT
Mobility of PVD is more than RD.
The spike of RD is more than PVD.
PVD becomes more prominent in higher gain settings
RETINAL DETACHMENTThe detachment produces a bright continuous, folded appearance with insertion into the disc and ora serrata.It is to determine the configuration of the detachment as shallow, flat or bullous
EXUDATIVE RETINAL DETACHMENT
RHEGMATOGENOUS RD
RHEGMATOGENOUS RETINAL DETACHMENT
CLOSED FUNNEL RD WITH RETINAL CYST
Retinal Tear
Appears as RD but it is a PVDClues: non uniform thickness of membrane very thin attachment to the disc.
Retinal Reattachment Surgery
Scleral Buckling Surgery with or without drainage Encircling Segmental
Temporary scleral buckle Lincoff balloon Absorbable material
Vitrectomy Classical Sutureless
Pneumoretinopexy Routine With drainage of SRF/intravitreal liquid
Aim of Surgery
To counter the factors & forces that cause retinal detachment Re-establish physiological conditions that maintain contact
between NSR & RPE
Principles of Treatment
Sealing of all retinal breaks Relief of vitreo-retinal traction Scleral buckling Pneumatic retinopexy Vitrectomy Adjuncts
Gonin’s principle
The retina has to be brought back into firm contact with the underlying pigment epithelium and choroid, at least in the area of the holes; and
The contact must be maintained whilst an inflammatory reaction causes the formation of a scar which involves both, retina and choroid and by this seals the retinal holes.
Classic Schepens Technique Localisation of break/s Lamellar scleral dissection Intrascleral buckle Encirclage SRF drainage
DACE procedure Drainage of SRF Air injection Cryotherapy Encirclage
Algorithm for approach to selection of appropriate retinal reattachment procedure
Scleral Buckling Surgery
How scleral buckle works???
Gold standard for uncomplicated RD
Relieves vitreous traction along the surface of the buckle
The buckle displaces the retinal break centrally, where the break becomes tamponaded by cortical vitreous
It displaces SRF away from the break & alters the shape of eyewall, thus reducing the effects of the intraocular fluid currents
Scleral Buckles
Permanent Solid Silicone Sponge Hydrogel
Absorbable Gelatin Synthetic suture Donor tissue
Effect depends upon Type of material Location & tension of scleral
sutures Circumferential tightening of
encircling buckle
Buckle configuration
Radial explants- right angle to limbus- to seal U tears/posterior breaks
Segmental circumferential- parallel to limbus
Encircling- entire circumference of globe for 360˚ buckle
Relative contraindications Thin sclera Glaucoma filtering blebs/valve implants Previous strabismus surgery Very posterior retinal breaks Giant retinal tears PVR grade C Significant vitreous opacities
Scleral Buckling Surgery
Procedure Under LA or GA 360˚ Conjunctival Peritomy with horizontal relaxing incisions Tractional sutures inserted beneath four recti Localisation of breaks and marking on scleral surface Mattress type buckle sutures Appropriate buckle selected, inserted & temporarily tightened SRF drainage Saline/Air injection Retinopexy- cryotherapy Buckle sutures finalized
Video
Complications Intraoperative
Scleral perforation Choroidal Haemorrhage Subretinal Bleed, Retinal Incarceration and perforation Impaired visibility- corneal haze, hyphema, miosis, air/gas injection Damage to vortex veins Vitreous loss
Postoperative Buckle infection, migration, extrusion Failed retinal reattachment Redetachment- PVR Anterior segment ischemia Choroidal edema, detachment Secondary Glaucoma Suboptimal visual recovery- CME, persistent subfoveal SRF Ptosis, diplopia and motility disturbances
Changes induced by scleral buckles in the eye Axial length of the eye-
Encircling- Increased/decreased axial length depending upon material, location, height of buckle
Induced spherical equivalent & astigmatic refractive error segmental- hyperopic shift
Volume of the eye Altered compliance, ocular rigidity
Lincoff’s balloon
Can be inserted under LA Minimal surgical trauma No scleral suturing
No changes in refractive status of the eye
SRF Drainage-
Indications Long standing RD Bullous elevated detachments No visible breaks Coexistent glaucoma Highly myopic detachments Aphakic & pseudophakic eyes Multiple breaks Significant vitreous traction Giant tears Inferior breaks Thin sclera
Technique Cut-down
Radial Sclerotomy, beneath the area of deepest SRF, 4mm long, sufficient depth to allow herniation of small dark knuckle of choroid
Gentle low-heat cautery to the knuckle/ puncture with 25G hypodermic needle
Prang Digital pressure applied on globe to occlude CRA & complete occlusion of
choroidal vasculature 27 G hypodermic needle bent at 2mm from tip, full thickness perforation Air injection after drainage of SRF
Complications Failure of drainage- dry tap Retinal perforation Intraocular haemorrhage Vitreous loss Retinal incarceration Endophthalmitis
Pars Plana Vitrectomy
Indicated in Media opacities- cataract , VH & advanced PVR Posteriorly located breaks RD with giant retinal tear or macular hole Pseudophakia Tractional RD
Relative contraindications Relatively simple phakic RD Inferior retinal dialysis
Video
Procedure
LA/GA 360˚/ Limited Conjunctival peritomy 3 Sclerotomies- ST, SN & IT quadrants PVD induction and thorough PPV Preretinal membranes peeled off Retinal breaks are marked with light cautery burns
Fluid gas exchange- endodrainage of SRF through pre-existing breaks/ Drainage retinotomy
Endophotocoagulation, Cryo for peripheral breaks Endotamponade- silicone oil/ Long acting gases Inferior PI in aphakic cases if silicone oil used
Sutureless Microincision Vitrectomy Transconjunctival sutureless MIVS using 23G/ 25G instrumentation
Advantages Shorter surgical time Less surgically induced astigmatism Reduced risk of post-operative corneal astigmatism Greater rigidity, better illumination, improved fluidics with 23 G Pneumatic dual drive cutter with ultrahigh cut rate 5000 cpm IOP compensation via direct control of infusion pressure Direct control of duty cycle New scleral entry system- MVR blade Wide angle viewing systems
Scleral Buckling+ PPV
Indicated in peripheral retinal involvement in Proliferative vitreoretinopathy Giant retinal tears Peripheral uveitis Viral retinitis Retinopathy of Prematurity Proliferative retinopathies
Pneumatic Retinopexy
Short, minimally invasive, OPD procedure Intravitreal injection of an expansile gas bubble, cryopexy,
postoperative patient positioning Indications
Fresh uncomplicated RRD Retinal break smaller than one clock hour Multiple breaks within one clock hour All breaks in superior 8 clock hours
Contraindications Inferior retinal breaks PVR Media opacities impairing proper assessment Uncontrolled glaucoma Air travel Patient unable to maintain postoperative positioning
Procedure Anaesthesia- Topical/LA Cryopexy around retinal breaks Single, expansile gas bubble injected in vitreous cavity through pars
plana using sterile 30 G needle Paracentesis Positioning- to ensure max. tamponade, retinal break should remain
at the top
Tamponading Agents in VR Surgery
Tamponading agents/ vitreous substitutes Materials used
Intraocular gases Silicone oil Perfluorocarbon liquid (PFCL)
Characteristics of gases High surface tension (occludes retinal break) Buoyancy (Force to push retina)
Used as Non-expansile mixture with air after PPV 100% concentration in pneumoretinopexy
Gases tried in vitreoretinal surgeryNon-expansile ExpansileAir SF6
Nitrogen C4F10
Helium CF4
Oxygen C2F6
Argon C3F8
Xenon C4F10
Krypton C5F12
Properties of intraocular gases
Gas Average Duration
Largest size of the bubble (duration)
Average expansion
Nonexpansile concentration
Typical Dose
Air 3 days Immediate No expansion
-- 0.8ml
SF6 12 days 36 hours 2 times 18% 0.5ml
C3F8 38 days 72 hours 4 times 14% 0.3ml
Advantages of intraocular gases vs use of silicon oil No need of repeat surgery for removal Absence of complications related to long-term presence of
silicone oil Disadvantages of intraocular gases
Requirement of strict postoperative positioning Risk of postoperative rise in IOP Restriction of air travel Development of lens opacity Delayed visual rehabilitation Short duration of tamponading effect Recurrent detachment from severe proliferation
Silicone Oil in RD Repair
FDA approved for VR surgery in 1994 Highly viscous, transparent liquid with high surface tension,
lighter than water Viscosity 1000-5000 centistokes Indications
Detachment with inferior breaks Extensive PVR One eyed patient with need of early visual recovery Giant retinal tears Traumatic detachments
Advantages Prolonged tamponading effect Less strict requirement of post-
operative positioning Early visual rehabilitation No restriction on air travel Hypotony less common
Disadvantages Needs repeat surgery for removal Cataract, raised IOP, BSK Inadequate tamponading for
inferior breaks Post-operative change in
refraction Perisilicone oil membrane &
macular pucker Redetachment after oil removal
(15-20%)
Comparison of various surgical techniquesMethod Reattachment
RateLimitations/Complications
Benefits
Scleral Buckling 94% Morbidity, infection, buckle extrusion, ocular motility disturbances
Excellent long term anatomic success, good visual outcome
Pars Plana Vitrectomy
71-92% (1˚ success rate)94% (2˚ success rate)
Iatrogenic retinal breaks, PVR, lens trauma, cataract progression
Visualization of all breaks, removal of opacities/synechiae, anatomic success in complicated detachments
Pneumatic Retinopexy
64% (1˚ success rate)
91% (2˚ success rate)
Limited use only in uncomplicated RRD with superior breaksPost-op positioning, iatrogenic breaks
In-office procedure, minimally invasive,↓ Recovery time, better post-op VA
Retinal Breaks
Factors to consider for treatment of retinal breaks Symptoms Age of patient Systemic status of the patient Refractive error (>6D myopia) Break- Location, age, type, size Status of fellow eye Aphakic/PCIOL/ needs cataract surgery
Increased chances of RD, needs T/t Phakic patients with symptomatic breaks Superotemporal breaks- macula off RD Larger breaks HST/ retinal dialysis Retinal tear at margin of lattice with symptoms
No treatment, observation Phakic patients- no prev H/O retinal disease, No high myopia With asymptomatic HST/ Atrophic holes/ with operculum
Management
Acute retinal break- new floaters and flashes- d/t acute PVD Presence or absence of symptoms with onset of break-
most important prognostic criterion for progression to retinal detachment
Anterior breaks--Cryotherapy/ LASER Posterior breaks--Slit Lamp/ Indirect Ophthalmoscopic
LASER delivery Large breaks--Anterior part- Cryotherapy Posterior part- LASER
LASER Photocoagulation
LASER used- Argon Green, Krypton Red, Diode Laser Delivery system- slit lamp/ indirect ophthalmoscopic Spot size 200µm Duration 0.1-0.2sec Goldmann Triple-mirror contact lens or wide-field lenses 2.2
panfundoscopic lens Surround the lesion with 3-4 rows of confluent burns of moderate
intensity No more than half spot size untreated retina between burns Patching, re-examine at 5-7 days
Post t/t patient should avoid strenuous physical exertion for upto 7 days until adequate adhesion has formed and lesion is securely sealed
Firm adhesion achieved at 3 weeks
Failure depends upon- failure rate 0-22% Type of break Indication of treatment Length of follow-up
Complications Macular pucker Epiretinal membrane formation Adie’s pupil Subretinal and vitreous
haemorrhage Breaks in Bruch’s membrane Scleral rupture- staphylomatous
sclera, cryo done
Cryotherapy
Mechanism- transconjunctival application- destroys choriocapillaris, RPE and outer retina- Adhesion between tear and adjacent retina
Partial adhesion at 1 week, Complete at 3 weeks Indications- media opacities
Extensive cataract Anterior/posterior capsular opacity Vitreous haemorrhage
Cryotherapy
Under topical anaesthesia/subconjunctival injection
Check cryoprobe for correct freezing and defrosting, rubber sleeve does not cover the slip
While viewing with IDO, gently indent sclera with tip of probe, start at ora serrata and move posteriorly
Surround the lesion with single row of application, terminate freezing as retina whitens, 2mm around entire break
Not to remove the probe until it has defrosted completely as premature removal may crack the choroid- leading to choroidal haemorrhage
Pad eye for 4 hours At 5 days, pigmentation begins
to appear Initially fine, then coarser, a/w
chorioretinal atrophy
Causes of failure Failure to surround the entire lesion Failure to apply contiguous treatment Failure to use an explant or gas tamponade New break formation
Cryotherapy vs LASER Retinopexy
Cryotherapy Use of external probe & IDO Can be used with moderate
media opacities Promotes dispersion of viable
RPE cells & breakdown of BRB CME, wrinkling of ILM Increased Postoperative flare,
extensive retinal oedema, necrosis
LASER Retinopexy Endolaser/ IDO with laser Difficult in moderate media
opacities/ shallow SRF Ideal for posteriorly located
breaks
Management of Retinal BreaksTreatment guidelines for retinal breaks
Type of break Phakic High Myopia Fellow eye Aphakia/Pseudophakia
HST symptomatic Treat Treat Treat Treat
HST Asymptomatic Observe Treat some Treat Treat some
Operculated symptomatic
Treat some Treat Treat Treat
Operculated asymptomatic
Observe Treat few Observe Observe
Round hole asymptomatic
Observe Observe Treat some Observe
Lattice without holes Observe Observe Treat some unless lattice >6clock hours
Observe
Lattice with round holes
Observe Observe Observe
Management of Tractional Retinal Detachment
TRD progresses very slowly, may reattach spontaneously Localized TRD away from macula- observation Indications for surgery
Macular threatened or detached Vitreous haemorrhage Retinal holes
Surgical Principles To relax the vitreoretinal traction Closure of retinal holes Drainage of SRF
PPV- to clear media, release of AP & tangential traction ERM- peeling/ segmentation/ delamination Enblock excision of traction membranes Retinotomy with internal drainage of SRF, internal tamponade
with LA gases/silicone oil injection Endodiathermy & endophotocoagulation- new vessels &
retinopexy
Conclusion
Scleral buckling : Standardized, predictable & successful Complications Alternative techniques : Limitations, selective Pneumoretinopexy- most popular Primary vitrectomy : more popular these days – 23 G or 25 G
No technique is the “ Best” Fundamental goal : Identify and functionally close all retinal
breaks Skill with Indirect Ophthalmoscopes - the Dying art of
localization Choice of surgery :
Individual experience Training Equipment available Changing contemporary practices
References
Clinical Ophthalmology, Kanski Ophthalmology, Myron Yanoff & Duker Retina , Stephen J. Ryan
THANK YOU!!!