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Dr Laltanpuia Chhangte
PG 3
GMC, Haldwani
TYPES OF RD
RHEGMATOGENOUS
RD HISTORY
Beer
RD History: cont.
Leber
RD EPIDEMIOLOGY
Incidence
in 10%
In aphakics: 1 3%.
In the second eye (-): 5%.
In the second eye (+): 10%.
99% of untreated symptomatic RE
blindness.
5 15% of population with retinal break(s)
7% of these develop new break(s).
Normal anatomical
landmarks
APPLIED PHYSIOLOGY
Retina stays attached because:Acid mucopolysaccharide (GAG) b/w RPE
Mechanics of RD formation
Vitreous liquefaction
Partial/complete posterior vitreous
detachment, VR traction
Retinal breaks
tear
hole
dialysis
Eye movements (Edies current)
PVD
to loss of hyaluronic acid collapse
of vit. collagen with liquifaction.
Rare before 30 yrs.
Increases with age (63% in > 70 yrs.)
15% of acute PVD have a retinal tear.
Increases significantly after cataract
extraction: pathologic vs physiologic PVD.
Due
RD
PVD
Acute
PVD:-
Examine periphery.
+ vit. Hem.
- rest, patching examine.
U/S.
Retinal pigment
epithelial clumps
Glaucoma
Trauma
Proliferative
Lattice degeneration
Snail track degeneration retinopathies
- Diabetes
Zonular retinal traction
- BRVO
tufts
- Sickle cell, ROP
Degenerative
Infections
retinoschisis
RD in fellow eye or F/H
Retinal pits and
of RD
rarefaction
Aphakia
1. Myopia and RD
Myopia constitute 10% of the general
Microcysto
id
degenerat
ion
Honeycom
b
(reticular)
degenerat
ion
Pavingstone
degeneratio
n
Peripheral druse
3. CATARACT Surgery
4. Glaucoma
5. Hereditary factors
The most common hereditary conditions
6. TRAUMA
7. Intraocular inflammations
CLINICAL EVALUATION
SIGNS AND SYMPTOMS
Sudden increase in Floaters
Photopsia
VISUAL FIELD DEFECT
Metamorphopsia and sudden
DOV
Sudden
VA
ASSOCIATED CONDITIONS
Drugs use; Glaucoma ; Past
SYSTEMIC HISTORY
CVS, RS, anticoagulants intake, DM
FAMILY HISTORY
RD myopia, lattice degeneration,
familial VR degenerations
Genetic diseases marfan,
homocystinuria, sticklers syndrome
EXAMINATION
VA
Pupils
VF
SCLERA
AMSLER grid
Anterior segment
Refractive error
IOP
Lens
Ext. Ocular examination
Examination techniques
Indirect ophthalmoscopy
Scleral indentation
Fundus drawing
Slit lamp biomicroscopy
Ultrasonography B scan
U-tear in
detached
retina
shallo
w
temp
oral
retina
l
detac
hmen
superior
bullous
retinal
detachment
Proliferative
vitreoretinopathy
Assessment of Breaks
Lincoffs RULE
Tractional
Exudative
Symptom
Floaters and
flashes
Absent
Absent
VF defect
Develops fast
Develops slowly
may remain statis
for months
Develops fast
Laterality
PVD
Not associated
with PVD, which is
incomplete
Not associated
with PVD
Break
Always present
Absent
Absent
RPE PUMP
Intact
Not affected
Configuration
Convex, bullous,
corrugated folds
Concave
Mobility of retina
Mobile in fresh
case, restricted in
old case
Restricted
Mobile
Extent
Extends to ora
Seldom extends
Extends to ora
PVR
Present in due
course of time
Absent
Absent
SRF SHIFT
No shitt
Shallous and no
CD
Symptoms
Absent
Develops fast
Absent unless it is
very extensive i.e.,
kissing choroidals
AC and IOP
Break
Present
Absent
Configuration
Greyish white,
corrugated, retinal
fold, mostly mobile
Convex, dome
shaped brownish,
smooth and not
mobile
Extent
Mostly anterior to
equator, it usually
extends beyond ora
Treatment
Surgical
Mostly there is
PRINCIPLES OF SURGERY
Emergency.
Localization of break(s).
Creation of C-R adhestion around the
break(s).
Closure of break(s).
Relief of V-R traction.
Advantages
1. CRYOTHERAPY
Disadvatages
2. DIATHERMY
3. Photocoagulation
Laser delivery systems coupled with indirect
ophthalmoscope
Great precision in intensity and location
Causes less breakdown of blood ocular barrier.
The thermal effect is confined to retina and RPE
sparing choroid and sclera
Induces adhesive reaction within 24 hours
However an attached retina is prerequisite and
hence SRF needs to be drained before laser
retinopexy.
Select a spot size of 200 m and set the duration to
0.1 or 0.2 seconds
Surround the lesion with two rows of confluent burns
of moderate intensity
RD TREATMENT CONTD/
LA/GA
By Earnst custodi
1. ENCIRCLAGE BUCKLES
360 deg buckling effect that relieves the
vitreoretinal traciton
Support the suspected but non visualized
pathology b/w the ora and equator
Achieve buckling effect with band only
Occupy volume replacing the drained fluid
Support a contracted retina in early PVR
FALSE ORA created prevents further hole
formation and detachment; this in practice
needs for deep indent and is not
recommended
Undetected holes are sealed when no
2. RADIAL BUCKLES
Used in
Wide horse shoe tears b/c they cause
3. CIRCUMFERENTIAL
BUCKLES
Used in
Dialysis
Multiple tears
Uncertain about breaks SRF not located,
Factors promoting
attachment
Physiologic adhesion of retina and
RPE
Thermal chorioretinal adhesions
Scleral buckling promotes
retinochoroidal approximation
Traction on retinal surface
reduced/eliminated
Buckles may favourably influence
fluid flux
Factors favouring
detachment
Vitreous traction
Fluid movements and retinal breaks
Epiretinal membranes
Gases
Physical characteristics
of gases
Purity
Expansion Longetivit Non
y
expansile
conc.
Air
5- 7 days
0%
SF6
99.9
2x
10- 14 days
18%
C3F8
99.7
4x
30-35 days
14%
Xe
99.995
Contraindications to pneumatic
retinopexy
a. Breaks larger than one clock
hour or multiple breaks over more
than one clock hour
b. Breaks in inferior four clock hours
c. Proliferative vitreoretinopathy grade
C or D
d. Physical disability or mental
incompetence preventing
maintainance of head positioning
4. Severe uncontroled glaucoma/recent
Catract surgery
5. Cloudy media preventing adequate
Postoperative complications
Elevated iop
Vitreous haemorrhage
Infective endophthalmitis
Vitreous incarceration
Cataract
Subconjunctival gas
Intravitreal proliferation
Extension of detachment
By Robert Machemer
OTHER MODALITIES
1. Lincoff balloon
2.
3.
4.
5.
(Orbital/Episcleral)
Absorbable scleral buckles
fascia lata or Gelatin
Suprachoroidal hyaluronic acid
Subretinal fluid drainage and
intraocular gas injection
Primary vitrectomy without
buckling
buckling
A deflated balloon with catheter is
inserted into the tenon space via a
conjunctival incision, which is then
inflated by fluid to cause scleral
indentation
Cryotherapy before or
photocoagulation after insertion to
create C-R adhesion
3. Suprachoroidal hyaluronic
acid
By injecting materials like
gas injection
Combines the advantages of
pneumatic retinopexy with that of
conventional RD surgery
CANDIDATE small or medium sized
breaks in the superior quadrants
without significant vitreoretinal traction
7. Combination of techniques
The most commonly used methods
PROPHYLAXIS OF RD
CANDIDATES
1.Symptomatic holes
2. Aphakic holes
3. Fellow eye with detachment
and breaks
4. Asymptomatic holes in
dialysis, GRT
5. Snail tract degeneration with
holes
6. Lattice degeneration in fellow
eyes, aphakia and myopia
Complication of RD surgery
Complication of RD surgery
contd/
COMPLICATIONS OF RD SX
contd/
late glaucoma
Pupillary
block
glaucoma
cataract in
an eye with
(inverted
pseudohypopyon
band keratopathy
LATE REDETACHMENT
- Approx. success.
Overall
If
If
RD Prognosis:
1.
RD Prognosis: cont.
2.
Aphakic detachments.
Total detachments.
Detachments with associated de-tachment of
the nonpigmented epithelium of the pars
plana.
Detachments caused by flap tears.
RD Prognosis: cont.
3.
Clinical Trials
Gas Injection: PR
Tornambe published experiences in 302
PR versus SB
The Retinal Detachment Study was a prospective
PR versus SB contd/
Mulvihillet al. conducted a small
PR versus SB contd/
In the comparative case series of Hanet
RECOMMENDATIONS FOR VR SX
Simple detachment (phakic eye, one
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