surgical retina for lecture dimc

8/3/2019 Surgical Retina for Lecture Dimc

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SURGICAL RETINA

D r. J a m s h e d A h m e dM B B S., M C P S., F C P S ( O P H T H )

ASSISTANT PROFESSOR

Department of Ophthalmology

Dow International Medical Collegehttp://www.youtube.com/watch?v=VHzJIUfO3ck


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Retinal Detachment(R.D)

R.D. is a separation of the sensory retina from theretinal pigment epithelium(R.P.E) by sub retinalfluid(S.R.F)

Two main types

1)Rhegmatogenous or Primary R.D

2)Nonrhegmatous or SecondaryR.D


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Types

Two main types

1. Rhegmatogenous or Primary R.D

2. Nonrhegmatous or Secondary R.D Tractional R.D.

Exudative(Serous)R.D


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Rhegmatogenous R.D

In Greek word,Rhegma meaning a rent or fissure

http://www.youtube.com/watch?v=9Lxu3cUguM0&feature=related

is a condition in which fluid from vitreous cavitypasses through a full thickness retinal defect into the sub retinal space to cause separation ofthe neural retina from the underlyingR.P.E

It affects about 1:10,000 of the population eachyear


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Pathogenesis

Acute posterior Predisposing

vitreous retinal degenerations

detachment AphakiaTrauma retinal break

degenerated vitreous passes via this breakbetween sensory retina and RPE collected as SRF

Retinal detachment


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Clinical Features

History age: Common age group is 40-70 years

No age is bar

Sex: 60 % case comprises by males

Hereditary: although a no.of pedigree shows

familial detachments, most cases aresporadic


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Symptoms :

Classic premonitory symptoms present in 60% ofpatients with Spontaneous rheg.R.D are

1) Flashes of lights(Photopsia)

2) floaters- may be Solitary ring shaped opacity(Weiss Ring)

Cobwebs Sudden shower of minute red colored or dark spots


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Contd

3) localized relative loss in field of vision-early

less aware of superior than inferior field defect

highly specific for localization ofR.D

cause -spread of SRF behind the equator

perceived by the patient as black curtain

4) sudden painless loss of vision in case of large or

centralR

.D


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Contd

Blurring of distant vision

40-45% R.D occurs in myopic patients

History of trauma:(Surgical/Accidental)

Surgical details

a)Aphakia

b) Pseudophakia with vitreous loss

Ocular Trauma


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Contd

History of previous ocular disease similar problem in other eye

glaucoma

more in pigment dispersion syndromeMiotic drugs

uveitis, vitreous hemorrhage, diabetic

retinopathy Cytomegalovirus retinitis


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Contd

History of systemic diseases eg.

Diabetes,tumors,angiomatosis of C.N.S,sickle

cell disease,leukemia and EclampsiaMarfan's syndrome,

Family history


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Signs

1) VisualAcuity less ifR.D extend up to fovea

2) Confrontation test;Visual field defect

3) External examination

4)Anterior segment examination Cornea is usually clear but descemet's folds

if hypotony

Mild flare and cells inAnterior chamber


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Signs

5) Pupillary reaction

Relative afferent pupillary

defect in extensiveR

.D6) Posterior segment

Tobacco dust in retrolental

vitreous, haemorrhages


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Signs

7) Fundus Examinationa Loss of normal fundal glowb)Retinal breaks: Present in about 70% of

the eyes with tobaccodust.

appears as reddiscontinuities in theretinal surface

Upper temporal quadrantis the commonest site forretinal break


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Signs

Breaks may be in the form of holes,tears or

dialysis

Shape may be variable

Can locate primary break by the shape of theR.D


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Shape of R.D in relation to primary break


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Signs

Retinal signs depends on

duration ofR.D

A) Fresh R.D

Detached retina has a

convex configuration,

slightly opaque and

corrugated appearance,undulates freely with eye

movements.


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Signs

loss of underlying choroidal pattern

retinal blood vessels appears darker so color

contrast vein and artery is less SRF extends up to ora serrata except caused

by macular hole

pseudo hole in posterior pole detachment


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Signs

B) Long standing retinal detachment

retinal thinning secondary to atrophy

secondary intraretinal cysts if more than 1 year sub retinal demarcation lines

present after 3 months.


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Signs

Macula

pigment of the macula may become more

evident as a yellow colour due to intraretinaloedema or sub retinal fluid

macular involvement is high in superior or

temporal break or if in equatorial region


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Signs

Apparent holes in macula are relatively common

Macular breaks leading toR.D are common instaphyloma of high myopia or following trauma

Associated retinal degenerations,

Intraocular pressure-low

Systemic evaluation


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Signs


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Differential diagnosis

Includes R.D from other causes and retinoschisis

1) Tractional R.D

Symptoms Photophobia and floaters usually absent

Visual field defect progressive


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Contd

Signs concave configuration ,

breaks absent

SRF - shallower, seldomextends to ora serrata

highest elevation at sites

of vitreo-retinal traction

severely reduced retinalmobility , shifting fluid

absent


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Contd

2) ExudativeRD : Symptoms

photopsia is absent

VF defects develop suddenly

and progress rapidly

Signs-

convex configuration

breaks are absent smooth surface, SRF deep, shifting fluid phenomenon present

Leopard spots in resolved RD


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Contd

Degenerative retinoschisis : Symptoms

photopsia and floaters absent

VF defects absolute scotoma

Signs

Elevation is convex, thin, smooth , relativelyimmobile

Demarcation lines and secondary cyst absent


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Management

Diagnosis/Treatment

Diagnosis

1. Clinical Feature

2. Investigations


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USG- B scan

RoutineTC, DC, Hb, ESR, Blood sugar,

Urine R/M

ERG (Brightflash)

Investigations


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Prophylaxis: Retinal Breaks

INDICATIONS

A. Characteristics of break

B. Predisposing Peripheral retinal degenerations


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High risk Breaks

1)Tears more dangerous than holes

2) Large break

3)Symptomatic tears4) Superior breaks

5) Equatorial breaks

6) Sub clinical R.D


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Other Considerations

Break with or without symptoms:

Aphakia

Myopia

One eyed

Family History

Systemic Diseases e.g. Marfan Syndrome,

Stickler Syndrome, Ehlers DanlosSyndrome


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Prophylaxis

Predisposing Peripheral retinal

degenerations (Lattice/Snail track)

R.D in the fellow eye Aphaka or pseudophakia

High Myopia

Strong family history of R.D

Systemic diseases


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Prophylaxis Contd.

White without pressure with fellow eye -

giant retinal tears

Fellow eye aphakic retinal detachment (

360 degree cryotherapy 4 weeks prior to

cataract surgery)


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Prophylaxis

Treatment Options

C seals the retina with the RPE and choroid

around the break,C 2-3 rows of nearly confluent laser burns

around e.g. break in lattice.

C

firm chorioretinal scar forms in 7-10 days.

Laser photocoagulation

Transcleral cryotherapy


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Cryotherapy/Laser

Therapy

Location of lesion

Clarity of the media

Pupil size


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Retinal Detachment Surgery

Historical Review:1920:T/t of R.D began in rational lines,

Jules Gonin-first man to appreciate the pathologicalsignificance and therapeutic effect of closing retinal

breaksT/t of R.D by sealing of the retinal breaks andevacuating the inter retinal fluid by puncture with agalvanocautery.

1930 : Rosengren tried intravitreal air injection in

upper half detachments.

1933: Deutschmann tried cryopexy for R.D

.


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History contd..

1949 Custodis : concept of ScleralBuckling

1957 Schepens : refined scleral buckling techniqueand devised encircling operation in 1960.

1949: Goldman devised three mirror funduscontact lens

1950 Schepens : Indirect ophthalmoscope1962 Cibis introduced silicon oil to tamponade

Lincoff and co-workers: Silicon sponge explant andcryotherapy


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History contd

1964 Lincoff revived Cryotherapy

1940 AmslerSRF distribution to find

probable hole, later in 1971 Lincoffprovided detail description.

1985 Gilbert and McLeod successfully tried

D-ACE procedure for upper half bullous R.D


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Preoperative considerations &

patient counseling

IfRRD threatening to detach the macula;surgery urgently necessary

Ifmacula is involved prompt surgery within 2-3 days

recovers reasonable central vision

macula off> 2 months postoperative Va usually poor

Ifmacula is not involved, most eyes maintain preop VA

Simple pathology and principles ofsurgery has to explained

Anatomic success does not equal visual success,

occassionally second surgery may be needed


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Anaesthesia

C Local or general anesthesia

Advantages of LA Shorter operating time

Quicker postoperative recovery

Decreased morbidity and mortality

C Peribulbar / retrobulbar


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Purpose of R.D surgery

To close the retinal hole

To relieve any vitreoretinal traction.


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Treatment options: RRD

C Permanent scleral buckle, with/withoutdrainage- radial, segmental or encirclage

C Temporary scleral buckle- Lincoff balloon, absorbable buckles

C Pneumatic retinopexyC Primary vitrectomy

C Combinations of aboveC Observation rarely


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Scleral buckling

C Purpose: to close retinal breaks

: to reduce VR traction

C Explants: material sutureddirectly onto the sclera

Implants: intrascleral placementof buckle

C Explant configuration1. Radial

2. Segmental circum

3. Encirclage

C Explant size1. Buckle width/length

2. Buckle height


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Scleral buckling

Indications for radial buckle

- Large U-tears

- relatively posterior

breaks

Indications for segmental buckle

- single or closely

spaced breaks

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