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!!!