Retinal Detachment: Dwika Hermia Putri I4061152040

Retinal Detachment
Dwika Hermia Putri

I4061152040
HISTOLOGY OF RETINA
1. Inner limiting membrane (glial cell fibers separating
the retina from the vitreous body).
2. Layer of optic nerve fibers (axons of the third
neuron).
3. Layer of ganglion cells (cell nuclei of the multipolar
ganglion cells of the third neuron; “data acquisition
system”).
4. Inner plexiform layer (synapses between the axons
of the second neuron and dendrites of the third
neuron).
5. Inner nuclear layer (cell nuclei of the bipolar nerve
cells of the second neuron, horizontal cells, and
amacrine cells).
6. Outer plexiform layer (synapses between the axons
of the first neuron and dendrites of the second
neuron).
7. Outer nuclear layer (cell nuclei of the rods and
cones = first neuron).
8. Outer limiting membrane (sieve-like plate of
processes of glial cells through which rods and
cones project).
9. Layer of rods and cones (the actual photoreceptors).
10.Retinal pigment epithelium (a single cubic layer of
heavily pigmented epithelial cells).
11.Bruch’s membrane (basal membrane of the choroid
separating the retina from the choroid). 2
Lang GK. Ophthalmology: A Short Textbook. Thieme Stuttgart, NewYork. p.301
Definition
• Retinal detachment is the
separation of the sensory retina,
ie, the photoreceptors and inner
tissue layers, from the
underlying retinal pigment
epithelium.
Riordan P, Whitcher JP. 2007. Vaughan & Asbury's General Ophthalmology. 16th Edition. USA: Mc Graw-Hill company.
Classification
There are three main types ;
• Rhegmatogenous Retinal Detachment
• Traction Retinal Detachment
• Serous & Hemorrhagic / Exudative Retinal
Detachment
Rhegmatogenous Retinal Detachment
• Rhegmatogenous retinal detachment is characterized by a full-
thickness break (a "rhegma") in the sensory retina, variable
degrees of vitreous traction, and passage of liquefied vitreous
through the break into the subretinal space.
Picture by: Editors: Ehlers, Justis P.; Shah, Chirag P. . 2008. Wills Eye Manual, The: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th Edition.
Lippincott Williams & Wilkins. P: 296
• Flashes of light
• Floaters
Symptoms: • A curtain or shadow moving over the field of
vision
• Peripheral or central visual loss, or both.
• Elevation of the retina from the RPE by fluid in the

subretinal space due to an accompanying full-
thickness retinal break or breaks.
Signs: • Anterior vitreous pigmented cells, vitreous
hemorrhage, PVD, usually lower IOP in the
affected eye, nonshifting clear subretinal fluid,
sometimes fixed retinal folds.
Editors: Ehlers, Justis P.; Shah, Chirag P. . 2008. Wills Eye Manual, The: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th Edition. Lippincott
Williams & Wilkins. P: 295
• Diagnotic
– The diagnosis is made clinically by indirect
ophthalmoscopy with mydriasis.
– Slit-lamp examination with contact lens may help in
finding small breaks.
– B-scan US
Editors: Ehlers, Justis P.; Shah, Chirag P. . 2008. Wills Eye Manual, The: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th Edition.
Types of retinal tears:
– Round hole with operculum – Horseshoe tear  The
 The operculum lies free anterior part of the
above the retinal hole. retina is elevated by
There is no vitreous pull at vitreous traction. A
the edges of the hole. The bridging vessel may be
most common in the seen.
superotemporal quadrant.
8
Lang GK. Ophthalmology: A Short Textbook. Thieme Stuttgart, NewYork. p.301
Types of retinal tears:
– Atrophic hole Often a – Dialysis The retinal
round retinal hole is defect is seen in the
seen in the middle of a region of the ora
palisade without serrata. The cause is
vitreous pull. often trauma.
9
Traction Retinal Detachment
• Traction retinal is most commonly due to proliferative
diabetic retinopathy, proliferative vitreoretinopathy,
retinopathy of prematurity, or ocular trauma.
• The typical traction retinal detachment  concave
surface and localized, usually not extending to the ora
serrata.
• The tractional forces actively pull the sensory retina
away from the underlying pigment epithelium toward
the vitreous base.
• Traction is due to formation of vitreal, epiretinal, or
subretinal membranes consisting of fibroblasts and glial
and retinal pigment epithelial cells.
• Symptoms: Signs:
• Photopsia and floaters are • The RD has a concave configuration and
usually absent because breaks are absent.
vitreoretinal traction develops • Retinal mobility is severely reduced and
insidiously and is not associated shifting fluid is absent.
with acute PVD. • The SRF is shallower than in a
• A visual field defect usually rhegmatogenous RD and seldom extends
progresses slowly and may be to the ora serrata.
stable for months or even years. • The highest elevation of the retina occurs
at sites of vitreoretinal traction.
• If a tractional RD develops a break it
assumes the characteristics of a
rhegmatogenous RD and progresses
rapidly (combined tractional-
rhegmatogenous RD).
Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 712
Etiology:
• Fibrocellular bands in the vitreous (e.g., resulting from
proliferative diabetic retinopathy (PDR), sickle cell
retinopathy, retinopathy of prematurity, toxocariasis,
trauma, previous giant retinal tear) contract and detach
the retina.
Diagnostic
• Indirect ophthalmoscopy with scleral depression. Slit-lamp
examination with contact lens may help in finding small breaks.
• B-scan US may be helpful if media opacities are present.
• OCT is useful in identifying tractional membranes and can be useful in
differentiating tractional membranes from detached retina.
Exudative Retinal Detachment
• Exudative RD is characterized by the accumulation of

SRF in the absence of retinal breaks or traction.
• It may occur in a variety of vascular, inflammatory and
neoplastic diseases involving the retina, RPE and choroid
in which fluid leaks outside the vessels and accumulates
under the retina.
• These detachments are the result of a collection of fluid
beneath the sensory retina and are caused primarily by
diseases of the retinal pigment epithelium and choroid.
Causes include:
• Choroidal tumours such as melanomas, haemangiomas and
metastases; it is therefore very important to consider that
exudative RD is caused by an intraocular tumour until proved
otherwise.
• Inflammation such as Harada disease and posterior scleritis.
• Bullous central serous chorioretinopathy is a rare cause.
• Iatrogenic causes include retinal detachment surgery and
panretinal photocoagulation.
• Choroidal neovascularization which may leak and give rise to
extensive subretinal accumulation of fluid at the posterior pole.
• Hypertensive choroidopathy, as may occur in toxaemia of
pregnancy, is a very rare cause.
• Idiopathic, such as uveal effusion syndrome
Symptoms. Signs:
• The RD has a convex configuration, as with a
Depending on the cause,
rhegmatogenous RD, but its surface is smooth
both eyes may be involved and not corrugated.
simultaneously.
• The detached retina is very mobile and exhibits
• There is no vitreoretinal the phenomenon of ‘shifting fluid’ in which SRF
traction, so photopsia is detaches the area of retina under which it
absent. accumulates.
• Floaters may be • The cause of the RD, such as a choroidal tumour,
present if there is may be apparent when the fundus is examined or
associated vitritis. on B-scan ultrasonography, or the patient may
have an associated systemic disease responsible
• A visual field defect for the RD (e.g. Harada disease, toxaemia of
may develop suddenly pregnancy).
and progress rapidly. • ‘Leopard spots’ consisting of scattered areas of
subretinal pigment clumping may be seen after
the detachment has flattened.
Diagnostic:
• Intravenous fl uorescein angiography (IVFA) may show source of
SRF.
• Optical coherence tomography (OCT) may help identify SRF as well
as the source (e.g.,CNV) .
• B-scan US may help delineate the underlying cause.
• Systemic work-up to rule out the above causes (e.g., HTN, multiple
myeloma, etc.).
Differential Diagnosis For All Three Types
of Retinal Detachment
• Acquired/age-related degenerative retinoschisis

• X-linked retinoschisis
• Choroidal detachment
Editors: Ehlers, Justis P.; Shah, Chirag P. . 2008. Wills Eye Manual, The: Office and Emergency Room Diagnosis and Treatment of Eye Disease,
MANAGEMENT
SURGERY
Indications for urgent surgery ;
• an acutely symptomatic RD should be operatively repaired urgently,
particularly if the macula is as yet uninvolved
• the presence of a superior or large break, from which SRF is likely
to spread more rapidly, and
• advanced syneresis as in myopia.
• Patients with dense fresh vitreous haemorrhage in whom
visualization of the fundus is impossible should also be operated on
as soon as possible if B-scan ultrasonography shows an underlying
RD.
Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 707-8
Pneumatic Retinoplexy
• Pneumatic retinopexy is an outpatient procedure in which an
intravitreal gas bubble together with cryotherapy or laser are used
to seal a retinal break and reattach the retina without scleral
buckling.
• It has the advantage of being a relatively quick, minimally invasive,
‘office-based’ procedure.
Pneumatic Retinoplexy
(A) (B) (C) (D)
(E) (F)
Pneumatic retinopexy. (A) Cryotherapy; (B) gas injection; (C) gas has sealed the retinal break and the retina is flat; (D)
gas has absorbed; (E) gas bubble in vitreous cavity; (F) ‘fish eggs’ due to gas bubble break-up
Scleral buckling
• is a surgical procedure in which material sutured onto the sclera
creates an inward indentation
• Its purposes are to close retinal breaks by apposing the RPE to the
sensory retina, and to reduce dynamic vitreoretinal traction at sites
of local vitreoretinal adhesion.
(A) (B) (C)
Scleral buckling. (A) Circumferential explant; (B) buckle induced by radial explant; (C) buckle
induced by circumferential explant
Pars Plana Vitrectomy
• pars plana vitrectomy (PPV) has greatly improved the prognosis for
more complex detachments.
Indications
Rhegmatogenous Tractional retinal

retinal detachment detachment
• When retinal breaks • Indications in diabetic

cannot be visualized RD
• In which retinal breaks • Indications in
are unlikely to be closed penetrating trauma
by scleral buckling
Pars Plana Vitrectomy
Technique :
• An infusion cannula is inserted (3.5 mm behind the limbus in
pseudophakic or aphakic eyes and 4 mm in phakic eyes) at the level of
the inferior border of the lateral rectus muscle; limbal peritomy
(conjunctival dissection) is required for conventional larger gauge
systems, but unnecessary in small gauge systems.
• Further sclerotomies are made at the 10 and 2 o’clock positions,
through which the vitreous cutter and fibreoptic probe are introduced.
These sclerotomies are self-sealing with modern small gauge systems,
though wound leak occasionally occurs
• The central vitreous gel and posterior hyaloid face are excised.
• The above basic steps apply to all vitrectomies; subsequent steps
depend on the specific indication.
• Transconjunctival small gauge systems do not require postoperative
suturing.
Terima Kasih

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Retinal Detachment

Dwika Hermia Putri

• Elevation of the retina from the RPE by fluid in the

• Exudative RD is characterized by the accumulation of

• Acquired/age-related degenerative retinoschisis

(A) (B) (C)

Rhegmatogenous Tractional retinal

• When retinal breaks • Indications in diabetic

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