19 Rationale of Retinal Detachment Management

Rationale of Retinal
Detachment Management
By
Dr. Vatsal S. Parikh
www.drushti.com
Drushti Eye & Retina Centre And Rajvi Nursing Home, Mumbai.
Introduction
• Retinal detachment occurs when fluid
accumulates between the sensory
retina and the retinal pigment
epithelium unlike retinoschisis or
choroidal detachment where retina is
elevated but not separated from the
RPE.
Bullous Superior Nasal Detachment Detachment with Posterior PVR
Lattice with Atrophic holes with Detachment Myopic posterior Staphyloma with detachment
CLASSIFICATION
1. RHEGMATOGENOUS :- fluid from vitreous
cavity enters through retinal break in
potential subretinal space.
2. TRACTIONAL :-Fibroproliferative
membranes that mechanically pull the
retina away from the underlying RPE.
3. EXUDATIVE :- RD caused by retinal or
choroidal conditions that disturb RPE or
blood retinal barrier, allowing fluid to build
up in subretinal space.
CLASSIFICATION
1. Rhegmaogenous :- detached retina is
typically corrugated or bullous and is
convex towards pupil, prescence of
rhegma or break
2. Tractional :- detached retina is
smooth and concave toward pupil,
does not extend till ora.
3. Exudative :- Fluid shift
CLASSIFICATION
• Treatment differs
• Rhegmatogenous : - Scleral Buckling
• Tractional :- Vitrectomy
• Exudative :- Medical
Rhegmatogenous Retinal
Detachment Pathogenesis
• Acute posterior vitreous detachment
with liquid vitreous and retinal tear
leads to retinal detachment.
• PVD occurs in elderly
patients,aphakics, myopes, following
cataract surgery, yag laser, trauma ,
intraocular inflammation or vitreous
haemorrhage.
PVD
• Acute Symptomatic PVD may be
followed in 5 to 7 % of patients with
acute retinal tear, and if PVD is
associated with vitreous haemorrhage,
incidence may be 70% of retinal breaks.
PREDISPOSING PERIFERAL
FUNDUS LESIONS
• LATTICE DEGENERATION: 0.3 TO 0.5 % of
lattice degeneration can lead to retinal
detachment. Incidence of lattice
degeneration is 7% in normal population,
small atrophic holes are seen in 25% of all
lattices. Atrophic holes rarely lead to
detachments.
• Retinal detachment is caused by atrophic
round holes in30 to 45% of lattice
degeneration, whereas 55 to 70% have it due
to horse shoe tears at the edge of lattice
degeneration.
LATTICE DENERATION
• 70% of retinal detachments due to
atrophic holes in lattice occur in young
people (<40 years of age) with myopia,
whereas 90 % of retinal detachment
due to horse shoe tears at the edge of
lattice occur in people above 50 only
43% of the detachments are associated
with myopia.
PREDISPOSING LESIONS
MYOPIA
• Myopia has higher risk of retinal
detachment than emmetrope( 0.7% to
6% compared to 0.06% for
emmetropes).
• 30% of all detachments have myopia.
• Detachment in myopia due to :
premature vitreous liquefaction and
detachment, more incidence of lattice
deg, possibly thin periferal retina
SENILE RETINISCHISIS
• 2 types of senile retinoschisis :
reticular and typical, reticular type :
23% had outer retinal layer holes on
autopsy, Byer’s study : 16 % of
retinoschisis had outer layer holes, and
58% of these eyes had localized retinal
detachment, rarely it extends to
rhegmatogenous retinal detachment
and posterior extension of schisis in
the macula also does not occur
CATARACT EXTRACTION
• 40% of all detachments occur in aphakic or
pseudophakic eyes, Incidence in ICCE eyes
is 2 to 5 %, ECCE : 0 to 3.6%, PHAKO 0.8 to
1.2%, incidence rises three fold after Yag
capsulotomy , and is 20% after vitreous loss,
Cataract in myopic eyes ,incidence is 6
%,rate goes with high myopia and one study
reported 40 % in patients with > -10.0D.
• 50% of retinal detachments occur in 1st year
after cataract surgery ,and thereafter it
remains higher than phakic eyes.
CATARACT EXTRACTION
• Congenital cataract surgery, incidence
is more, long and bilateral.
• Detachments : bullous, spread faster
and involves macula, thin ,multiple,flap
tears at the vitreous base,
PREDISPOSING LESIONS:
OTHER OCULAR SURGERY
• Penetrating Keratoplasty 2 to 4% especially
when anterior vitrectomy is required
• Pars plana vitrectomy 3 to 6% due to traction
on vitreous base , or uncut vitreous
incarcerated in sclerotomies, repeated entry
,exit of instruments, giant tear when
vitrectomy is incomplete especially
beginners, measures to reduce are free flow
of saline at the end from sclerotomy,
OTHER OCULAR SURGERY
• SQUINT SURGERY: Inadvertent needle
perforation of the globe, leading retinal
holes, vitreous liquefaction and retinal
detachments
• INTRAOCULAR PERFORATION by
anesthetic block
• Placement of superior rectus bridle
suture
TRAUMA
• Blunt trauma constitute about 1/3 of all
retinal detachments
• 75% of all traumatic detachments are
due to retinal dialysis, typically due to
blunt trauma ,more common in males,
• PENETRATING trauma leads to
fibroproliferative membranes leading to
tractional and combined detachment
COLOBOMA OF CHOROID &
RETINA
• Retinal detachment occurs in patients
with coloboma choroid and disc and is
treatable. Breaks occur within
coloboma or outside coloboma in
general retina.
INTRAOCULAR INFLAMMATION
INFECTION
• Acute Retinal Necrosis :- 50 to 75%
develop retinal detachment
• CMV Retinitis :15 to 35% patients
develop Retinal detachment
• Toxoplasma, toxocara, pars planitis
can be complicated by retinal
detachment
SYNDROMES
• Wagner- Stickler Syndrome:- Optically empty
vitreous cavity with peripheral lattice
degeneration and retinal detachment
• Goldmann Favre Syndrome:- cataract, with
optically clear vitreous cavity, peripheral
pigmentary retinal degeneration, lattice deg,
macular and peripheral retinoschisis and
retinal detachment, autosomal recessive
condition
• X linked Juvenile Retinoschisis :- rarely
associated with retinal detachment.
MARFAN’S SYNDROME
• Axial myopia, ectopia lentis, and retinal
detachment
• One study showed that Marfan’s with
normal axial length did not have higher
incidence of retinal detachment
• Homocystinuria:- Ectopia lentis and
similar incidence of retinal detachment
like Marfan’s.
TRACTIONAL RETINAL
DETACHMENT
• Proliferative Diabetic Retinopathy
• Sickle Cell Disease
• Eales’ disease
• FEVR
• ROP
EXUDATIVE RETINAL
DETACHMENT
• VKH Syndrome
• Choroidal tumors
• Inflammatory Posterior Scleritis
• Idiopathic CSR
• Idiopathic Uveal Effusion Syndrome
• Nanophthalmos
• Malignant Hypertension, Toxemia of pregnancy
• Disseminated Intravascular Coagulopathy
• Collagen Vascular Disease
• Retinal Telengiectasia
MISCELLANEOUS CONDITIONS
• Optic Nerve Pit
• Morning Glory syndrome
PRINCIPLES OF TREATMENT
• Permanent closure of the hole/holes
• Relieving the traction on holes
• Techniques
• SCLERAL BUCKLING
• PNEUMORETINOPEXY
• VITRECTOMY with gas temponade
• VITRECTOMY with Silicone oil temponade
• Combination
HISTORICAL BACKGROUND
• For almost 50 years, scleral buckling was the
mainstay of treatment, though it was not the
first treatment ,but the most successful
treatment.
• Retinal hole was identified immediately after
advent of ophthalmoscope, but it was not
attributed as a causative factor for retinal
break until Leber suggested it to be a cause
in retinal detachment with vitreous bands
• Gonin first successfully treated retinal
detachment by ignipuncture, first described
in 1921 , wherein sclera was incised on the
retinal break and Paqulin cautery instrument
was introduced over the break 3 to 4 mm
deep for 2 to3 sec. The procedure was not
easily accepted, but eventually gained
acceptance as it showed modest success
and it proved that closing the retinal break is
important in treatment
• Ignipuncture was followed by chemical
cautery and then diathermy in the scleral
bed. Then came scleral shortening procedure
as myopia was thought to be responsible for
detachment , shortening of scleral length
seemed logical answer, and it produced the
buckling effect on the break, so came in
buckling element initially polyviol and then
silicone buckles
• Diathermy and scleral buckle (implant)
remained for long time, then came cryopexy
in 1970 after cryo was used for intracapsular
cataract operation.
• So , cryopexy with exoplant became
standard treatment.
• Intraocular air injection was undertaken as
early as 1911, but Norton popularized it in
1960.
• Machemer started vitrectomy in 1970 and has
come a long way since then
PHYSIOLOGIC BASIS OF
ATTACHMENT OF NORMAL
RETINA
• Retinal Attachment remains due to
hydrostatic pressure , acid
mucopolysacchrides between RPE and
photoreceptors, presence of
interdigitating RPE projections
containing actin filaments,RPE pump
CLINICAL PRESENTATION OF
RRD
• Symptoms:- Flashes of light, floaters, field
loss, loss of acuity, progressive visual field
defects
• Signs:- Visual acuity, IOP , aqueous flare and
cells; identification of all retinal breaks,
extent of retinal detachment, various features
like fixed folds, subretinal or epiretinal
membrane, macular status, choroidal
detachment, preop. detailed examination is a
must .
LINCOFF’S RULES
• For the detachments involving
superonasal or superotemporal
quadrants, the obscure retinal break is
found at or near the most superior
border of the detachment.
• If detachment involves both superior
quadrant, break will be at midline,
•
LINCOFF’S RULES
• For inferior retinal detachments, breaks
would be inferior, usually on the side
where detachment is higher
• For inferior bullous detachment, break
is usually above horizontal meridian.
GOALS OF SURGERY
• Preservation or restoration of central
vision is the primary goal. Indeed
surgery would not be indicated if there
is peripheral detachment and macula
would not be thratened
• Closure of retinal breaks is the goal of
surgery and relief of inward traction on
the retina is another goal of surgery
PRINCIPLES OF SCLERAL
BUCKLING
• Closes the break by bringing the RPE
in apposition to sensory retina
• By indentation it reduces inward
traction on the retina though these
forces are still present.
• Cryopexy or diathermy or
photocoagulation closes permanent
chorioretinal scarring around the break
and closes it.
PRINCIPLES OF SCLERAL
BUCKLING
• Drainage of subretinal fluid :- reduces the
volume of eye so buckling is possible, brings
retina in contact with RPE ,primarily
reattaches retina.
• STEPS IN SB:- localization of retinal breaks,
cryopexy, drainage of subretinal fluid,
applying scleral sutures and buckle,
encirclage , injection of intraocular air or gas
•
Ref no. 24579
PRE OP 30-8-05 Post Scleral Buckling PRE OP 30-8-05
POST OP 29-11-05
Ref No:- 25319
POST OP 05-01-06 Macular Pucker follwing
PRE OP 05-01-06 Detachment with Posterior PVR vitrectomy with Silicon oil
09-01-08 Post Silicon oil Removal
Ref No:- 27024
PRE OP 13-09-06 POST OP 27-09-06
Ref No:- 25448
PRE OP 23-01-06 POST OP 27-04-06
PRE OP 01-12-04 Ref No:- 22878 PRE OP 01-12-04
PRE OP 01-12-04 POST OP 27-06-05
POST OP 06-04-06
Ref No:- 24352
PRE OP 19-7-05 POST OP 01-08-05
Ref No:- 24947
PRE OP 14-11-05 POST OP 06-01-06
Ref No:- 24666
PRE OP 19-9-05 POST OP 29-09-06
Ref No:- 23081
PRE OP 28-04-05 PRE OP 28-04-05 PRE OP 28-04-05
POST OP 10-06-06 POST OP 20-05-05
Ref No:- 23782
PRE OP 11-04-05 Detachment withPVR
POST OP 04-07-05 Retina Attached following 360° retinectomy & vitrectomy
Ref No:-2100.2006
PRE OP 4-11-06 POST OP 19-12-06
PRE-OP15-5-06 Ref No:- 1566 PRE-OP15-5-06
POST OP 23-08-06
Ref No:- 22692
PRE OP 29-10-04 POST OP 23-12-04
PRE-OP 30-11-04 Ref No:- 22859 PRE-OP 30-11-04
POST OP
04-03-05
Ref No:- 22764
PRE OP 15-11-04 POST OP 14-11-05
Ref No:- 22692
PRE OP POST OP 27-09-06
Ref No:- 23998
PRE OP 14-5-05
Ref No:- 23998
POST OP 20-08-05
Ref No:- 23688
PRE OP 25-03-05 Retinal Detachment with Choroidal detachment
POST OP 09-01-06 Attached Retina
POST OP
12-07-06
Ref No:- 26577
PRE OP 28-06-06
Giant Tear with Detachment
POST OP 15-07-06
Silicon Oil & Buckle
Ref No:- 2022
PRE LASER 11-08-06 POST LASER 11-08-06
ALTERNATIVE PROCEDURE
• PNEUMORETINOPEXY : Use of intravitreal
gas to treat retinal detachment was
described in 1938, however in 1960 use of
intravitreal air was rediscovered,
subsequently 2 decades later , it was
suggested that intravitreal gas alone may
close the break and subsequent laser or
cryotherapy will reattach retina avoiding
complications of scleral buckling
PNEUMORETINOPEXY
• When retinal breaks are situated in 1
clock hours and above midline, without
vitreous traction on the breaks,
pneumoretinopexy can be attempted.
Primary cryopexy or subsequent laser
photocoagulation to the breaks can be
done. Success rate varies between 63
to 83% whereas for the same group
undergoing SB was 96% So, it has not
picked up as a primary procedure.
INTRAVITREAL GAS
Gas half life of gas
intraocular
expansion of gas
SF6 5 days 2.5 times
C2F6 10days 3.3 times
C3F6 35days 4 times
Nonexpansile Concentration 18% for SF6
Nonexpansile Concentration 12%for C3F8
OTHER ALTERNATIVE
PROCEDURES
• Lincoff Inflatable Balloon
• Delimiting laser or cryotherapy for
periferal retinal detachement
SPECIAL CIRCUMSTANCES
• UNSEEN RETINAL BREAKS:- Rule out
other causes of retinal detachment,
media opacity or small peripheral
breaks , end to end buckle and cryo
posterior to ora all around, drainage is
the procedure, vitrectomy may help to
find out breaks
MACULAR BREAKS
• Macular hole with retinal detachment
with peripheral break, treat like regular
detachment
• Macular hole alone with retinal
detachment: myopic, aphakic or blunt
trauma . Pneumoretinopexy or
vitrectomy with gas , silicone oil or
endolaser to macular hole may be
required.
GIANT RETINAL TEAR
• Surgical approach to GTR varies:
• GTR with no retinal detachment, laser
• GTR with shallow rd,
Pneumoretinopexy or SB
• GTR with rolled edge, rd : Vit, pfcl, gas,
or oil or buckle
• Success rate up to 95%
PVR
• 10% of all detachments fail due to PVR,
anterior or posterior PVR, Precipitating
factors: multiple breaks, cryopexy, Choroidal
detachment, Vitreous hemorrhage, postop.
hypotony, preop inflammation, previous
vitrectomy operation
• TREATMENT:- revitrectomy, membrane
removal, retinectomy, silicone oil injection
COMPLICATIONS
• Intraoperative:- scleral perforation, retinal
incarceration, retinal break, vitreous ,
subretinal hemorrhage, Choroidal
detachment, central retinal artery occlusion,
• Postoperative:- squint, buckle infection,
angle closure glaucoma, secondary
glaucoma, macular pucker, redetachment,
Endophthalmitis, CME, myopic shift
PROGNOSIS
• Anatomic success is usually 90%
• Almost 100% success in patients with
dialysis or small atrophic holes with
lattice degeneration in phakic eyes.
• Horse shoe flap tears fare slightly
worse with 90 to 95% success rate.
• AC IOL have 60 to 70% ,compared to
PC IOL > 80% reattachement rate
PROGNOSIS
• PVR brings down success rate to 50 to
75% with SB ,although it continues to
improve
• Giant retinal tear without PVR ,success
rate is 90 to 95 %. With PVR ,it reduces.
• Preoperative choroidal detachment ,
reduces success to 50 % with primary
buckling procedure.
PROGNOSIS
• Functional Success:- depends on the
preoperative visual acuity and age of
the patient.
• 85 to 90% of patients with preop. Vision
of 20/30 or better will retain 20/30 or
better vision postoperatively.
• Macular detachment is a major
determinant of post op vision.
PROGNOSIS
• Macular detachment of even 1 day
results in reduced visual acuity.
• If retina is reattached in 2 days of
macular detachment, chances of
recovery of good visual acuity are high
CONCLUSIONS
• From incurable disease a century
earlier, retinal detachment has been
largely a treatable condition, thanks to
Gonin’s ignipuncture , diathermy to
scleral resection techniques which led
to scleral buckling surgeries in 1950 . It
raised success from 50 % to 80%.
Today, various microsurgical advances
and vitreous surgery techniques has
added results to > 90 %
Ref no. 20.2009
03-01-2009 infected Buckle with Attached Retina
02-02-2009 Recurrent detachment with PVR following Buckle Removal
Ref no. 20.2009
Post op Attached Retina
17-2-09
31-3-09 09-07-09
Reg no. 1856.2009
12-11-09 12-11-09
12-11-09 12-11-09
Reg no. 527.2006
Reg no. 403.2009
23-2-09
14-11-09
Reg no. 1353.2008
18-06-08 Detachment with Choroidal Detachment
Reg no. 1353.2008
23-06-08
Post op Attached Retina
Recurrent Detachment 14-07-2008 Reattached with one more surgery
Reg no. 1353.2008
08-09-08 Attached Retina
12-02-2009 Shallow Recurrent Retinal detachment
Ref no: 64.2010 9-1-2010
Vitreous Hamorrhage Horse Shoe Tear in lower quadrant
Ref No: 279.2010
06-02-2010 Pre op PVR D3 06-03-2010 Almost Attached retina post Vit

19 Rationale of Retinal Detachment Management

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Rationale of Retinal

09-01-08 Post Silicon oil Removal

PRE OP 13-09-06 POST OP 27-09-06

PRE OP 23-01-06 POST OP 27-04-06

PRE OP 01-12-04 POST OP 27-06-05

PRE OP 19-7-05 POST OP 01-08-05

PRE OP 14-11-05 POST OP 06-01-06

PRE OP 19-9-05 POST OP 29-09-06

POST OP 10-06-06 POST OP 20-05-05

POST OP 04-07-05 Retina Attached following 360° retinectomy & vitrectomy

PRE OP 4-11-06 POST OP 19-12-06

PRE OP 29-10-04 POST OP 23-12-04

PRE OP 15-11-04 POST OP 14-11-05

PRE OP POST OP 27-09-06

POST OP 09-01-06 Attached Retina

PRE LASER 11-08-06 POST LASER 11-08-06

02-02-2009 Recurrent detachment with PVR following Buckle Removal

Recurrent Detachment 14-07-2008 Reattached with one more surgery

12-02-2009 Shallow Recurrent Retinal detachment

06-02-2010 Pre op PVR D3 06-03-2010 Almost Attached retina post Vit

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