Retinal

Detachment
M. HAMMAM FAISHAL F
HISTOLOGY OF RETINA
2
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).
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.
 Definition and classification
• Break - full-thickness defect in sensory retina
• Hole - caused by chronic retinal atrophy
• Tear - caused by dynamic vitreoretinal traction
Morphology of tears

a. Complete U-tear d. Operculated

b. Linear e. Dialysis
c. Incomplete L-shaped
Classification

There are three main types ;

 Rhegmatogenous Retinal Detachment
 Traction Retinal Detachment
 Serous & Hemorrhagic / Exudative Retinal Detachment

Riordan P, Whitcher JP. 2007. Vaughan & Asbury's General Ophthalmology. 16th Edition. USA: Mc Graw-Hill company.
 Retinal detachment (RD)
Separation of sensory retina from RPE by subretinal fluid (SRF)

Rhegmatogenous - caused by a Non-rhegmatogenous - tractional or

retinal break exudative
 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.

Riordan P, Whitcher JP. 2007. Vaughan & Asbury's General Ophthalmology. 16th Edition. USA: Mc Graw-Hill company.
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
 Rhegmatogenous Retinal Detachment

• Flashes of light
• Floaters
• A curtain or shadow moving over the field of
vision
Symptoms: • Peripheral or central visual loss, or both.

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
 Rhegmatogenous Retinal Detachment

 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. Lippincott
 Rhegmatogenous Retinal Detachment
10
Types of retinal tears:
 Round hole with operculum – Horseshoe tear  The
 The operculum lies free anterior part of the retina
above the retinal hole. There is elevated by vitreous
is no vitreous pull at the traction. A bridging
edges of the hole. The most vessel may be seen.
common in the
superotemporal quadrant.

Lang GK. Ophthalmology: A Short Textbook. Thieme Stuttgart, NewYork. p.301

Rhegmatogenous Retinal Detachment
11
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 serrata.
palisade without The cause is often
vitreous pull. trauma.
 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.
Pathogenesis of diabetic tractional RD (1)
Antero-posterior
traction RD

Preretinal
haemorrhage
Traction Retinal Detachment

 Symptoms:
 Photopsia and floaters are
usually absent because
vitreoretinal traction develops
insidiously and is not associated
with acute PVD.
 A visual field defect usually
progresses slowly and may be
stable for months or even years.
 Traction Retinal Detachment

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 (Optical coherence tomography) is useful in identifying tractional
membranes and can be useful in differentiating tractional membranes
from detached retina.

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: 297
 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.

Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 712
Riordan P, Whitcher JP. 2007. Vaughan & Asbury's General Ophthalmology. 16th Edition. USA: Mc Graw-Hill company.
 Exudative Retinal Detachment

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

Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 712
 Exudative Retinal Detachment
Symptoms.
Depending on the cause,
both eyes may be involved
simultaneously.
 There is no vitreoretinal
traction, so photopsia is
absent.
 Floaters may be present
if there is associated
vitritis.
 A visual field defect
may develop suddenly
and progress rapidly.
Signs:
 The RD has a convex configuration, as with a
rhegmatogenous RD, but its surface is smooth
and not corrugated.
 The detached retina is very mobile and exhibits
the phenomenon of ‘shifting fluid’ in which SRF
detaches the area of retina under which it
accumulates.
 The cause of the RD, such as a choroidal tumour,
may be apparent when the fundus is examined or
on B-scan ultrasonography, or the patient may
have an associated systemic disease responsible
for the RD (e.g. Harada disease, toxaemia of
pregnancy).
 ‘Leopard spots’ consisting of scattered areas of
subretinal pigment clumping may be seen after
the detachment has flattened.
 Exudative Retinal Detachment

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.

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: 297
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.

Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 707-8
 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
Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 707-8
 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
Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 707-8
 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

Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 717
 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.

Bowling B. Kanski's Clinical Ophtalmology; A Systematic Approach, Eight Edition. 2016. Elsevier: Sydney, Australia. P: 717
Terima Kasih