2. Retinal Detachment Abdulkrim Alkharashi, MD

3. RD History: 1. Theory of distension. 2. Theory of hypotony. 3. Theory of exudation. 4. Theory of retinal breaks.  Causes of primary RD:-

4. RD History: cont.  Beer – 1817 first to detect RD clinically.  Von Helmholtz – 1851 invented the ophthalmoscope.  Coccius – 1853 first to find retinal breaks (r.b.).  De Wecker – 1870 first suggested that r.b. were the causes of  RD.

5. RD History: cont.  Leber – 1882 found r.b. in 70% of RD, vit. deg. and collapse  traction  r.b.  RD. Changed to pre-retinal memb.  r.b. (in PVR).  Jules Gonin – 1919 Father of RD surgery. Performed the first RD operation to close r.b. – Ignipuncture of Thermocautery.

8. RD:  Rhegmatogenous – Greek thegma = rent  Tractional  Exudative

9. RD Epidemiology: o Incidence 1: 10,000 / year. o In aphakics: 1– 3%. o In the second eye (-): 5%. o In the second eye (+): 10%. o 99% of untreated symptomatic RD  blindness. o 5 – 15% of population with retinal break(s)  7% of these develop new break(s).

10. Rhegma. RD:  Some degree of vitreous liquifaction.  Retinal break: - tear - hole - hole - dialysis - dialysis  Eye movements (Edie’s currents)  PVD, V-R traction  Pre-requisite:-

11. PVD _______________________________  Due to loss of hyaluronic acid  collapse of vit. collagen with liquefaction.  Rare before 30 yrs.  Increases with age (63% in > 70 yrs.)  Most PVDs are asymptomatic. 2 nd eye in 1 yr.  15% of acute PVD have a retinal tear (pathologic).  Increases significantly after cataract extraction: pathologic vs. physiologic PVD.

12. RD  13-19% of PVD have vit. Hem.  PVD + hem.  70% with tears.  PVD + no hem.  2-4% with tears.  PVD

19. RD F/U:  Examine periphery.  + vit. Hem. - rest, patching  examine. - rest, patching  examine.  U/S.  Acute PVD:-

20. RD Risk Factors:  Present in 8% of the population. In SA – 9.1%  As a cause of RD in 20-30%.  In RDs with L.D.:- 30-45%  Atrophic holes. 30-45%  Atrophic holes. 55-70%  A tear at edge of L.D. 55-70%  A tear at edge of L.D. 1. Lattice and other peripheral deg.:

29. RD Risk Factors: cont.  > 6 D.  60 yr. myope risk of RD is 2.4% whereas normal risk 0.06% 2. High myopia:

30. RD Risk Factors: cont.  Increases PVD: Does it convert physiological PVD to a pathological one?  1.3% RD in aphakes.  ICCE > ECCE.  Risk of RD increased with:- - P.C. otomy: 1.3%. - P.C. otomy: 1.3%. - Vit. loss. - Vit. loss.  50% of RDs in 1 st year. 3. Cataract surgery:

31. RD Risk Factors: cont.  In general population – 1% COAG.  In RD patients – 4-7% COAG.  > in pigment dispersion synd. ? myopia. ? myopia.  Miotics & RD. 4. Glaucoma:

32. RD Risk Factors: cont. 5. RD in fellow eye or F/H of RD. 6. Trauma.

34. RD Symptoms:  PVD – flaches & floaters.  Painless loss of peripheral VF.  Painless loss of central vision.

35. RD Examination:  VA.  IOP.  SLE – blood, pigment (Shafer’s sign) in the vitreous.  Careful binocular indirect ophthalmoscopy with scleral indentation.  C.L. exam.

40. RD Types of Breaks:  Fresh (acute) tear either:- Symptomatic tear. Symptomatic tear. Tear with retinal hem. at the edge. Tear with retinal hem. at the edge. A new tear in that location. A new tear in that location.  Flap (horseshoe) tear.  An operculated hole.  Atrophic holes.

43. RD DDX:  Neoplasms.  Inflammations – VKH, ICSC, post. Scleritis.  Cong. Anomalies – optic pit, morning glory, choroidal coloboma, nanophthalmos, uveal effusion syndrome  Exudative RD:-

44. RD DDX: cont.  Traction RD.  Retinoschisis – senile, juvenile.  Choroidal detachment.

47. RD Treatment:  Olny selected breaks require Rx.  A symptomatic tear – caused by PVD or vit. Traction in the eye of a pt. C/O photopsias +/- floaters.  Prophylactic Rx:-

48. Indications for Prophylactic Treatment of Retinal Tears and Holes in Symptomatic Patients: Flap tears Frequently (always) Operculated holes Sometimes Atrophic holes No Macular holes Rarely Lesion Treatment _____________________________________

49. RD Treatment:  Cryotherapy.  Photocoagulation.  Surround it ant. & post.  Macular pucker.  Tears at margins of Rx scar.  Prophylactic Rx to breaks:-

50. RD Treatment: cont.  Emergency.  Localization of break(s).  Creation of C-R adhestion around the break(s).  Closure of break(s).  Relief of V-R traction.  Principles of Surgery:-

51. RD Treatment: cont.  Scleral buckle.  Orbital balloon.  Pneumatic retinopexy.  Primary vitrectomy + GFX, Long-term tamponade.  LA/GA Surgical techniques:- Surgical techniques:-

58. RD prognosis & VA:  90-95% - Anatomic success.  Overall 40-50%  20/50 or > 25%  20/60 – 20/100 25%  20/60 – 20/100 25%  20/200 or < 25%  20/200 or <

59. RD prognosis & VA: cont.  If macula off.  If macula off 1-8 wk – 50%  20/70 pr >.  If macula on 90%  Preop. VA  pucker, CME, recurrent RD.

62. RD Prognosis:  Detachments due to dialysis or to small or round holes.  Detachments with demarcation lines.  Detachments with minimal subretinal fluid. 1. Excellent prognosis (nearly 100%):

63. RD Prognosis: cont.  Aphakic detachments.  Total detachments.  Detachments with associated detachment of the nonpigmented epithelium of the pars plana.  Detachments caused by flap tears. 2. Slightly poorer prognosis (95%):

64. RD Prognosis: cont.  Detachments with associated choroidal detachment  Detachments with breaks larger than 180 .  Detachments with PVR.  Detachments in patients with stickler’s syndrome.  Detachments caused by acute retinal necrosis. 3. Poor prognosis (50 to 70%):