2. Little QUIZ (10min)
1. how to differentiate RRD/TRD/ERD
from fundus findings?
2. risk of PVR
3. contraindication for pneumatic
retinopexy
4. compare PPV vs SBP for RRD
5. compare laser vs cryo retinopexy
5. The Vitreous
Water 98-99% water
1-2%
collagen type II fibres*
salts, sugars
glycosaminoglycan, hyaluronic acid
very few cells
mostly phagocytes
hyalocytes of Balazs (surface/ hyaluronate)
refractive index of 1.336
6. The Vitreous *
Condense and attach more at
Optic disc rim
Along blood vessels
Macula
Peripheral retinal abnormalities
○ Chorioretinal scar
○ Lattice degeneration and others
Ora serrata (Vitreous base: 2mmA, 4mmP)
10. Posterior vitreous detachment
Prevalence increase with
AXL
age
○ < 10% at < 50 yrs
○ 30% at 50-70 yrs
○ >60% at > 70 yrs
Other associate
Cataract Sx, within 2 yrs after surgery
○ ICCE 84% = ECCE c PC tear76%
○ ECCE c intact PC40%
○ PE 30%
inflammation / uveitis
trauma
syndromes
11. Posterior vitreous detachment
Symptoms
most asymptomatic
photopsia
○ physical stimulate of vitreoretinal traction
floaters
○ Weiss ring and V.condensation in the posterior
hyaloid surface
○ vitreous opacity eg. blood , glia cell
VH rupture of retinal vessel
14. Rhegmatogenous retinal
detachment
-
A hole, tear, or break
in the neuronal layer
allowing fluid from the
vitreous cavity to
seep in between and
separate sensory and
RPE layers
15. RB and PVD*
acute symptomatic PVD
15% retinal tear
PVD with VH
50-70 % retinal tear
PVD without VH
10-12 % retinal tear
19. Mortality/Morbidity*
1: 10,000 population : yr
15% of people with RD in one eye
develop RD in the other eye. (lifetime)
Risk of bilateral RD is increased
(25-30%) in patients who have had bilat
eral cataract extraction.
21. History
Detachments anterior to the equator are
very unlikely to affect the VF
Detachment posterior to the equator can
be isolated with visual field testing, but
many patients aware of a defect only when
it involved the posterior pole and macula.
Photopsia and floaters not helpful in
locating the position of the retinal tear or
detachment
visual field defect very specific for
locating the detachment.
22. History
FHx of RRD
History of trauma
previous surgery
cataract extraction/ esp c cpx (-L-’)
intraocular foreign body removal
retinal procedures
23. Physical examination
VA/ VF
IOP : hypotony of >4-5 mm Hg less than
the fellow eye is common
Vitreous
tobacco dust (Shafer’s sign), pathognomonic for
a retinal tear in 70% of cases with no previous
eye disease or surgery.
26. Retinal detachment
Which one is this case?
1. Rhegmatogenous retinal detachment (RRD)
2. Exudative retinal detachment (ERD)
3. Traction retinal detachments (TRD)
27. Is this RRD/ TRD or ERD *
symptoms
RRD
TRD
ERD
floaters
++
+/-
+/-
flashing
++
-
-
Progressio
n of VA
loss
acute
chronic
Subacute/
chronic
Fluctuation
of vision
-
+/-
+
31. CLINICAL FEATURES:early
Early
retina lost transparency and assumes a
gray, translucent appearance
fine, irregular corrugations usually present
○ result of intraretinal edema
33. CLINICAL FEATURES : early
fine details of the choroidal vasculature
obscured by overlying detached retina
within days of RRD
outer retinal degeneration starts to occur
photoreceptor damage related to height and
duration
circulation of inner retina not affected
34. CLINICAL FEATURES : early
If retina reattached within a week
most of cellular changes reversible
RPE cells underlying RRD released
into SRF and may pass through RB into
vitreous cavity
tobacco dust 70% of case
35. CLINICAL FEATURES :early
Lincoff and Geiser reported 4 guidelines
for locating RB causing RRD *
determined by
○ location of causative break
○ anatomic barriers (optic n.,ora serrata,
existing chorioretinal adhesions)
○ effect gravity on SRF in upright
position
Note : only for fresh RD with 1 RB
37. Lincoff rule
total or superior RD
that cross midline
primary hole usually
within 1 clock hr. of
o'clock meridian
12-
If detachment extends
more inferiorly on
either nasal or
temporal side
RB usually on same
side of 12-o'clock
meridian
38. Lincoff rule
superotemporal RD
RB lies near superior edge of detached retina
superior nasal or temporal RD
RB lies within 1.5 clock hr. of the highest border 98%
39. Lincoff rule
inferior RD
higher side indicates
which side of the disc
an inferior hole lies
95% of the time
inferior detachment
is bullous
primary hole lies
above horizontal
meridian
41. CLINICAL FEATURES :LONG-STANDING
RRD ≥ 3 mo.
RPE metaplasia at border of detachment
Most RRD surrounded by demarcation line
eventually progress; nonetheless, surgical
repair of these eyes has an excellent
prognosis
44. CLINICAL FEATURES :LONGSTANDING
very long-standing
extensive capillary nonperfusion lead to
peripheral retinal NV
IOP can rise
○ TM impeded by pigment clumps or the outer
segments of photoreceptors
45. PROLIFERATIVE
VITREORETINOPATHY
occurs ~ 10% of all RRD which ¼ require
additional surgical intervention
most common cause of failure to repair
risk factor
aphakia , preop PVR , extensive RD , uveitis ,
excessive cryo, GRT, massive VH
46. Classification
RD with vitreoretinopathy1983*
Grade
Name
Signs
A
Minimal
vitreous haze ,pigment clump
B
Moderate
wrinkling inner retinal surface,roll edge RB ,
retinal stiffness , vessel tortous
C
Marked
full thickness fix retinal fold
C1,C2,C3
D
Massive
full thickness fix retinal fold 4 quadrants
D1 wide ,D2 narrow
D3 close not seen optic disc
47. Classification of PVR 1991*
grade
features
A
vitreous haze ,pigment clump,pigment cluster inferior
retina
B
wrinkling inner retinal surface,roll and irregular edge RB ,
retinal stiffness , vessel tortous ,vitreous mobility ,
CP1-12
posterior to equator : focal , diffuse ,or circumferential full
thickness fold , subretinal strands
CA1-12
anterior to equator : focal ,diffuse ,or circumferential full
thickness fold , subretinal strands
48. Management RRD
Retinal repositioning
Push the retina-eyewall
○ Pneumatic retinopexy
○ Scleral buckle procedure
○ vitrectomy
Remove SRF/ perfluorocarbon liquid
Remove fibrous membrane/traction
Seal the break(s)
Cryoretinopexy
Laser retinopexy
Temponade the retina
Gas/ silicone oil
50. Pneumatic retinopexy *
intravitreal gas tamponade RB temporary
100%C3F8
4X at 72 hrs
SRF will resolve
Need laser / cryo to permanently close the
RB
55. Scleral buckle : Segmental *
usually reserved for
RRD < 1 clock hour
posterior breaks
primary advantage
easy of placement
minimal refractive error change
avoid effects of large encircling elements
however, for most large posterior breaks ,
all MH prefer closure with gas and
vitrectomy
56. Scleral buckle : Segmental
not provide retinal support elsewhere
vitreoretinal traction away from
segmental element not supported,
which may result in formation of new RB
because of limited support , some
surgeon prefer encircling when possible
57. Scleral buckle :encircling
particularly indicated in *
multiple breaks in different quadrants
Aphakia/ pseudophakia
High/pathologic myopia
diffuse vitreoretinal pathologic eg. extensive
lattice degeneration or vitreoretinal
degenerations
PVR ≥ grade B
61. Scleral buckle
macula off VA ≥ 20/50 ~ 40-60%
duration of macula detachment relate
with final VA
VA ≥ 20/40
71% if detach < 10 days
VA ≥ 20/40 27% if detach 11days-6 weeks
VA ≥ 20/40
14% if detach > 6 weeks
71. Laser photocoagulation
usually cannot seal RB if presence SRF
may be use to create barrier to prevent
progression of RD
esp. useful in
chronic inferior RD
systemic illness contraindicate to surgery
73. Laser photocoagulation*
Slit-lamp
better magnified
Safer in inexpertise
operator
Less need of corneal
care during laser
Less pain
LIO
significant cataracts,
PCO, mild VH more
easily treated with
LIO
indentation
Need more skill
not be readily
available
Any patient position
75. Laser photocoagulation *
Compared with diathermy and cryopexy
less breakdown of blood–ocular barrier
thermal effect confined predominantly to
retina and pigment epithelium
little or no effect on choroid or sclera
induces adhesive effect between retina &
pigment epithelium within 24hr
76. Cryoretinopexy
RD with very shallow fluid can be cure by
cryoretinopexy alone
using cryoprobe and indirect ophthalmoscope
testing cryoprobe prior to make sure probe is
freezing
77. Cryoretinopexy
freezing or whitening of RPE will noticed first,
followed by delineation of edges of retinal tear
and whitening of retina
excessive freezing or ice crystal formation
should be avoided
78. Cryoretinopexy
histologic response depends on whether
RPE alone or RPE and overlying detached
retina together are frozen
only RPE froze once retina reattached
○ pigment epithelial hyperplasia
○ loss of retinal outer segments
○ normal microvillous interdigitations seen between
retina and RPE are missing
79. Cryoretinopexy
If both RPE and overlying retina frozen
cellular connections between retina and RPE
consisting of desmosome formation between
retinal glia and pigment epithelium or direct
contact between retinal glia and Bruch's
membrane
80.
81. Cryoretinopexy
Disadvantage
dispersion of pigment epithelial cells, which can
result in subretinal pigmentary changes after
reattachment
dispersion of viable pigment epithelial cells
capable of causing PVR following cryopexy
82. Cryoretinopexy
Some study suggest cryopexy is risk factor of
post-op PVR whereas others not show an
association
minimize cryotherapy-induced pigment epithelial cell
dispersion by
○ not over treating
○ avoiding unnecessary scleral depression of treated
areas
localization and examination with scleral
depression should be performed before
cryopexy
83. Cryoretinopexy : disadvantage
induce choroidal congestion &hyperemia
although not permanent
may complicate drainage of SRF through
treated areas
breakdown of BRB
cause post-op CME and ERD