Retinal Detachment

Management
Moderator : Dr. S.S.Patel Sir
Presentor : Dr. Swati
 Pre-operative Evaluation
• Clinical Examination

•  Slit Lamp Examination to rule out anterior segment pathology

•  Binocular Indirect Ophthalmoscopy with scleral indentation

•  Goldmann Three-mirror Examination

•  Fundus drawing with Localisation of Primary Break

• Ultrasonography

• OCT- to detect SRF, other pathologies

• Haematological Investigations

• CT and MRI
ULTRASONOGRAPHIC
CHARACTERISTICS
RETINAL DETACHMENT
The detachment produces a
bright continuous, folded
appearance with insertion
into the disc and ora
serrata.

It is to determine the
configuration of the
detachment as shallow, flat
or bullous
EXUDATIVE RETINAL DETACHMENT
RHEGMATOGENO
US RD
RHEGMATOGENOUS RETINAL DETACHMENT
CLOSED FUNNEL RD
Retinal Tear
WITH RETINAL CYST
Appears as RD but it is a PVD
Clues: non uniform thickness of membrane very
thin attachment to the disc.
 Retinal Reattachment Surgery
 Scleral Buckling Surgery with or without drainage
 Encircling
 Segmental
 Temporary scleral buckle
 Lincoff balloon
 Absorbable material
 Vitrectomy
 Classical
 Sutureless
 Pneumoretinopexy
 Routine
 With drainage of SRF/intravitreal liquid
 Aim of Surgery
 To counter the factors & forces that cause retinal
detachment

 Re-establish physiological conditions that maintain

contact between NSR & RPE
• Management of Rhegmatogenous Retinal
Detachment
• Treatment principle in
Rhegmatogenous retinal detachment -
1.Identify and close all retinal breaks.
2.Relive vitreoretinal traction.
• Step 1- Identify all breaks.

Linkoff rule.
• Step 2- Close all break and relieve traction.

• Bring eye wall towards break / traction.

• Push break towards eye wall - Gas/ Oil.
• Seal break with retinopathy- cryo/laser.
Scleral Buckling Surgery
 Introduction
• Scleral buckling procedures
have a long history of use
• Jules Gonin - break is
responsible for
Rhegmatogenous retinal
detachment
• Closure of break will result
in reattachment of retina
• He preformed the first
successful surgery for the
treatment of RRD
 Principle of Buckle
• Localized indentation of the sclera, choroid , and
pigment epithelium beneath a retinal break alters the
anatomical and physiological factors responsible for RD.
• The fundamental goal of scleral buckling is the
functional closure of all retinal breaks, so that normal
physiological forces can maintain a permanent state of
attachment.
 How scleral buckle works ???
• Gold standard for uncomplicated RD

• Relieves vitreous traction along the surface

of the buckle

• The buckle displaces the retinal break

centrally, where the break becomes
tamponaded by cortical vitreous

• It displaces SRF away from the break &

alters the shape of eyewall, thus reducing
the effects of the intraocular fluid
currents
 Scleral Buckles
Permanent • Effect depends upon
 Solid Silicone  Type of material

 Sponge  Location & tension of scleral

 Hydrogel sutures

 Circumferential tightening of encircling

Absorbable
buckle
 Gelatin

 Synthetic suture

 Donor tissue
 Choosing the right explant
• Break - location, number, size, and types of retinal breaks are important

variables affecting the selection of a specific buckling technique

• Area involved –

 If retinal breaks, vitreoretinal degenerative disorders, and significant

vitreoretinal traction are present in multiple quadrants, a

circumferential buckle is usually favored.

 A single retinal break unassociated with additional significant problems

may be managed with an isolated segmental buckle

 Buckle positioning
• Crucial for successful surgery

• The anterior - posterior dimensions of retinal

break(s)

• Scleral buckles should support all edges of the

retinal breaks and associated areas of

vitreoretinal degeneration.

• Vitreoretinal traction are also important

considerations in planning a buckling procedure.

• In general, the buckling effect should extend

into the zone of the vitreous base to eliminate

current and future traction forces.

 Buckle configuration
• Radial explants- right angle
to limbus- to seal U
tears/posterior breaks

• Segmental circumferential-
parallel to limbus

• Encircling- entire
circumference of globe
for 360˚ buckle
 Basic principles
• Understanding role of Explants
• Need of SRF drainage?
• Careful to avoid/ minimize complications
• Control IOP through out the surgery
 Basic principles
• Learn a good indirect ophthalmoscopy.
• To localize all possible breaks and
• Retinopexy/cryotherapy of them
• Appropriate buckle positioning and height
adjustment
 Indications of Scleral Buckling
• RRD with PVR less than or equal to C1

• Anterior break(s)/degenarations preferably in less than 2 quadrant

• Retinal dialysis

• Preferred in young patients/myopic eyes with RRD

• Fellow eye in patients with GRT having WWOP, multiple areas of lattice

/ thinning/ degenerative changes

• With advent in PPV, use has diminished and the art of doing a good

buckling surgery is diminishing

 Relative contraindications
 Thin sclera

 Glaucoma filtering blebs/valve implants

 Previous strabismus surgery

 Very posterior retinal breaks

 Giant retinal tears

 PVR grade C

 Significant vitreous opacities

 Complications
• Intraoperative
 Scleral perforation

 Choroidal Haemorrhage

 Subretinal Bleed, Retinal Incarceration and perforation

 Impaired visibility- corneal haze, hyphema, miosis, air/gas injection

 Damage to vortex veins

 Vitreous loss
 Postoperative
 Buckle infection, migration, extrusion

 Failed retinal reattachment

 Redetachment- PVR

 Anterior segment ischemia

 Choroidal edema, detachment

 Secondary Glaucoma

 Suboptimal visual recovery- CME, persistent subfoveal SRF

 Ptosis, diplopia and motility disturbances

Changes induced by scleral buckles in the eye

 Axial length of the eye - Encircling- Increased/decreased axial

length depending upon material, location, height of buckle

 Induced spherical equivalent & astigmatic refractive error

 segmental- hyperopic shift

 Volume of the eye

 Altered compliance, ocular rigidity

 S R F Drainage -
• Indications

 Long standing RD

 Bullous elevated detachments

 No visible breaks

 Coexistent glaucoma

 Highly myopic detachments

 Aphakic & pseudophakic eyes

 Multiple breaks

 Significant vitreous traction

 Giant tears

 Inferior breaks

 Thin sclera
 Complications
 Failure of drainage- dry tap

 Retinal perforation

 Intraocular haemorrhage

 Vitreous loss

 Retinal incarceration

 Endophthalmitis
 Pars Plana Vitrectomy
 Indicated in

 Media opacities- cataract , VH & advanced PVR

 Posteriorly located breaks

 RD with giant retinal tear or macular hole

 Pseudophakia

 Tractional RD

 Relative contraindications

 Relatively simple phakic RD

 Inferior retinal dialysis

 PPV in Retinal Detachment

• The principles of retinal detachment repair via

pars plana vitrectomy are to remove the vitreous
gel and any vitreoretinal traction, locate and laser
any retinal tears, and insert an intraocular
tamponade.
 Basic Setup
The basic components of a vitrectomy setup include the following elements:

• Vitrectomy machine (e.g., Alcon Constellation, DORC EVA, Bausch + Lomb

Stellaris PC)

• Surgical microscope and wide-angle viewing system (e.g., Zeiss RESIGHT,

Oculus BIOM, AVI)

• Infusion cannula: to maintain intraocular pressure set by the vitrectomy

machine

• Endoillumination light source: for visualization of the posterior segment

including vitreous and retina

• Vitrectomy cutter (or vitrector): for vitreous removal, aspiration, and peeling

and cutting membranes among other functions

 Procedure
 LA/GA

 360˚/ Limited Conjunctival peritomy

 3 Sclerotomies- ST, SN & IT quadrants

 PVD induction and thorough PPV

 Preretinal membranes peeled off

 Retinal breaks are marked with light cautery burns

•Fluid gas exchange- endodrainage of SRF through pre-existing
breaks/ Drainage retinotomy

•Endophotocoagulation, Cryo for peripheral breaks

•Endotamponade- silicone oil/ Long acting gases

•Inferior PI in aphakic cases if silicone oil used

 Sutureless Microincision Vitrectomy
 Transconjunctival sutureless MIVS using 23G/ 25G instrumentation

 Advantages

 Shorter surgical time

 Less surgically induced astigmatism

 Reduced risk of post-operative corneal astigmatism

 Greater rigidity, better illumination, improved fluidics with 23 G

 Pneumatic dual drive cutter with ultrahigh cut rate 5000 cpm

 IOP compensation via direct control of infusion pressure

 Direct control of duty cycle

 New scleral entry system- MVR blade

 Wide angle viewing systems

 Scleral Buckling+ PPV
Indicated in peripheral retinal involvement in

 Proliferative vitreoretinopathy

 Giant retinal tears

 Peripheral uveitis

 Viral retinitis

 Retinopathy of Prematurity

 Proliferative retinopathies
 Pneumatic Retinopexy
 Short, minimally invasive, OPD procedure
 Intravitreal injection of an expansile gas bubble, cryopexy,
postoperative patient positioning

 Indications

 Fresh uncomplicated RRD

 Retinal break smaller than one clock hour

 Multiple breaks within one clock hour

 All breaks in superior 8 clock hours

 Contraindications
 Inferior retinal breaks

 PVR

 Media opacities impairing proper assessment

 Uncontrolled glaucoma

 Air travel

 Patient unable to maintain postoperative positioning

 Procedure
 Anaesthesia- Topical/LA

 Cryopexy around retinal breaks

 Single, expansile gas bubble injected in vitreous cavity through pars

plana using sterile 30 G needle

 Paracentesis

 Positioning- to ensure max. tamponade, retinal break should remain at

the top
 Tamponading Agents in VR Surgery
 Tamponading agents/ vitreous substitutes

 Materials used

 Intraocular gases

 Silicone oil

 Perfluorocarbon liquid (PFCL)

 Characteristics of gases

 High surface tension (occludes retinal break)

 Buoyancy (Force to push retina)

 Used as

 Non-expansile mixture with air after PPV

 100% concentration in pneumoretinopexy

 Gases tried in vitreoretinal surgery

Non-expansile Expansile

Air SF6

Nitrogen C4F10
Helium CF4

Oxygen C2 F 6

Argon C3 F 8

Xenon C4F10
Krypton C5F12
 Properties of intraocular gases

Gas Average Largest size Average Nonexpansi Typical

Duration of the expansion l Dose
bubble e
concentra
(durati tio n
on)

Air 3 days Immediate No -- 0.8ml

expansion

SF6 12 days 36 hours 2 times 18% 0.5ml

C3F8 38 days 72 hours 4 times 14% 0.3ml

 Advantages of intraocular gases vs use of silicon oil

 No need of repeat surgery for removal

 Absence of complications related to long-term presence of silicone oil

 Disadvantages of intraocular gases

 Requirement of strict postoperative positioning

 Risk of postoperative rise in IOP

 Restriction of air travel

 Development of lens opacity

 Delayed visual rehabilitation

 Short duration of tamponading effect

 Recurrent detachment from severe proliferation

 Silicone Oil in RD Repair
 FDA approved for VR surgery in 1994
 Highly viscous, transparent liquid with high surface tension, lighter
than water

 Viscosity 1000-5000 centistokes

 Indications

 Detachment with inferior breaks

 Extensive PVR

 One eyed patient with need of early visual recovery

 Giant retinal tears

 Traumatic detachments
 Advantages
 Prolonged tamponading effect
 Less strict requirement of post-
operative positioning
 Early visual rehabilitation
 No restriction on air travel
 Hypotony less common
Disadvantages
 Needs repeat surgery for removal
 Cataract, raised IOP, BSK
 Inadequate tamponading for inferior
breaks
 Post-operative change in refraction
 Perisilicone oil membrane &
macular
 Redetachment after oil removal (15-20%)
Comparison of various surgical techniques
Method Reattachment Limitations/ Benefits
Rate Complications
Scleral Buckling 94% Morbidity, infection, Excellent long term
buckle anatomic success,
extrusion, ocular good visual
motility outcome
disturbances
Pars Plana 71-92% (1˚ Iatrogenic retinal Visualization of all
Vitrectomy success breaks, breaks,
rate) PVR, lens trauma, removal of
94% (2˚ cataract opacities/syne
success progression chiae,
rate) anatomic
success in
complicated
detachments
Pneumatic 64% (1˚ success Limited use only in In-office
Retinopexy rate) uncomplicated RRD procedure,
with minimally invasive,
91% (2˚ superior breaks ↓ Recovery time,
success Post-op positioning, better
rate) post-op VA
 Retinal Breaks
 Factors to consider for treatment of retinal breaks
 Symptoms

 Age of patient

 Systemic status of the patient

 Refractive error (>6D myopia)

 Break- Location, age, type, size

 Status of fellow eye

 Aphakic/PCIOL/ needs cataract surgery

Increased chances of RD, needs T/t
 Phakic patients with symptomatic breaks

 Superotemporal breaks- macula off RD

 Larger breaks

 HST/ retinal dialysis

 Retinal tear at margin of lattice with symptoms

 No treatment, observation
 Phakic patients- no prev H/O retinal disease, No high myopia

 With asymptomatic HST/ Atrophic holes/ with operculum

 Management
 Acute retinal break- new floaters and flashes- d/t acute PVD
 Presence or absence of symptoms with onset of break- most
important prognostic criterion for progression to retinal
detachment

 Anterior breaks--Cryotherapy/ LASER

 Posterior breaks--Slit Lamp/ Indirect Ophthalmoscopic LASER

delivery

 Large breaks--Anterior part- Cryotherapy Posterior part-

LASER
 LASER Photocoagulation
 LASER used- Argon Green, Krypton Red, Diode Laser

 Delivery system- slit lamp/ indirect ophthalmoscopic

 Spot size 200µm Duration 0.1-0.2sec

 Goldmann Triple-mirror contact lens or wide-field lenses 2.2

panfundoscopic lens

 Surround the lesion with 3-4 rows of confluent burns of moderate

intensity

 No more than half spot size untreated retina between burns

 Patching, re-examine at 5-7 days

  Complications

 Post t/t patient should avoidstrenuous  Macular pucker

physical exertion for upto 7 days until  Epiretinal
adequate adhesion has formed and lesion is membrane formation
securely sealed
 Adie’s pupil
 Firm adhesion achieved at 3 weeks
 Subretinal and
 Failure depends upon- failure rate 0-22% vitreous haemorrhage
 Type of break
 Breaks in Bruch’s
 Indication of treatment
membrane
 Length of follow-up
 Scleral rupture-
staphylomatous sclera, cryo
done
 Cryotherapy
 Under topical  Not to remove the probe until it has
anaesthesia/subconjunctival injection defrosted completely as premature
removal may crack the choroid-
 Check cryoprobe for correct freezing
leading to choroidal haemorrhage
and defrosting, rubber sleeve does not
 Pad eye for 4 hours
cover the slip
 At 5 days, pigmentation begins to
 While viewing with IDO, gently indent
appear
sclera with tip of probe, start at ora
 Initially fine, then coarser, a/w
serrata and move posteriorly
chorioretinal atrophy
 Surround the lesion with single row of
application, terminate freezing as
retina whitens, 2mm around entire
break
 Causes of failure
 Failure to surround the entire lesion

 Failure to apply contiguous treatment

 Failure to use an explant or gas tamponade

 New break formation

 Cryotherapy vs LASER
Retinopexy
Cryotherapy LASER Retinopexy
 Use of external probe & IDO
 Endolaser/ IDO with laser
 Can be used with moderate media
 Difficult in moderate media
opacities
opacities/shallow SRF
 Promotes dispersion of viable RPE
 Ideal for posteriorly located breaks
cells & breakdown of BRB

 CME, wrinkling of ILM

 Increased Postoperative flare,

extensive retinal oedema, necrosis
 Management of Retinal Breaks
Treatment guidelines for retinal breaks

Type of break Phakic High Myopia Fellow eye Aphakia/

Pseudophakia
HST symptomatic Treat Treat Treat Treat

HST Observe Treat some Treat Treat some

Asymptomatic
Operculated Treat some Treat Treat Treat
symptomatic
Operculated Observe Treat few Observe Observe
asymptomatic

Round hole Observe Observe Treat some Observe

asymptomatic

Lattice without Observe Observe Treat some unless Observe

holes lattice >6clock
hours
Lattice with Observe Observe Observe
round holes
 Management of Tractional Retinal
Detachment
TRD progresses very slowly, may reattach spontaneously

 Localized TRD away from macula- observation

 Indications for surgery

 Macular threatened or detached

 Vitreous haemorrhage

 Retinal holes

 Surgical Principles

 To relax the vitreoretinal traction

 Closure of retinal holes

 Drainage of SRF
 PPV- to clear media, release of AP & tangential traction

 ERM- peeling/ segmentation/ delamination

 Enblock excision of traction membranes

 Retinotomy with internal drainage of SRF, internal

tamponade with LAgases/silicone oil injection

 Endodiathermy & endophotocoagulation- new vessels &

retinopexy
Causes of early Failure
 Control of IOP
In order to avoid increases in intraocular pressure,

• Preoperative IV mannitol / oral acetazolamide ( especially in nondrainage ) ;

can also be used intra - op & post – op

• During Surgery :

 Drainage of subretinal fluid

 AC paracentesis, or

 Removal of liquid vitreous with vitreous cutter may be required,

• To be very careful in particularly in eyes with compromised aqueous outflows/

pre- existing glaucoma
 Exudative retinal detachment -
• Treatment depends on the cause.Some cases
resolves spontaneously.Systemic corticosteroid in
case of Harada disease and posterior
scleritis.Bullous central serous chorioretinopathy-
laser photocoagulation.