RRD PPT by Dr Sidesh Hendavitharana

1. Dr.Sidesh Hendavitharana
(Registrar in Ophthalmology)

2. .
 RD is seperation of neurosensary retina
from RPE.
 FOUR types,
1) Rhegmatogenous RD
2) Tractional RD
3) Exudative RD
4) Combined rhegmatogenous and tractional RD

3. Rhegmatogenous RD
 Also called primary RD
 Greek,rhegma=break
 Usually due to break in retina in form of
hole or tear through which vitreous gains
access into subretinal space and
seperates sensary retina from pigment
epithelium.

4. Predisposing(risk) factors
 Age-most common in 40-60yrs of age
 Sex-more common in male(3:2 compared to females)
 Myopia-account for 30% of RD(more common in myope
over -3.0D
 Aphakia
 Peripheral retinal degeneration-S-W-A-F-L,
 S-snail track degeneration
 White with or without pressure
 Acquired retinoschisis
 Focal retinal clumps
 Lattice degeneration
 Trauma-commonest in young adults
 Cataract surgery-more in ICCE
 Senile posterior vitreous detachment

5. Typical lattice degeneration
• Present in about 8% of general population
• Present in about 40% of eyes with RD
• Spindle-shaped islands of retinal thinning
• Network of white lines within islands
• Variable associated RPE changes
• Small round holes within lesions are common
• Overlying vitreous liquefaction
• Exaggerated attachments
around margin of lesion
Retina Vitreous

6. Complications of lattice degeneration
Indications for prophylaxis
• No complications - in most cases
• RD associated with atropic holes, particularly in young myopes
• RD associated with tractional tears in eyes with acute PVD
• RD in fellow eye
• Extensive lattice in high myopia

7. Snailtrack degeneration
Indications for prophylaxis - presence of holes
Sharply demarcated, frost-like bands
which are longer than lattice
Large round holes which carry
high risk of RD

8. White-without-pressure
Indications for prophylaxis - giant tear in other eye
Translucent grey appearance of
retina
Occasional giant tear formation along
posterior margin of lesion

9. Pathogenesis
Retinal detachment
Seeping or degenerated vitreous fluid through retinal break into
subretinal space and collects as SRF
Retinal break
Risk factors,senile PVD,peripheral retinal
degenerations,aphakia,trauma

10. Clinical features
 Symptoms
Dark spot in front of eye(floaters)-due to
rapid vitreous degeneration.
Transient light flashes(photopsia)-due to
irritation of retina by vitreous movements.
Muscae volitantes and distortion of objects
Shadow or clouds in front of eye,percieved
as black curtain
Localized profound dimness of vision(in
cases of large and central retinal hole)

11. signs
 Pupillary reflex-marcus Gunn pupil in
eyes with extensive RD
 IOP-usually slightly lower or may be
normal.
 Fundus examination (indirect
ophthalmology -investigation of choice)

12. Fresh retinal detachment
 Grayish white,opaque,raised detached retina(convex
configuration) and corrugated appppearance(due to
intraretinal edema) with loss of underlying choroidal
pattern
 Dark retinal vessels with no central light reflex.
 No shifting of fliud
 Oscillation of multiple retinal folds with movement of
eye
 One or more retinal breaks or holes in upper
temporal region
 Vitreous show pigment in anterior vitreous(tobacco
dusting or shafer sign)with posterior detachmnet.
 Associated degeneration,pigmentation and
haemorrhage in retina.

13. Old retinal detachment
 Retinal thining(due to atrophy)
 Fixed retinal folds(absence of retinal
undulation)
 Subretinal demarcation lines(due to
proliferation of RPE cells at junction of flat
detachment)
 secondary intraretinal cysts(in very old RD)
 Multiple opaque strands of subretinal
fibrosis.
 Proliferative vitreoretinopathy.

14. Classification Of PVR
 The term "proliferative vitreoretinopathy" was coined in 1983
by the Retina Society Terminology Committee.
 In 1989, the classification was amended by the Silicone
Study Group before being most recently modified in 1991 to
its current classification.
 Currently, PVR is divided into grades A, B, and C.
 Grade A is limited to the presence of vitreous cells or haze.
 Grade B is defined by the presence of rolled or irregular
edges of a tear or inner retinal surface wrinkling, denoting
subclinical contraction.
 Grade C is recognized by the presence of preretinal or
subretinal membranes. Grade C is further delineated as
being anterior to the equator (grade Ca) or posterior to the
equator (grade Cp) and by the number of clock hours
involved (1 to 12).

15. Proliferative vitreoretinopathy
• Vitreous haze and
tobacco dust
Grade A (minimal)
• Rigid retinal folds
• Vitreous condensations
and strands
Grade C (severe)
• Retinal wrinkling and
stiffness
• Rolled edges of tears
Grade B (moderate)

17. Retinal breaks,

24. Primary retinal break
It is responsible for RD and determines configuration of SRF
Quadratic distribution of breaks in eyes
with RD
Configuration of SRF in relation
to primary break

25. Fundus drawing,

28. Investigations
 Visual fields-scotomas corresponding to
areas of RDs
 Slit lamp examination with 3 mirror
gonioscope-helps detect breaks and
evaluate vitreous condition.
 ERG-subnormal or absent
 US-A scan and B scan
 Confirm the diagnosis
 Particularly used in pts with hazy media or
dense cataract.

29. Differential diagnosis
 Senile retinoschisis
 Splitting of retina at the level of inner nuclear
layer and outer plexiform layer
 Commonly occur in lower temporal
quadrant.
 Progresses slowly
 Presence of absolute field defect
 Presence of transparent and immobile inner
retinal layer.

30. Treatment
 Aims,
1) To find retinal break and seal it.
2) To relieve vitreoretinal traction
3) To drain SRF

31. Operative
 Sealing the retinal breaks
 Involves the detection,accurate localization and
sealing by producing aseptic chorioretinitis with
cryoretinopexy at -70 c ,laser photocoagualation
or diathermy to sclera.
 SRF drainage
 Involve drainage of subretinal fluid by inserting a
fine needle through sclera and choroid into
subretinal space
 Allow immediate apposition between sensary
retina and RPE.

32. Mainain chorioretinal apposition
 Chorioretinal apposition to be maintained
for atleast couple of weeks
 Sclera buckling or encirclage
 Procedure
 Involves inward indentation of sclera by
inserting an explants(radial explants for isolated
hole and circumferential explants for breaks
involving 3 or more quadrants)with help of
matresses suturing of sclera.
 Indications
 Uncomplicated primary detschment

33. Pneumatic retinopexy
 Indication
 Fresh superior RD with1-2 small holes
extending over less than 2 o’clock hours in
upper temporal quadrant in peripheral retina.
 Procedure
 Involves sealing breaks with cryopexy
followed by injection of expanding gas
bubble into vitreous to remain in contact with
tear for 5-7 days.

34. Parsplana vitrectomy ,endolaser
photocoagulation and internal tamponade
 Indication
 Complicated RD
 TRD
 Procedure
 Multistep procedure involving
 3 port pars plana vitrectomy to remove all membranes and
vitreous
 Internal drainage of SRF through existing retinal breaks
using fine needle or through a posterior retinotomy
 Flaterning of retina by injecting silicone oil or
perfluorocarbon liquid
 Creation of chorioretinal adhesions by endolaser around
area of retinal tear and holes.
 Maintain retinal tamponade by retaining silicone oil inside
or exchange long acting gas.

35. Configuration of scleral buckles
Radial
Segmental
circumferential
Encircling
augmented by radia
sponge
Encircling
augmented by solid
silicone tyre

36. Preliminary steps
Peritomy Insertion of squint hook under
rectus muscle
Insertion of bridle suture Inspection of sclera for thinning
or anomalous vortex veins

37. Localization of breaks
• Insert 5/0 Dacron scleral suture
at site of apex of break
• Grasp cut suture with curved mosquito
forceps close to knot
• While viewing with indirect
ophthalmoscope check position of
indentation in relation to break

38. While viewing with indirect ophthalmoscope
indent sclera gently with tip of cryoprobe
Freeze break until sensory retina just
turns white
Cryotherapy

39. Insertion of local explant
Distance separating sutures
measured and marked
Ends trimmedSutures tightened over explant
Insertion of mattress-type suture

40. Encircling procedure
Strap fed under four recti Ends secured with Watzke sleeve
Strap slid posteriorly and secured
in each quadrant
Strap tightened to produce required
amount of internal indentation

41. Drainage of subretinal fluid
Indications
Haemorrhage
• Difficulty in localizing break
• Immobile retina
• Longstanding RD
• Inferior RD
Retinal incarceration
Complications
Technique

42. Causes of early failure
May be associated
with communicating
radial retinal fold
Insert additional radial
buckle
Buckle failure
‘ Fishmouthing ’ of retinal tear
Buckle
inadequate
size or height
Buckle incorrectly
positioned

43. Technique
(a) Cryotherapy
Pneumatic retinopexy
Indications
RD with superior breaks
(b) Gas injection
(c) Postoperative positioning
(d) Flat retina

44. Vitrectomy for giant tears
Unrolling of flap with light
pipe and probe
Completion of unrolling Injection of silicone oil or
heavy liquid

45. Vitrectomy for PVR
• Dissection of star folds and peeling of membranes
• Injection of expanding gas or silicone oil

46. Vitrectomy for diabetic tractional RD
Release of circumferential
traction
Release of antero-
posterior traction Endophotocoagulation

47. Thank you