RETINAL RETINAL DETACHMENTDETACHMENT

DR KALPANA SANGWANDR KALPANA SANGWAN

DEFINITION?DEFINITION?

RETINAL DETACHMENTRETINAL DETACHMENT

• Separation of the Separation of the neural retina from the pigment neural retina from the pigment epithelium of the retina epithelium of the retina thus re-establishing the thus re-establishing the potential space that exists between the original potential space that exists between the original layers of the embryonic optic cup.layers of the embryonic optic cup.

TYPES?TYPES?

•RhegmatogenousRhegmatogenous (“rhegma”- break) -Most (“rhegma”- break) -Most commoncommon

•TractionalTractional- - Mechanical pullMechanical pull ofof V-R adhesionsV-R adhesions

•CombinedCombined Rhegmatogenous & TractionalRhegmatogenous & Tractional

•ExudativeExudative (Serous)(Serous)• Secondary to an associated process e.g Secondary to an associated process e.g

Tumour or an InflammationTumour or an Inflammation

EMBRYOLOGYEMBRYOLOGY

EMBRYOLOGYEMBRYOLOGY

FACTORS KEEPING THE FACTORS KEEPING THE RETINA ATTACHEDRETINA ATTACHED

FACTORS KEEPING THE FACTORS KEEPING THE RETINA ATTACHEDRETINA ATTACHED

• Tamponading effect of intact vitreous gelTamponading effect of intact vitreous gel

• Active RPE pumping of subretinal fluid to Active RPE pumping of subretinal fluid to choroidchoroid

• Interdigitation between RPE & photoreceptor Interdigitation between RPE & photoreceptor outer segmentsouter segments

INTER PHOTORECEPTOR INTER PHOTORECEPTOR MATRIXMATRIX• Presence of Presence of

mucopolysaccharidemucopolysaccharides (mainly G.A.G.S) in s (mainly G.A.G.S) in the inter - the inter - photoreceptor matrix photoreceptor matrix plays a role of “glue” plays a role of “glue” between between Photoreceptors & Photoreceptors & RPERPE

WHEN DOES RD OCCUR WHEN DOES RD OCCUR ????

•Normal physiological forces (mentioned above) Normal physiological forces (mentioned above) compromised compromised →→ RD occurs RD occurs

•Rhegmatogenous R.DRhegmatogenous R.D →→ Tear held open by Tear held open by traction allows liquified vitreous gel to migrate traction allows liquified vitreous gel to migrate to S.R spaceto S.R space

• Exudative/Serous R.DExudative/Serous R.D →→ S.R.F secondary to S.R.F secondary to diseases of RPE & choroiddiseases of RPE & choroid

• Tractional R.DTractional R.D →→ Retina pulled away from RPE Retina pulled away from RPE

ARCHITECTURE OF RETINAARCHITECTURE OF RETINA• As seen in light As seen in light

microscopy cross microscopy cross section from out to section from out to insideinside• RPERPE• Photo receptor layers Photo receptor layers

of rods & casesof rods & cases• ELMELM• Outer nucleus layer Outer nucleus layer • Outer plexiform layerOuter plexiform layer• Inner nuclear layerInner nuclear layer• Inner plexiform layerInner plexiform layer• Ganglion cell layerGanglion cell layer• Nerve fibre layerNerve fibre layer• ILMILM

VITREOUS ADHESIONSVITREOUS ADHESIONS

Normal:Normal:

The peripheral cortical vitreous is loosely attached to the The peripheral cortical vitreous is loosely attached to the internal limiting membrane (ILM) of the sensory retina. internal limiting membrane (ILM) of the sensory retina. Stronger adhesions occur at the following sites: Stronger adhesions occur at the following sites:

•Vitreous baseVitreous base, where they are very strong. , where they are very strong.

•Around the optic nerve headAround the optic nerve head, where they are fairly , where they are fairly strong strong

••Around the foveaAround the fovea, where they are fairly weak, except in , where they are fairly weak, except in eyes with vitreo-macular traction and macular hole eyes with vitreo-macular traction and macular hole formation. formation.

•Along peripheral blood vesselsAlong peripheral blood vessels, where they are usually , where they are usually weak. weak.

……………………....

• Abnormal adhesions at the following sites Abnormal adhesions at the following sites may be may be associated with retinal tear formation as a result of associated with retinal tear formation as a result of dynamic vitreo-retinal traction associated with acute dynamic vitreo-retinal traction associated with acute PVD .PVD .

• Posterior border of islands of Posterior border of islands of lattice degeneration. lattice degeneration.

•Retinal pigment clumps.Retinal pigment clumps.

• Peripheral Peripheral para-vascular condensationspara-vascular condensations. .

• Vitreous base anomalies such as Vitreous base anomalies such as tongue-like tongue-like extensions and posterior islands. extensions and posterior islands.

• ‘‘White with pressureWhite with pressure’ & ‘’ & ‘white without pressurewhite without pressure’.’.

VITREORETINAL VITREORETINAL TRACTIONTRACTION

Vitreoretinal traction is a force exerted on the retina by Vitreoretinal traction is a force exerted on the retina by structures originating in the vitreous, and may be dynamic or structures originating in the vitreous, and may be dynamic or static. static.

The difference between the two is crucial in understanding The difference between the two is crucial in understanding the pathogenesis of the various types of RD :the pathogenesis of the various types of RD :

1.Dynamic traction 1.Dynamic traction is induced by eye movements and exerts is induced by eye movements and exerts a centripetal force towards the vitreous cavity. It plays an a centripetal force towards the vitreous cavity. It plays an important role in the important role in the pathogenesis of retinal tears and pathogenesis of retinal tears and rhegmatogenous RD.rhegmatogenous RD.

2.Static traction 2.Static traction is independent of ocular movements. It is independent of ocular movements. It plays a key role in the pathogenesis of plays a key role in the pathogenesis of Tractional RD and Tractional RD and proliferative vitreoretinopathy proliferative vitreoretinopathy

POSTERIOR VITREOUS POSTERIOR VITREOUS DETACHMENTDETACHMENT• Separation of Separation of cortical vitreous from the internal limiting cortical vitreous from the internal limiting

membrane of NSR posterior to vitreous basemembrane of NSR posterior to vitreous base

• ONSET: ONSET:

• Acute PVD by far is the most common. It develops Acute PVD by far is the most common. It develops suddenly & usually becomes complete soon after suddenly & usually becomes complete soon after onset.onset.

• Chronic PVD occurs gradually & may take Chronic PVD occurs gradually & may take weeks or weeks or

monthsmonths to become complete. to become complete.

Biomicroscopy showing posterior vitreous detachment without collapse. The posterior hyaloid face is indicated by the long arrow ‘a’ and the retina by the short arrow ‘b’

EXTENT O F PVDEXTENT O F PVD

A) A) Complete :Entire vitreous cortex detaches up Complete :Entire vitreous cortex detaches up to the posterior margin of the vitreous base.to the posterior margin of the vitreous base.

B) Incomplete : Residual vitreoretinal B) Incomplete : Residual vitreoretinal attachments remain posterior to the vitreous attachments remain posterior to the vitreous base.base.

•Rhematogenous RD is associated with acute Rhematogenous RD is associated with acute

PVD,tractional RD with chronic,incomplete PVD,tractional RD with chronic,incomplete

PVD,exudative RD unrelatedPVD,exudative RD unrelated

CLINICAL EXAMINATION & CLINICAL EXAMINATION & DIAGNOSISDIAGNOSIS

INCLUDESINCLUDES•Head mount indirect ophthalmoscopyHead mount indirect ophthalmoscopy

• Scleral indentationScleral indentation

•Goldmann 3 mirror lensGoldmann 3 mirror lens

• Finding the retinal breakFinding the retinal break

•UltrasonographyUltrasonography

HEAD MOUNT INDIRECT HEAD MOUNT INDIRECT OPHTHALMOSCOPYOPHTHALMOSCOPY

• Provides stereoscopic view Provides stereoscopic view of the fundusof the fundus• Inverted & laterally reversed Inverted & laterally reversed

image of the fundusimage of the fundus• Condensing lens …as the Condensing lens …as the

power increases working power increases working distance is decreased & distance is decreased & magnification increases but magnification increases but field of view is reducedfield of view is reduced• 20 D =magnifies*3 20 D =magnifies*3

field=45degreefield=45degree

SCLERAL SCLERAL INDENTATIONINDENTATION

•Its main function Its main function is to enhance is to enhance visualization of the visualization of the peripheral retina peripheral retina anterior to the anterior to the equator equator

•It also permits a It also permits a kinetic evaluation kinetic evaluation of the retinaof the retina

GOLDMANN 3 MIRROR GOLDMANN 3 MIRROR LENSLENS• Goldmann three-mirror lens Goldmann three-mirror lens

consists of four parts; the central consists of four parts; the central lens and three mirrors set at lens and three mirrors set at different angles. different angles.

• The central part- 30° upright The central part- 30° upright view of the posterior poleview of the posterior pole..

• The equatorial mirror -visualization The equatorial mirror -visualization from 30° to the equator.from 30° to the equator.

• The peripheral mirror -between the The peripheral mirror -between the equator and the ora serrata.equator and the ora serrata.

• The gonioscopy mirror -extreme The gonioscopy mirror -extreme retinal periphery and pars plana retinal periphery and pars plana

FINDING THE PRIMARY FINDING THE PRIMARY BREAKBREAK

• The primary break is the one responsible for The primary break is the one responsible for the RD. the RD.

• A secondary break is not responsible for the A secondary break is not responsible for the RDRD

• Because it was either present Because it was either present before the before the development of the RD or formed after the development of the RD or formed after the retina detached. retina detached.

…………..

• Distribution of breaks in eyes with RD is Distribution of breaks in eyes with RD is approximately as follows:approximately as follows:

• 60% in the upper temporal quadrant; 60% in the upper temporal quadrant;

• 15% in the upper nasal quadrant; 15% in the upper nasal quadrant;

• 15% in the lower temporal quadrant; 15% in the lower temporal quadrant;

• 10% in the lower nasal quadrant. 10% in the lower nasal quadrant.

………………

• The The upper temporal quadrant is therefore by far the upper temporal quadrant is therefore by far the

most common site for retinal break formation most common site for retinal break formation and and should be examined in great detail if a retinal break should be examined in great detail if a retinal break cannot be detected initially. cannot be detected initially.

• It should also be remembered that It should also be remembered that about 50% of about 50% of

eyes with RD have more than one breakeyes with RD have more than one break, and in , and in most eyes these are located most eyes these are located within 90° within 90° of each of each other.other.•

CONFIGURATION OF CONFIGURATION OF SRF SRF

• SRF spreads in a SRF spreads in a gravitational fashiongravitational fashion

• SHAPE:SHAPE:

1.1.Anatomical limits (ora serrata and optic nerve) and Anatomical limits (ora serrata and optic nerve) and by the by the

2.2.Location of the primary retinal break.Location of the primary retinal break.

• If the primary break is If the primary break is located superiorly, the SRF located superiorly, the SRF first spreads inferiorly on the same side as the break first spreads inferiorly on the same side as the break and then spreads superiorly on the opposite side of and then spreads superiorly on the opposite side of the fundus. the fundus.

……………………

• The likely location of the primary retinal break The likely location of the primary retinal break can therefore be can therefore be predicted by studying the predicted by studying the

shape of the RD. shape of the RD.

• a)A shallow inferior RD in which the SRF is a)A shallow inferior RD in which the SRF is slightly higher on the temporal side points to a slightly higher on the temporal side points to a primary break located inferiorly on that side primary break located inferiorly on that side

………………....

• The above points are important because they aid in The above points are important because they aid in prevention of the treatment of a secondary break prevention of the treatment of a secondary break whilst overlooking the primary break. whilst overlooking the primary break.

• It is therefore essential to ensure that the shape of It is therefore essential to ensure that the shape of the RD corresponds to the location of a presumed the RD corresponds to the location of a presumed primary retinal break.primary retinal break.

HISTORYHISTORY• Although the location of light flashes is of no value Although the location of light flashes is of no value

in predicting the site of the primary break,in predicting the site of the primary break, the the

quadrant in which a visual field defect first appears quadrant in which a visual field defect first appears

may be of considerable value. may be of considerable value.

• For example, if a field defect started in the upper For example, if a field defect started in the upper nasal quadrant the primary break is probably nasal quadrant the primary break is probably located in the lower temporal quadrant.located in the lower temporal quadrant.

ULTRASONOGRAPHYULTRASONOGRAPHY

•B-scan ultrasonography (US) B-scan ultrasonography (US) is very useful in is very useful in the diagnosis of RD in eyes with :the diagnosis of RD in eyes with :

•Opaque mediaOpaque media

• Severe vitreous haemorrhage that precludes Severe vitreous haemorrhage that precludes visualization of the fundus visualization of the fundus

RHEGMATOGENOUS RETINAL RHEGMATOGENOUS RETINAL DETACHMENTDETACHMENT

RHEGMATOGENOUS RHEGMATOGENOUS RETINAL RETINAL DETACHMENT(RRD)DETACHMENT(RRD)

• Also referred as PRIMARY/IDIOPATHIC Also referred as PRIMARY/IDIOPATHIC

• Exudative & Tractional as SECONDARY/NON-Exudative & Tractional as SECONDARY/NON-RHEGMATOGENOUSRHEGMATOGENOUS

• Results from a retinal break Results from a retinal break

• It is characterized by the presence of a retinal break It is characterized by the presence of a retinal break held open by vitreoretinal traction that allows held open by vitreoretinal traction that allows accumulation of liquefied vitreous under the NSR, accumulation of liquefied vitreous under the NSR, separating it from the RPE.separating it from the RPE.

…………..

•The retinal breaks responsible for RD are The retinal breaks responsible for RD are caused by caused by interplay between dynamic interplay between dynamic

vitreo-retinal traction and an underlying vitreo-retinal traction and an underlying

weakness in the peripheral retina weakness in the peripheral retina referred to referred to as predisposing degeneration.as predisposing degeneration.

EPIDEMIOLOGYEPIDEMIOLOGY

•RRD occurs in about 12/100,000 RRD occurs in about 12/100,000 people(0.01% annual risk) with a lifetime risk of people(0.01% annual risk) with a lifetime risk of 0.6%.0.6%.

•Rhegmatogenous RD affects about 1 in 10,000 Rhegmatogenous RD affects about 1 in 10,000 of the population each year and both eyes may of the population each year and both eyes may eventually be involved in about 10% of eventually be involved in about 10% of patients.patients.

RACE & SEXRACE & SEX

•Relatively frequent in Relatively frequent in Jewish ethnicity Jewish ethnicity & & relatively relatively low in persons of African descentlow in persons of African descent

• Approximately 60% of detachments occur in Approximately 60% of detachments occur in malesmales

AGE AGE

• Peak incidence is between Peak incidence is between 40-70 yrs40-70 yrs

• Lower incidence in the age group of birth to 18 Lower incidence in the age group of birth to 18 yrs which accounts for only 3.2 to 5.6% of Total yrs which accounts for only 3.2 to 5.6% of Total RRD patientsRRD patients

•Retinal detachment surgeries performed in Retinal detachment surgeries performed in children constitute approx. 3.1% of Total RD children constitute approx. 3.1% of Total RD surgeries.surgeries.

HEREDITY & HEREDITY & BILATERALITYBILATERALITY

• Positive family history of RD is a relevant risk Positive family history of RD is a relevant risk factor.factor.

(primarily because of (primarily because of high myopia & lattice high myopia & lattice degeneration degeneration which are important predisposing which are important predisposing factors for RD)factors for RD)

•Risk of bilateral detachments is 15% in adults & Risk of bilateral detachments is 15% in adults & 22% below 18yrs age22% below 18yrs age..

PATHOGENESIS PATHOGENESIS OF RETINAL OF RETINAL DETACHMENTDETACHMENT

PREDISPOSING FACTORSPREDISPOSING FACTORS

•Presence of posterior vitreous detachmentPresence of posterior vitreous detachment

•High myopiaHigh myopia

•History of ocular surgeryHistory of ocular surgery

•History of traumaHistory of trauma

•Predisposing peripheral retinal lesionsPredisposing peripheral retinal lesions

THREE PRE-REQUISITES FOR THREE PRE-REQUISITES FOR THE DEVELOPMENT OF RRDTHE DEVELOPMENT OF RRD

• Liquefaction of the vitreousLiquefaction of the vitreous

•Tractional forces that produce a retinal Tractional forces that produce a retinal break &break &

•A retinal break, through which fluid gains A retinal break, through which fluid gains access into the subretinal spaceaccess into the subretinal space

DYNAMIC VITREORETINAL DYNAMIC VITREORETINAL TRACTIONTRACTION

Syneresis defines liquefaction of the vitreous gel.Syneresis defines liquefaction of the vitreous gel.

•Some eyes with syneresis Some eyes with syneresis develop a hole in the develop a hole in the posterior hyaloid membrane posterior hyaloid membrane and fluid from within the and fluid from within the centre of the vitreous cavity centre of the vitreous cavity passes through this passes through this defect into the newly formed retrohyaloid space. defect into the newly formed retrohyaloid space.

•This process forcibly This process forcibly detaches the posterior vitreous detaches the posterior vitreous and the posterior hyaloid membrane from the ILM of and the posterior hyaloid membrane from the ILM of the sensory retina the sensory retina as far as the posterior border of the as far as the posterior border of the vitreous base vitreous base

A) Vitreous syneresis;

B) uncomplicated posterior vitreous detachment

• The remaining solid vitreous gel collapses inferiorly The remaining solid vitreous gel collapses inferiorly and the retrohyaloid space is occupied entirely by and the retrohyaloid space is occupied entirely by synchytic fluid. synchytic fluid.

Acute PVD with collapse Acute PVD with collapse

WITH AGE,POCKETS OF WITH AGE,POCKETS OF LIQUEFACTION FORM IN LIQUEFACTION FORM IN VITREOUSVITREOUS

RHEGMATOGENOUS RD

PRESENTATIONPRESENTATION

• Age at onset is typically 45–65 years in the general Age at onset is typically 45–65 years in the general population but may occur population but may occur earlier in myopic or earlier in myopic or otherwise predisposed individuals (e.g. trauma, otherwise predisposed individuals (e.g. trauma, uveitis).uveitis).

• The fellow eye frequently becomes affected within The fellow eye frequently becomes affected within 6 6 months to 2 yearsmonths to 2 years

• Floaters & Flashes of lightFloaters & Flashes of light

Biomicroscopy showing posterior vitreous detachment with collapse

COMPLICATIONS OF COMPLICATIONS OF ACUTE PVDACUTE PVD

•Patients with isolated PVD should therefore Patients with isolated PVD should therefore be re-examined after 1–6 weeks depending on be re-examined after 1–6 weeks depending on risk factors. risk factors.

Fig. 16.22 (A) U-tear and localized subretinal fluid associated with acute posterior vitreous detachment;

(B) the vitreous shows syneresis, posterior vitreous detachment with partial collapse, and retained attachment of cortical vitreous to the flap of the tear

…………

• Tears associated with acute PVD are usually Tears associated with acute PVD are usually symptomaticsymptomatic, , U-shaped, located in the upper fundus U-shaped, located in the upper fundus

and may be associated with vitreous haemorrhage and may be associated with vitreous haemorrhage

resulting from rupture of a peripheral retinal blood resulting from rupture of a peripheral retinal blood vessel.vessel.

• After a tear has formed, the retrohyaloid fluid has After a tear has formed, the retrohyaloid fluid has direct access to the subretinal space.direct access to the subretinal space.

HIGH MYOPIAHIGH MYOPIA

• High myopia (>-High myopia (>-6.0 D or AXL at 6.0 D or AXL at least 26mm) least 26mm) have about 5-6 have about 5-6 times higher times higher risk for risk for developing RDdeveloping RD

• Almost 40% of RD are associated with high myopiaAlmost 40% of RD are associated with high myopia

• Risk of RRD Degree of myopiaRisk of RRD Degree of myopia

• An increase in Axl length of 1MM increases the risk An increase in Axl length of 1MM increases the risk of RD by a hazard ratio of 1.3of RD by a hazard ratio of 1.3

FACTORS PREDISPOSING A FACTORS PREDISPOSING A MYOPIC EYE TO DEVELOP MYOPIC EYE TO DEVELOP RDRD

VITREOUS LOSS DURING CATARACT SURGERY & LASER POSTERIOR CAPSULOTOMY

HISTORY OF CATARACT HISTORY OF CATARACT SURGERYSURGERY

• 40% Of patients with RRD give history of cataract 40% Of patients with RRD give history of cataract surgery in the same eyesurgery in the same eye

• 50% detachments occur within 150% detachments occur within 1 stst year following year following surgerysurgery

• ICCE & ECCE complicated by Posterior capsular rent ICCE & ECCE complicated by Posterior capsular rent carry a higher risk than uncomplicated ECCE.carry a higher risk than uncomplicated ECCE.

• Cumulative risk of RRD within 3 yrs of ECCE surgery Cumulative risk of RRD within 3 yrs of ECCE surgery is 0.81% in pseudophakes & 1.1 to 3.6% in aphakesis 0.81% in pseudophakes & 1.1 to 3.6% in aphakes

• Myopes have a higher incidence ,increasing to Myopes have a higher incidence ,increasing to almost 7% if posterior capsular rent(PCR) occurs.almost 7% if posterior capsular rent(PCR) occurs.

• Post-cataract RRD tends to be more advanced,with Post-cataract RRD tends to be more advanced,with total detachment(often involving the macula),multiple total detachment(often involving the macula),multiple tiny breaks,fixed folds & a higher incidence of tiny breaks,fixed folds & a higher incidence of PVR(proliferative vitreo-retinopathy)PVR(proliferative vitreo-retinopathy)

• Occurrence of PVD , increased liquefaction & collapse Occurrence of PVD , increased liquefaction & collapse of the vitreous secondary diffusion of hyaluronic acid of the vitreous secondary diffusion of hyaluronic acid during surgeryduring surgery

• Increased dynamic vitreous traction with ocular Increased dynamic vitreous traction with ocular movements due to loss of adhesion between the movements due to loss of adhesion between the vitreous & posterior capsule vitreous & posterior capsule

• are the probable causes of RRD after cataract are the probable causes of RRD after cataract surgery.surgery.

HISTORY OF TRAUMAHISTORY OF TRAUMA

• Trauma is one of the most common causes of RRD Trauma is one of the most common causes of RRD especially especially in childrenin children..• Leading causes of blunt trauma in indian children are Leading causes of blunt trauma in indian children are

cricket ball injuries.cricket ball injuries.• Blunt trauma causes rapid compression of the eye Blunt trauma causes rapid compression of the eye

along AP diameter which results in tractional forces at along AP diameter which results in tractional forces at the vitreous base upon re-expansion of the eyethe vitreous base upon re-expansion of the eye

• • Linear retinal tears & dialysisLinear retinal tears & dialysis

…………....

• Retinal detachments occur in almost 1/5Retinal detachments occur in almost 1/5 thth of patients of patients with posterior segment penetrating injuries,and is with posterior segment penetrating injuries,and is 4.5 times more likely if vitreous hemorrhage is 4.5 times more likely if vitreous hemorrhage is presentpresent

• Late retinal breaks may also occur with contraction Late retinal breaks may also occur with contraction of the episcleral fibrovascular tissue,which can of the episcleral fibrovascular tissue,which can proliferate into the intravitreal space at the site of proliferate into the intravitreal space at the site of penetrationpenetration

……..

• After blunt trauma, retinal tear is generally produced After blunt trauma, retinal tear is generally produced at the time of impact, but RD doesn’t develop at the time of impact, but RD doesn’t develop immediately in young patients , due to tamponading immediately in young patients , due to tamponading effect of formed vitreous.effect of formed vitreous.• Once vitreous liquefaction starts ,fluid then starts Once vitreous liquefaction starts ,fluid then starts

seeping in the sub-retinal space through the break seeping in the sub-retinal space through the break leading to retinal detachmentleading to retinal detachment• Average interval between trauma & diagnosis of Average interval between trauma & diagnosis of

RRD is 17.3 months in cases of blunt trauma & 14.7 RRD is 17.3 months in cases of blunt trauma & 14.7 months in case of penetrating trauma.months in case of penetrating trauma.

•High myopes are more prone to develop retinal High myopes are more prone to develop retinal detachment following blunt traumadetachment following blunt trauma

PREDISPOSING RETINAL PREDISPOSING RETINAL LESIONSLESIONS

•RETINAL BREAKS RETINAL BREAKS • RETINAL HOLESRETINAL HOLES• RETINAL TEARS/HORSE SHOE TEARSRETINAL TEARS/HORSE SHOE TEARS• RETINAL DIALYSISRETINAL DIALYSIS

RETINAL BREAKRETINAL BREAK

• For retinal detachment to occur there must be For retinal detachment to occur there must be presence of 1 or more of retinal breaks which allow presence of 1 or more of retinal breaks which allow passage of liquefied vitreous in the sub-retinal spacepassage of liquefied vitreous in the sub-retinal space

• Primary & SecondaryPrimary & Secondary

• Retinal breaks are classified into Retinal breaks are classified into Tears, Holes & Tears, Holes & Retinal dialysisRetinal dialysis

…………..

• A retinal break is a full-thickness defect in the A retinal break is a full-thickness defect in the sensory retina. sensory retina.

• Breaks can be classified according to Breaks can be classified according to

• (a)pathogenesis,(a)pathogenesis,

• (b) morphology and(b) morphology and

• (c) location.(c) location.

PATHOGENESIS PATHOGENESIS

• A)Tears are caused by dynamic vitreo-retinal A)Tears are caused by dynamic vitreo-retinal traction and have a predilection for the traction and have a predilection for the superior superior

fundus (temporal more than nasal).fundus (temporal more than nasal).

• B)Holes are caused by chronic atrophy of the B)Holes are caused by chronic atrophy of the sensory retina and may be round or oval. They sensory retina and may be round or oval. They have a predilection for the have a predilection for the temporal fundus temporal fundus

(upper more than lower).(upper more than lower).

MORPHOLOGYMORPHOLOGY

• U-tearsU-tears (horseshoe, flap or arrowhead) consist of a (horseshoe, flap or arrowhead) consist of a flap, the apex of which is pulled anteriorly by the flap, the apex of which is pulled anteriorly by the vitreous, the base remaining attached to the retina . vitreous, the base remaining attached to the retina . The tear itself consists of two anterior extensions The tear itself consists of two anterior extensions (horns) running forward from the apex(horns) running forward from the apex

• Incomplete U-tearsIncomplete U-tears, which may be , which may be linear, L-shaped linear, L-shaped

or J-shaped, are often paravascular.or J-shaped, are often paravascular.

…………....

• Operculated tears Operculated tears in which the flap is completely torn in which the flap is completely torn away from the retina by detached vitreous gel.away from the retina by detached vitreous gel.

•DialysesDialyses are are circumferential tears circumferential tears along the ora along the ora serrata with vitreous gel attached to their posterior serrata with vitreous gel attached to their posterior margins.margins.

…………………………

• Giant tears involve Giant tears involve 90° or more of the circumference 90° or more of the circumference

of the globeof the globe. .

• They are most frequently located in the They are most frequently located in the immediate immediate

post-oral retina or, less commonly, at the equator. post-oral retina or, less commonly, at the equator.

• Giant tears are a variant of U-shaped tears with the Giant tears are a variant of U-shaped tears with the vitreous gel attached to the anterior margin of the vitreous gel attached to the anterior margin of the break.break.

LOCATIONLOCATION

•Oral breaks Oral breaks are located within the vitreous are located within the vitreous base.base.•Post-oral breaks Post-oral breaks are located between the are located between the

posterior border of the vitreous base and the posterior border of the vitreous base and the equator. equator. • Equatorial breaks Equatorial breaks are at or near the equator.are at or near the equator.• Post-equatorial breaks Post-equatorial breaks are behind the are behind the

equator.equator.• Macular breaks Macular breaks (invariably holes) are at the (invariably holes) are at the

fovea. fovea.

Fig. 16.6 (A) Giant retinal tear involving the immediate post-oral retina; (B) vitreous cortex is attached to the anterior margin of the tear

• About 60% of all breaks develop in areas of the About 60% of all breaks develop in areas of the peripheral retina that show specific changes. peripheral retina that show specific changes.

• These lesions may be associated with a These lesions may be associated with a spontaneous breakdown of pathologically thin spontaneous breakdown of pathologically thin retinal tissue to cause a retinal hole, or they may retinal tissue to cause a retinal hole, or they may predispose to retinal tear formation in eyes with predispose to retinal tear formation in eyes with acute PVD. acute PVD.

…………

•Retinal holes are round or oval, usually smaller Retinal holes are round or oval, usually smaller than tears and carry a lower risk of RD. than tears and carry a lower risk of RD.

•Retinal detachment without PVD is usually Retinal detachment without PVD is usually associated with either retinal dialysis, or round associated with either retinal dialysis, or round holes predominantly in young female myopes.holes predominantly in young female myopes.

LATTICE DEGENERATIONLATTICE DEGENERATION

•Prevalence: Prevalence: • Lattice degeneration is present in about 8% of the Lattice degeneration is present in about 8% of the

population. population.

• Peak incidence during the Peak incidence during the second and third decadessecond and third decades. .

• It is found more commonly in It is found more commonly in moderate myopes and is moderate myopes and is

the most important degeneration directly related to RDthe most important degeneration directly related to RD. .

• It is usually It is usually bilateralbilateral and most frequently located in the and most frequently located in the temporaltemporal rather than the nasal fundus, and rather than the nasal fundus, and superiorlysuperiorly rather than inferiorly. rather than inferiorly.

• Lattice is present in about 40% of eyes with RD.Lattice is present in about 40% of eyes with RD.

PATHOLOGY :PATHOLOGY :

• There is discontinuity of the internal limiting There is discontinuity of the internal limiting membrane with variable atrophy of the underlying membrane with variable atrophy of the underlying NSR. NSR.

• The vitreous overlying an area of lattice is The vitreous overlying an area of lattice is synchyticsynchytic but the vitreous attachments around the margins but the vitreous attachments around the margins are exaggerated are exaggerated

SIGNSSIGNS

• • Spindle-shaped areas of retinal thinning, Spindle-shaped areas of retinal thinning, commonly located between the equator and the commonly located between the equator and the posterior border of the vitreous base.posterior border of the vitreous base.

•A characteristic feature is an arborizing network A characteristic feature is an arborizing network of white lines within the islandsof white lines within the islands

COMPLICATIONSCOMPLICATIONS

• No complications in most patientsNo complications in most patients

• TearsTears

• Atrophic holesAtrophic holes

Complications of lattice degeneration. (A) Atypical radial lattice without breaks; (B) two U-tears, the larger one of which shows a small patch of lattice on its flap and is surrounded by a small puddle of subretinal fluid; (C) linear tear along the posterior margin of lattice; (D) multiple small holes within islands of lattice

SNAIL TRACK SNAIL TRACK DEGENERATIONDEGENERATION

• Snail-track degeneration is characterized by sharply Snail-track degeneration is characterized by sharply demarcated bands of tightly packed demarcated bands of tightly packed ‘Snowflakes‘Snowflakes’ which ’ which give the peripheral retina a give the peripheral retina a white frost-like appearancewhite frost-like appearance. .

• The islands are usually The islands are usually longer than in lattice longer than in lattice degeneration degeneration and may be associated with overlying and may be associated with overlying vitreous liquefaction. vitreous liquefaction.

• Marked vitreous traction at the posterior border of the Marked vitreous traction at the posterior border of the lesions is seldom present lesions is seldom present so that tractional U-tears so that tractional U-tears rarely occur, although round holes within the snail-rarely occur, although round holes within the snail-tracks may be present.tracks may be present.

Islands of snail-track degeneration, some of which contain holes

DEGENERATIVE DEGENERATIVE RETINOSCHISISRETINOSCHISIS

•PrevalencePrevalence• Degenerative retinoschisis is present in about 5% of Degenerative retinoschisis is present in about 5% of

the population over the age of 20 years and is the population over the age of 20 years and is particularly prevalent in particularly prevalent in hypermetropeshypermetropes (70% of (70% of patients are hypermetropic). patients are hypermetropic).

• Both eyes are frequently involvedBoth eyes are frequently involved•

PATHOLOGYPATHOLOGY

• There is There is coalescence of cystic lesions coalescence of cystic lesions as a result of as a result of degeneration of neuro-retinal and glial supporting degeneration of neuro-retinal and glial supporting elements within elements within areas of peripheral cystoid degeneration. areas of peripheral cystoid degeneration.

• Separation or splitting of the NSR into an inner (vitreous) Separation or splitting of the NSR into an inner (vitreous) layer and an outer (choroidal) layer layer and an outer (choroidal) layer with severing of with severing of neurones and complete loss of visual function in the neurones and complete loss of visual function in the affected area. affected area.

• In typical retinoschisis the split is in the In typical retinoschisis the split is in the outer plexiform outer plexiform layerlayer, and in reticular retinoschisis, which is less common, , and in reticular retinoschisis, which is less common, splitting occurs at the level of the splitting occurs at the level of the nerve fibre layer.nerve fibre layer.

Microcystoid degeneration. (A) Histology shows spaces in the nerve fibre layer delineated by delicate vertical columns of Müller cells; (B) circumferential microcystoid degeneration and mild retinoschisis in the inferotemporal and superotemporal quadrants

SIGNSSIGNS

• Early retinoschisis usually Early retinoschisis usually involves the extreme involves the extreme inferotemporal periphery inferotemporal periphery of both fundi, appearing as of both fundi, appearing as an exaggeration of microcystoid degeneration with a an exaggeration of microcystoid degeneration with a smooth immobile elevation of the retina.smooth immobile elevation of the retina.

• The lesion may The lesion may progress circumferentially until it progress circumferentially until it has involved the entire fundus peripheryhas involved the entire fundus periphery. .

• The typical form usually remains anterior to the The typical form usually remains anterior to the equator although the reticular type may spread equator although the reticular type may spread beyond the equator.beyond the equator.

Retinoschisis with breaks in both layers. The inner layer shows snowflakes and ‘silver-wiring’ of blood vessels, and the cavity is bridged by torn grey-white tissue

……....

• Microaneurysms and small telangiectases are Microaneurysms and small telangiectases are common, particularly in the reticular type.common, particularly in the reticular type.

COMPLICATIONSCOMPLICATIONS

RETINOSCHISIS. (A) LARGE BREAKS IN BOTH LAYERS BUT RETINOSCHISIS. (A) LARGE BREAKS IN BOTH LAYERS BUT ABSENCE OF RETINAL DETACHMENT; (B) LINEAR BREAK ABSENCE OF RETINAL DETACHMENT; (B) LINEAR BREAK IN THE OUTER LAYER ASSOCIATED WITH LOCALIZED IN THE OUTER LAYER ASSOCIATED WITH LOCALIZED SUBRETINAL FLUIDSUBRETINAL FLUID

WHITE WITH PRESSUREWHITE WITH PRESSURE

•White with pressure’ is a translucent grey appearance White with pressure’ is a translucent grey appearance of the retina, of the retina, induced by indenting the sclerainduced by indenting the sclera. .

• Each area has a fixed configuration which does not Each area has a fixed configuration which does not change when the scleral indenter is moved to an change when the scleral indenter is moved to an adjacent area. adjacent area.

• Frequently seen in normal eyes and may be Frequently seen in normal eyes and may be associated with abnormally strong attachment of the associated with abnormally strong attachment of the vitreous gel. vitreous gel.

• It is also observed along the posterior border of It is also observed along the posterior border of islands of lattice degeneration, snail-track islands of lattice degeneration, snail-track degeneration and the outer layer of acquired degeneration and the outer layer of acquired retinoschisisretinoschisis

Fig. 16.31 (A) ‘White with pressure’; (B) extensive vitreous syneresis and strong attachment of condensed vitreous gel to an area of ‘white without pressure’

WHITE WITHOUT WHITE WITHOUT PRESSUREPRESSURE

• ‘‘Without scleral indentationWithout scleral indentation same appearance but is same appearance but is present. present.

• On cursory examination a normal area of retina On cursory examination a normal area of retina surrounded by ‘white without pressure’ may be surrounded by ‘white without pressure’ may be mistaken for a flat retinal hole. mistaken for a flat retinal hole.

• Giant tears occasionally develop along the posterior Giant tears occasionally develop along the posterior border of ‘white without pressure’. border of ‘white without pressure’.

• For this reason, if ‘white without pressure’ is found in For this reason, if ‘white without pressure’ is found in the fellow eye of a patient with a spontaneous giant the fellow eye of a patient with a spontaneous giant retinal tear, prophylactic therapy should be retinal tear, prophylactic therapy should be performed.performed.

(A) Pseudoholes within an area of ‘white without pressure’; (B) total retinal detachment caused by a giant tear

DIFFUSE CHORIORETINAL DIFFUSE CHORIORETINAL ATROPHYATROPHY• Choroidal depigmentation and thinning of the Choroidal depigmentation and thinning of the

overlying retina in the equatorial area of highly overlying retina in the equatorial area of highly myopic eyes. myopic eyes.

• Retinal holes developing in the atrophic retina may Retinal holes developing in the atrophic retina may lead to RD. lead to RD.

• Because of lack of contrast between the Because of lack of contrast between the depigmented choroid and sensory retina, depigmented choroid and sensory retina, small holes small holes may be very difficult to visualize without the help of may be very difficult to visualize without the help of slit-lamp biomicroscopy.slit-lamp biomicroscopy.

Diffuse chorioretinal atrophy with holes and localized subretinal fluid

SYMPTOMS OF RETINAL SYMPTOMS OF RETINAL DETACHMENTDETACHMENT

) Weiss ring; (B) B-scan shows a Weiss ring associated with posterior vitreous detachment

SIGNS:SIGNS:

GENERALGENERAL

•MARCUS GUNN PUPILMARCUS GUNN PUPIL

•LOW IOPLOW IOP

•IRITISIRITIS

•TOBACCO DUST TOBACCO DUST

•RETINAL BREAKSRETINAL BREAKS

RETINAL SIGNSRETINAL SIGNS::

•Depend on the duration of RD & the presence Depend on the duration of RD & the presence or absence of proliferative vitreoretinopathy.or absence of proliferative vitreoretinopathy.

• FRESH RETINAL DETACHMENT FRESH RETINAL DETACHMENT

• LO NG STANDING RETINAL DETACHMENTLO NG STANDING RETINAL DETACHMENT

• PRO LIFERATIVE VITREO RETINO PATHYPRO LIFERATIVE VITREO RETINO PATHY

FRESH RETINAL FRESH RETINAL DETACHMENTDETACHMENT

• The RD has a convex configuration and a slightly The RD has a convex configuration and a slightly opaque and corrugated appearance as a result of opaque and corrugated appearance as a result of retinal oedema. retinal oedema.

• There is loss of the underlying choroidal pattern and There is loss of the underlying choroidal pattern and retinal blood vessels appear darker than in flat retina, retinal blood vessels appear darker than in flat retina, so that colour contrast between venules and arterioles so that colour contrast between venules and arterioles is less apparent.is less apparent.

• SRF extends up to the ora serrata, except in the rare SRF extends up to the ora serrata, except in the rare cases caused by a macular hole in which the SRF is cases caused by a macular hole in which the SRF is initially confined to the posterior pole.initially confined to the posterior pole.

……………………..

• Because of the thinness of the retina at the fovea, Because of the thinness of the retina at the fovea, a pseudo hole is frequently seen if the posterior a pseudo hole is frequently seen if the posterior pole is detached. This should not be mistaken for pole is detached. This should not be mistaken for a true macular hole, which may give rise to RD in a true macular hole, which may give rise to RD in highly myopic eyes or following blunt ocular highly myopic eyes or following blunt ocular trauma.trauma.

• B-scan ultrasonography shows good mobility of B-scan ultrasonography shows good mobility of the retina and vitreousthe retina and vitreous..

LONG STANDING RETINAL LONG STANDING RETINAL DETACHMENTDETACHMENT

Main features of a long-standing rhegmatogenous Main features of a long-standing rhegmatogenous RD: RD: •Retinal thinning secondary to atrophy is a characteristic Retinal thinning secondary to atrophy is a characteristic finding which must not be mistaken for retinoschisis.finding which must not be mistaken for retinoschisis.

•Secondary intraretinal cysts may develop if the RD has Secondary intraretinal cysts may develop if the RD has been present for about 1 year, these tend to disappear been present for about 1 year, these tend to disappear after retinal reattachment.after retinal reattachment.

•Sub-retinal demarcation lines (‘high water marks’) caused Sub-retinal demarcation lines (‘high water marks’) caused by proliferation of RPE cells at the junction of flat and by proliferation of RPE cells at the junction of flat and detached retina are common and take about 3 months to detached retina are common and take about 3 months to develop.develop.

………………

• They are initially pigmented but tend to lose this with They are initially pigmented but tend to lose this with time. Demarcation lines are convex with respect to time. Demarcation lines are convex with respect to the ora serrata and, although they represent sites of the ora serrata and, although they represent sites of increased adhesion, they do not invariably limit increased adhesion, they do not invariably limit spread of SRF.spread of SRF.

Long-standing retinal detachment. (A) Secondary retinal cyst; (B) B-scan shows a retinal cyst; (C) ‘high water mark’ in an eye with an inferior retinal detachment

PROLIFERATIVE PROLIFERATIVE VITREORETINOPATHYVITREORETINOPATHY

• Proliferative vitreoretinopathy (PVR) is caused by Proliferative vitreoretinopathy (PVR) is caused by epiretinal and sub-retinal membrane formation. epiretinal and sub-retinal membrane formation.

• Cell-mediated contraction of these membranes causes Cell-mediated contraction of these membranes causes tangential retinal traction and fixed retinal folds. tangential retinal traction and fixed retinal folds.

• Usually, PVR occurs following surgery for Usually, PVR occurs following surgery for rhegmatogenous RD or penetrating injury. rhegmatogenous RD or penetrating injury.

• However, it may also occur in eyes with However, it may also occur in eyes with rhegmatogenous RD that have not had previous vitreo-rhegmatogenous RD that have not had previous vitreo-retinal surgeryretinal surgery. .

……………………

• The main features are The main features are retinal folds and rigidity so retinal folds and rigidity so that retinal mobility induced by eye that retinal mobility induced by eye movements or scleral indentation is movements or scleral indentation is decreaseddecreased..

CLASSIFICATIONCLASSIFICATION• Grade A (minimal) PVR is characterized by diffuse vitreous haze and Grade A (minimal) PVR is characterized by diffuse vitreous haze and

tobacco dust. There may also be pigmented clumps on the inferior tobacco dust. There may also be pigmented clumps on the inferior surface of the retina. Although these findings occur in many eyes with surface of the retina. Although these findings occur in many eyes with RD, they are particularly severe in eyes with early PVR.RD, they are particularly severe in eyes with early PVR.

• Grade B (moderate) PVR is characterized by wrinkling of the inner Grade B (moderate) PVR is characterized by wrinkling of the inner retinal surface, tortuosity of blood vessels, retinal stiffness, decreased retinal surface, tortuosity of blood vessels, retinal stiffness, decreased mobility of vitreous gel and rolled edges of retinal breaksThe epiretinal mobility of vitreous gel and rolled edges of retinal breaksThe epiretinal membranes responsible for these findings cannot be identified membranes responsible for these findings cannot be identified clinically.clinically.

• Grade C (marked) PVR is characterized by rigid full-thickness retinal Grade C (marked) PVR is characterized by rigid full-thickness retinal folds with heavy vitreous condensation and strands. It can be either folds with heavy vitreous condensation and strands. It can be either anterior (A) or posterior (P), the approximate dividing line being the anterior (A) or posterior (P), the approximate dividing line being the equator of the globe. The severity of proliferation in each area is equator of the globe. The severity of proliferation in each area is expressed by the number of clock hours of retina involved. Although expressed by the number of clock hours of retina involved. Although proliferations need not be contiguous. proliferations need not be contiguous.

…………..

• B-scan ultrasonography in advanced disease shows B-scan ultrasonography in advanced disease shows gross reduction of retinal mobility with retinal gross reduction of retinal mobility with retinal

shorteningshortening and the and the characteristiccharacteristic triangular sign. triangular sign.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Degenerative retinoschisisDegenerative retinoschisis

• Uveal effusion syndromeUveal effusion syndrome

• Choroidal detachmentChoroidal detachment

DEGENERATIVE DEGENERATIVE RETINOSCHISISRETINOSCHISIS

• Symptoms:Symptoms:

• Photopsia and floaters are absent because there is no Photopsia and floaters are absent because there is no vitreoretinal traction. vitreoretinal traction.

• A visual field defect is seldom observed because A visual field defect is seldom observed because spread posterior to the equator is rare. spread posterior to the equator is rare.

• If present it is absolute and not relative as in RD. If present it is absolute and not relative as in RD. Occasionally symptoms occur as a result of either Occasionally symptoms occur as a result of either vitreous haemorrhage or the development of vitreous haemorrhage or the development of progressive RDprogressive RD

RetinoschisisRetinoschisis Retinal DetachmentRetinal Detachment

Usually bilateralUsually bilateral Usually unilateralUsually unilateral

AsymptomaticAsymptomatic SymptomaticSymptomatic

NonfamilialNonfamilial May be familialMay be familial

Hyperopic eyeHyperopic eye Usually MyopicUsually Myopic

Absolute field defectAbsolute field defect Relative defect in shallow RDRelative defect in shallow RD

No pigment in vtreousNo pigment in vtreous Pigments in vitreousPigments in vitreous

Smooth taut elevationSmooth taut elevation Undulating\fixedUndulating\fixed

RetinoschisisRetinoschisis Retinal DetachmentRetinal Detachment

Outer layer can`t be approximatedOuter layer can`t be approximated Can be approximated to inner layerCan be approximated to inner layer

Very slowly or non-progressiveVery slowly or non-progressive ProgressiveProgressive

Inner layer white flecksInner layer white flecks Not presentNot present

Vermiform edema absentVermiform edema absent PresentPresent

Breaks in outer or inner layersBreaks in outer or inner layers Full thickness breakFull thickness break

Indirect ophthalmoscopy perimetry -veIndirect ophthalmoscopy perimetry -ve Positive in shallow RDPositive in shallow RD

SIGNSSIGNS

• Breaks may be present in one or both layersBreaks may be present in one or both layers

• • The elevation is convex, smooth, thin and The elevation is convex, smooth, thin and relatively immobile, unlike the opaque and relatively immobile, unlike the opaque and corrugated appearance of a rhegmatogenous RD.corrugated appearance of a rhegmatogenous RD.

• • The thin inner leaf of the schisis cavity may be The thin inner leaf of the schisis cavity may be mistaken, on cursory examination, for an atrophic mistaken, on cursory examination, for an atrophic long-standing rhegmatogenous RD but long-standing rhegmatogenous RD but demarcation lines and secondary cysts in the inner demarcation lines and secondary cysts in the inner leaf are absent. leaf are absent.

UVEAL EFFUSION UVEAL EFFUSION SYNDROMESYNDROME

• Rare , Idiopathic condition Rare , Idiopathic condition

• Frequently affects middle aged hypermetropic menFrequently affects middle aged hypermetropic men

• SIGNSSIGNS

• Ciliochoroidal detachment followed by exudative RD Ciliochoroidal detachment followed by exudative RD which may be bilateralwhich may be bilateral

• Following resolution, the RPE frequently shows a Following resolution, the RPE frequently shows a characteristic residual “characteristic residual “leopard spot”mottling leopard spot”mottling caused caused by degenerative changes in the RPE associated with by degenerative changes in the RPE associated with high concentration of protein in the SRF.high concentration of protein in the SRF.

Fig. 16.42 (A) Degenerative retinoschisis showing peripheral vascular sheathing and ‘snowflakes’; (B) uveal effusion characterized by choroidal detachment and exudative retinal detachment

CHOROIDAL CHOROIDAL DETACHMENTDETACHMENT

• Symptoms:Symptoms:

• Photopsia and floaters are absent because there is Photopsia and floaters are absent because there is no vitreoretinal traction.no vitreoretinal traction.

• A visual field defect may be noticed if the choroidal A visual field defect may be noticed if the choroidal detachment is extensivedetachment is extensive

SIGNS:SIGNS:• Low intraocular pressure is common as a result of Low intraocular pressure is common as a result of

concomitant detachment of the ciliary body.concomitant detachment of the ciliary body.

• The anterior chamber may be The anterior chamber may be shallowshallow in eyes with in eyes with extensive choroidal detachments. extensive choroidal detachments.

• The elevations are brown, convex, smooth and relatively The elevations are brown, convex, smooth and relatively immobile. immobile.

• Temporal and nasal bullae tend to be most prominent. Temporal and nasal bullae tend to be most prominent.

(A) Choroidal detachment. (B) B-scan image of extensive choroidal detachment almost touching in the middle of the vitreous cavity

• The elevations do not extend to the posterior pole The elevations do not extend to the posterior pole because they are limited by the firm adhesion because they are limited by the firm adhesion between the suprachoroidal lamellae where the between the suprachoroidal lamellae where the vortex veins enter their scleral canals vortex veins enter their scleral canals

TRACTIONAL RETINAL TRACTIONAL RETINAL DETACHMENTDETACHMENT

CAUSESCAUSES

• The main causes of tractional RD are:The main causes of tractional RD are:

• (a) proliferative retinopathy such as diabetic and (a) proliferative retinopathy such as diabetic and retinopathy of prematurity, and retinopathy of prematurity, and

• (b) penetrating posterior segment trauma (b) penetrating posterior segment trauma

MAIN CAUSESMAIN CAUSES

• DiabetesDiabetes

• Intraocular HgeIntraocular Hge

• Penetrating traumaPenetrating trauma

• Sickle cell diseaseSickle cell disease

• ROPROP

Fibrovascular ProliferationFibrovascular Proliferation

TractionTraction

PATHOGENESIS OF DIABETIC PATHOGENESIS OF DIABETIC TRACTIONAL RETINAL TRACTIONAL RETINAL DETACHMENTDETACHMENT

Tractional RD is caused by progressive contraction of Tractional RD is caused by progressive contraction of fibrovascular membranes over large areas of fibrovascular membranes over large areas of vitreoretinal adhesion. vitreoretinal adhesion.

•In contrast to acute PVD in eyes with In contrast to acute PVD in eyes with rhegmatogenous RD, PVD in diabetic eyes is gradual rhegmatogenous RD, PVD in diabetic eyes is gradual and frequently incomplete.and frequently incomplete.

• It is thought to be caused by leakage of plasma It is thought to be caused by leakage of plasma constituents into the vitreous gel from a fibrovascular constituents into the vitreous gel from a fibrovascular network adherent to the posterior vitreous surfacenetwork adherent to the posterior vitreous surface

………………..

• Owing to the strong adhesions of the Owing to the strong adhesions of the cortical vitreous to areas of fibrovascular cortical vitreous to areas of fibrovascular proliferation, PVD is usually incomplete. In proliferation, PVD is usually incomplete. In the very rare event of a subsequent the very rare event of a subsequent complete PVD, the new blood vessels are complete PVD, the new blood vessels are avulsed and RD does not develop.avulsed and RD does not develop.

STATIC VITREORETINAL STATIC VITREORETINAL TRACTION OF THE TRACTION OF THE FOLLOWING THREE TYPES FOLLOWING THREE TYPES IS RECOGNIZEDIS RECOGNIZED

a)Tangential traction is caused by the contraction a)Tangential traction is caused by the contraction of epiretinal fibrovascular membranes with of epiretinal fibrovascular membranes with puckering of the retina and distortion of retinal puckering of the retina and distortion of retinal blood vessels.blood vessels.b) Antero-posterior traction is caused by the b) Antero-posterior traction is caused by the contraction of fibrovascular membranes extending contraction of fibrovascular membranes extending from the posterior retina, usually in association from the posterior retina, usually in association with the major arcades, to the vitreous base with the major arcades, to the vitreous base anteriorly.anteriorly...

• c)Bridging (trampoline) traction is the result of c)Bridging (trampoline) traction is the result of contraction of fibrovascular membranes which stretch contraction of fibrovascular membranes which stretch from one part of the posterior retina to another or from one part of the posterior retina to another or between the vascular arcades, tending to pull the two between the vascular arcades, tending to pull the two involved points togetherinvolved points together

Tractional retinal detachment associated with anteroposterior and bridging traction

DIAGNOSISDIAGNOSIS

• SymptomsSymptoms

Photopsia and floaters are usually absent because vitreoretinal Photopsia and floaters are usually absent because vitreoretinal traction develops insidiously and is not associated with acute traction develops insidiously and is not associated with acute PVD. The visual field defect usually progresses slowly and PVD. The visual field defect usually progresses slowly and may become stationary for months or even years.may become stationary for months or even years.

Tractional retinal detachment in severe proliferative diabetic retinopathy; (B) B-scan image of another patient shows posterior vitreous detachment and a shallow tractional retinal detachment

FEATURES OF TRACTIONAL FEATURES OF TRACTIONAL RD??RD??

• Concave taut retina with no mobility, no breaksConcave taut retina with no mobility, no breaks • Localized - not extending to oraLocalized - not extending to ora

• SRF is shallower clear with no shiftingSRF is shallower clear with no shifting

• IOP usually normalIOP usually normal

• Secondary breaks may develop (if breaks developSecondary breaks may develop (if breaks develop

combined RDcombined RD

• The highest elevation of the retina occurs at sites The highest elevation of the retina occurs at sites of vitreoretinal traction.of vitreoretinal traction.

………………

• B-scan ultrasonography shows posterior B-scan ultrasonography shows posterior vitreous detachment and a relatively immobile vitreous detachment and a relatively immobile retina.retina.

EXUDATIVE RETINAL EXUDATIVE RETINAL DETACHMENTDETACHMENT

PATHOGENESISPATHOGENESIS

• Exudative RD is characterized by the accumulation of Exudative RD is characterized by the accumulation of SRF in the absence of retinal breaks or traction. SRF in the absence of retinal breaks or traction. • It may occur in a variety of vascular, inflammatory and It may occur in a variety of vascular, inflammatory and

neoplastic diseases involving the NSR, RPE and choroid neoplastic diseases involving the NSR, RPE and choroid in which fluid leaks outside the vessels and accumulates in which fluid leaks outside the vessels and accumulates under the retina. under the retina. • As long as the RPE is able to compensate by pumping As long as the RPE is able to compensate by pumping

the leaking fluid into the choroidal circulation, no fluid the leaking fluid into the choroidal circulation, no fluid accumulates in the subretinal space and RD does not accumulates in the subretinal space and RD does not occur. occur. • However, when the normal RPE pump is overwhelmed, However, when the normal RPE pump is overwhelmed,

or if the RPE activity is decreased, then fluid starts to or if the RPE activity is decreased, then fluid starts to accumulate in the subretinal space.accumulate in the subretinal space.

CAUSES :CAUSES :

• Choroidal tumours such as melanomas, Choroidal tumours such as melanomas, haemangiomas and metastases; it is therefore very haemangiomas and metastases; it is therefore very important to consider that exudative RD is caused by important to consider that exudative RD is caused by an intraocular tumour until proved otherwisean intraocular tumour until proved otherwise

• Inflammation such as Harada disease and posterior Inflammation such as Harada disease and posterior scleritis.scleritis.

• Bullous central serous chorioretinopathy is a rare Bullous central serous chorioretinopathy is a rare cause.cause.

• Iatrogenic causes include retinal detachment surgery Iatrogenic causes include retinal detachment surgery and panretinal photocoagulation.and panretinal photocoagulation.

Exudative retinal detachment caused by a choroidal melanoma

…………

• Subretinal neovascularization which may leak and Subretinal neovascularization which may leak and give rise to extensive subretinal accumulation of give rise to extensive subretinal accumulation of fluid at the posterior polefluid at the posterior pole

• Hypertensive choroidopathy, as may occur in Hypertensive choroidopathy, as may occur in toxaemia of pregnancy, is a very rare cause.toxaemia of pregnancy, is a very rare cause.

• Idiopathic such as the uveal effusion syndrome Idiopathic such as the uveal effusion syndrome

DIAGNOSISDIAGNOSIS• SYMPTOMS:SYMPTOMS:

• Photopsia is absent because there is no vitreoretinal Photopsia is absent because there is no vitreoretinal traction, although floaters may be present if there is traction, although floaters may be present if there is associated vitritis . associated vitritis .

• The visual field defect may develop suddenly and The visual field defect may develop suddenly and progress rapidly.progress rapidly.

• Depending on the cause both eyes may be involved Depending on the cause both eyes may be involved simultaneously (e.g. Harada disease).simultaneously (e.g. Harada disease).

Exudative retinal detachment with shifting fluid. (A) Inferior collection of subretinal fluid with the patient sitting; (B) the subretinal fluid shifts upwards when the patient assumes the supine position

SIGNS:SIGNS:

• The RD has a convex configuration, just like a The RD has a convex configuration, just like a rhegmatogenous RDrhegmatogenous RD, but its surface is smooth and not , but its surface is smooth and not corrugated.corrugated.

• The detached retina is very mobile and exhibits the The detached retina is very mobile and exhibits the phenomenon of ‘phenomenon of ‘shifting fluid’ shifting fluid’ in which SRF responds to in which SRF responds to the force of gravity and detaches the area of retina under the force of gravity and detaches the area of retina under which it accumulates.which it accumulates.

• For example, in the upright position the SRF collects under For example, in the upright position the SRF collects under the inferior retina, but on assuming the supine position for the inferior retina, but on assuming the supine position for several minutes, the inferior retina flattens and the SRF several minutes, the inferior retina flattens and the SRF shifts posteriorly detaching the superior retina.shifts posteriorly detaching the superior retina.

‘Leopard spot’ pigmentation following resolution of exudative retinal detachment

……………………..

• The cause of the RD, such as a choroidal tumour The cause of the RD, such as a choroidal tumour may be apparent when the fundus is examined, or may be apparent when the fundus is examined, or the patient may have an associated systemic disease the patient may have an associated systemic disease responsible for the RD (responsible for the RD (e.g. Harada disease, e.g. Harada disease, toxaemia of pregnancytoxaemia of pregnancy).).

• ‘‘Leopard spots’ Leopard spots’ consisting of scattered areas of sub-consisting of scattered areas of sub-retinal clumping may be seen after the detachment retinal clumping may be seen after the detachment has flattened.has flattened.

THANK YOUTHANK YOU