RETINAL DETACHMENT (Rhegmatogenous)

Dr. H. S. Ray (M.S., Ophthalmology, FRF)- Drishti Eye Hospital, Madan Mahal main road, Jabalpur-2
Session dated: 20-02-2005, Hotel Krishna. Dinner meeting sponsored by Ajanta Pharma.

Important Features of Retina

o Translucent Structure - 0.5mm / 0.2mm / 0.1mm
o Sensory Retina a continuous sheet of tissue
o Extends from Optic Nerve to Ora Serrata.
o Firmly Attached at Ora Serrata & Optic Nerve
o Retina is derived from inner layer of embryonic optic cup.
o RPE from outer layer of the cup.
o No junction system between Retina & RPE

Forces of Retinal Adhession

o Viscoelastic tamponade of Vitreous Gel.
o Hydrostatic Intraocular Pressure.
o Transretinal Fluid Gradient
o Interphotoreceptor Matrix (RPE). Acts as Glue
o Suction forces of RPE Pump. Bd Retinal Barrier
o Choroidal Concentration gradients:

(a) Ionic Forces
(b) Osmotic Forces
(c) Oncotic Forces

Normal Adhesion Forces

Areas of Adhesion of Vitreous & Retina

Surgical Anatomy of Macula

o 5.5mm in Diameter & Within Temporal Arcades
o Double Layered ganglion cells
o Consists of :
1. Umbo- Basal Lamina, Muller Cells, Cones, 0.13mm
2. Foveola- 0.35mm, Cones & Muller Cells, 0.55mm
3. Fovea- 0.5mm, Capillary & Rod Free,
4. Parafovea- 0.5mm around Fovea, 10 layers of Retina, 4- 6 layers of Ganglion cells, 7-11 layers of Bipolar Cells
5. Perifovea- 1.5mm belt around Parafovea,
6. Peripheral Retina- 1.5mm at near periphery, 3mm at Mid periphery, 10-16mm at Far periphery

Schematic of Retinal Tear with RD -

Clinical Types of RD

o Rhegmatogenous - Retinal Tear
o Nonrhegmatogenous - No Tear Exudative & Tractional

Causes of Rhegmatogenous RD

o Peripheral Retinal Lesions
o PVD - Age, Yag, Vit-He, Inflammation, DM
o Myopia
o Ocular Sx- Cataract, TPPV, PKP, Ant Vit
o Scleral Perforation
o Trauma
o Ocular Inflammation / Infection- CMV retinitis, ARN, Pars Planitis, Toxocara, Toxoplasma
o Coloboma of Choroid & Retina
o Retinoschisis- Senile & X-Linked Juvenile
o Marfan's Syndrome, Wagner-Jansen-Stickler's Synd., Goldman- Favre, Homosystineuria, Ehlers-Danlos Synd.

Causes of Tractional RD

o PDR
o Sickle- Cell Retinopathy
o ROP
o Familial Exudative Vitreoretinopathy
Causes of Exudative RD
o Choroidal Tumours
o Harada's Disease
o Posterior Scleritis
o Idiopathic Central Serous Chorioretinopathy
o Idiopathic Uveal Effusion Synd.
o Nanophthalmos
o Malignant Hypertension
o Toxemia of Pregnancy
o Collagen Vascular Disease
o Retinal Telangiectasia
o DIC, Optic Nerve Pit, Morning Glory Synd

OPTIC NERVE PIT - Pre-LASER/Post-LASER

Rhegmatogenous RD

o Physical Rupture of Retinal Tissue -Break
o Acess of fluid into the Subretinal Potential Space
o In Majority of RRD a Break is seen with IO
o In others a Small Atrophic Hole -3 Mirror
o In small percentage No Breaks can be found
"Un-Holy RD"

Symptoms of RD

o Flashes of light "Photopsiae"
o Floaters "Tobacco Dust"
o Shimmering Vision - wavy or watery quality
o Obscuration of Visual Field- "Dark Shadow"
o Blurring of Central Vision
o Sudden Loss of Vision- Vit. Haemorrhage

Signs Of RD

o Bullous Contour
o Tortuous Vessels
o Corrugation of Retinal Surface
o Undulating movement, Ripples Like a Parachute
o Retinal Breaks
o High Risk Characteristics:
Anterior Vitreous Pigment Granules -14% Tear
Vitreous Cells, Preretinal or Vit Haemorrhage

Types of Retinal Breaks

o Horse Shoe Tear (Flap Tear) (aka HST)
o Arrow Head Tear
o Operculated Tear- Strong Vit Traction
o Giant Retinal tears- 90 Degree or more
o Retinal Dialysis - Posterior Edge is Attached to the Vit Base,- No Curling
o Atrophic Holes- No Vit Traction

HST

HST with RD

ATROPHIC HOLE

DOUBLE HST

GIANT RETINAL TEAR

HST

MACULAR HOLE

Lincoff's & Giesser's Rule

RD in Both Quad. On same side

Sub-Total RD- Both Upper Quad.

RD One Upper & Both Lower Quad

High Total Bullous RD

Near Total RD

RD with Posterior attached Retina

Superior Bullous RD

Inferior Low RD - Bisecting Line

Highly Elevated Inferior RD- Gutter

Longstanding RD with Demarcation Lines

Peripheral Conditions Associated with Retinal Tears

o Lattice Degeneration
o Vitreoretinal Tufts
o Meridional Folds

1. Lattice Degeneration

o An Area with Absence of ILM
o Overlying Area of Liquefied Vitreous
o Condensation & Adherence of Vit Gel
o Inner Retinal Layer Atrophy
o Incidence- 8% to 10%
o In RRD Lattice account for 20%
o In 30% to 40% RD caused by LD- Atrophic Holes
o Majority of RD by LD are caused by Tear at Posterior Edge of LD
o Retinal Tears form after PVD
o Radial or Perivascular LD - Severe type of RD
o Sticklers Syndrome - 47% Bilateral RD

Pathogenesis of Lattice Degeneration

o Localized Vitreous Traction
o Primary Retinal Vasculopathy
o Localized Anomaly of ILM

Schematic of Lattice Degeneration

Management of Lattice Degeneration

o Lattice without Retinal Breaks - No Rx
o Lattice with Atrophic Holes - No Rx
o Lattice + Holes+ Sub clinical RD - Treat
o Lattice+ Traction Tear -
Treat : If Fellow eye has RD
Strong Family History of RD
Aphakic Eyes
o Asymptomatic Traction Tear - No Rx
o Acute Symptomatic Tears - Treat in Phakics & Aphakics

2. Vitreoretinal Tufts

o Small Peripheral Retinal Elevation
o Focal Vitreous Traction
o RPE Hyperplasia surrounding the Tufts
o Excessive VR Traction - Retinal Tears
o Small Clumps of Peripheral Pigments may provide a clue to identify Retinal Tears

3. Meridional Folds

o Congenital Pleat of Retinal Tissue underlying Vitreous Base
o Usually Located Supranasally
o Associated with Dentate Process of Ora Serrata, may extend posteriorly between Oral Bays
o With enlarged Ciliary Process Meridional Complex
o Retinal Tears seen in the thin retina at the Posterior Limit of these Folds

Meridional Folds Image 1

Meridional Folds Image 2

Peripheral Conditions Not Associated with RD

o Typical Microcystoid Degeneration
o Reticular Microcystoid Degeneration
o Cobblestone Degeneration
o RPE Hyperplasia
o Congenital Hypertrophy of RPE
"Bear Tracks"

1. Microcystoid Degeneration

o Progressive cavitation of outer Plexiform & Inner Nuclear Layers
o Reticular Microcystoid Degeneration -18%
o May lead to Retinoschisis
o Have negligible clinical significance
o Typical & Reticular Microcystoid Degn. are precursers of Typical & Reticular Retinoschisis

2. Cobblestone Degeneration

(Paving stone)
o Atrophy or Absence of Outer Layers of Retina
o Loss of RPE
o Absence of Chriocapillaries
o Lesions occur as Single or Confluent areas
o Not related to Primary RD
o Sometimes Retina Tears occurs along the Posterior Edge of Cobblestone Degeneration

Cobblestone Degeneration Image

3. RPE Hyperplasia

o Posterior to the Ora Serrata along the Vitreous Base
o Not associated with RD
o Should not be confused with Lattice Deg.

4. Congenital Hypertrophy of RPE

o Large, Well Demarcated, Usually Black area
o May contain Round Lacunae of normal Retinal colour
o Often surrounded by a Halo
o As a Wedge-shaped area of small pigmentation
o Apex pointing to the Optic Nerve- Bear Tracks
o Histologically: Enlarged RPE cells, with Large Spherical Melanin Granules, or Macromelanosomes
o No Retinal Breaks
o If seen Bilaterally - Rule our Gardner's Syndrome
Carcinoma COLON

Congenital Hypertrophy of RPE Image

Bear Tracks Image

Vitreous Conditions / PVD

o Posterior Vitreous body separates from Retina
o Collapse of Vitreous Gel anteriorly towards Vitreous Base "Syneresis"--- "Vitreoschisis"
o Collagen Fibres in Vitreous Base are firmly attached to Basement Membrane of Retina & Pars Plana Epithelium
o Retinal Breaks seen at Posterior to Vit. Base
o 2mm to 3mm posterior to Ora - 360 degrees
o Vitreous attached to Anterior Edge of Tear / Flap

PVD Image

PVD & Mechanics of Retinal Breaks Image

PVD

o Spontaneous event
o Incidence increases with Age / Large Axial Length
o 27% bet 60-69yrs
o 63% above 70yrs
o Higher in Aphakics & Myopes
o Symptoms of Flashes of Light / Floaters
o Floaters- Weiss Ring, RBC & Cells from Optic Disc, Aggregation of Collagen Fibers

Incidence of Retinal Tears with PVD

o 10% to 15% with symptoms of PVD have Retinal Tears
o With Vitreous Haemorrhage incidence is 70%
o Without Haemorrhage - only 2% to 4%

Traumatic Retinal Breaks

o Blunt Trauma
o Anteroposterior Compresses the Globe
o Retinal Breaks- Infratemporally & Supranasally
o Avulsion of Vitreous Base with no Retinal Tear
o Acute Retinal Breaks with Vit Hem. & PVD - More dangerous
Mechanism of Trauma Image

Treatment of Retinal Breaks

o Aim - Chorioretinal Scar at Posterior & Anterior Edges
o Symptomatic HST -Treat
o Cryopexy & Laser Retinopexy
o Lattice without symptoms- Don't Treat
o Treat
o Symptomatic Lattice with Breaks
o Lattice with Retinal Breaks in other part
o Lattice with High Myopia & RD in fellow eye

Treatment of RRD

o Aim- Anatomically repose the sensory Retina to the RPE Chorioretinal Scar
o Retinal Break- Cryo / Laser
o SRFD
o Retinal Break supported & closed (Externally / Internally)
o Scleral Buckling - Silicon Tyre / Band / Sponge / Fascia Lata / Temporary Balloon
o Pneumatic Retinopexy- Air / SF6 / C3F8 / C2F6
"Positioning of patient"
o TPPV- Gas / Silicon Oil Tamponade

Examination of Retina

o Indirect Ophthalmoscope
o Goldman,s Three Mirror Lens
o 90 D Lens
o Mainster's Quadriscopic Lens
o Rodenstock Panfundoscopic Lens
o USG
o OCT
o UBM

Retinal Diagram Image

Basics of RD Surgery (1/Cryo, 2/SRDF, 3/Buckling)

Complications of RD Surgery

o Corneal
o Conjunctival / Tenons capsule
o Squint
o Scleral- Perforation , Intrusion of Buckle
o Compression of Vortex Veins - Effusion
o Anterior Segment Ischaemia
o Raised IOP - Retinal Ischaemia
o PVR & Redetachment
o Cataract - Gas, Silicon Oil
o Emphatic Buckle
o Infection - Buckle or Endophthalmitis

Pneumatic Retinopexy

CRYO / LASER SRFD?? AIR+GAS SF6 / C3F8/C2F6
Indications of Pneumo-Retinopexy
o Isolated superior Break less than 1 Clock Hrs.
o Multiple sup. Breaks within 1 Clock Hrs
o Macular Breaks or Posterior Breaks
o Redetachment after RD Sx due to Superior Break
o Fishmouthing of HST after RD Sx

Contraindication of PR
o Multiple Breaks over more than 1 Clock Hrs.
o Single Large Break > 1 Clock Hrs.
o Breaks in Inferior 4 Clock Hrs.
o PVR of Grade C or more
o Uncontrolled Glaucoma
o Hazy media & Poor preoperative Assessment
o Physical Disability

Complications of PR
o New or Missed Breaks, Reopening of Breaks
o PVR changes
o Redetachment
o Persistent SRF
o Macular Pucker
o ERM formation
o Vitreous Haze
o Sub-Retinal gas, Sub-Retinal Pigment Migration
o Raised IOP
o Lens Opacities, Dislocation of IOL
o Bullous Keratopathy

VR surgery (TPPV)

PVR

o Ugly Complication of Retinal Sx & Large HST
o RPE, Glial, Totepotent cells proliferate on the Inner & Outer surface of the Retina
o Contraction of Surface Membranes - Fixed Retinal Folds, Equatorial Traction, Anterior Loop Traction
o Creates New Retinal Breaks, Reopens Old Breaks
o Cause TRD

Grades of PVR

Grade-A : Clouding of Vitreous Cavity
Grade-B : Surface Wrinkling + Rolled or Irregular Edges of Breaks
Grade-C : Full- thickness Rigid Retinal Folds
Equator Divides Grade-C :
(P) Posterior Form
(A) Anterior Form
Extent of Proliferation Expressed in Clock Hrs 1-12
PVR Grade-C - Types of Contraction
Type -1:P Focal Contraction- Starfolds
Type -2:P Diffuse Contraction, Confluent Irregular
Fullthickness Retinal Folds-Disc not seen
Type -3:P Sub-Retinal Proliferation + Fixed retinal
Folds - "Napkin Ring"
Type -4:A Irregular Circumferential Retinal Folds
Type -5:A Smooth Circumferential Retinal Folds
Type -6:A Anterior Displacement of Vitreous Base
Anterior Loop Traction

PVR Clouding of Vitreous Cavity Grade A

PVR Grade B

PVR Grade C -Type - 1

PVR Grade C - Type - 2

PVR (Contraction of Membranes)

Grade C + Type 3

PVR Grade C - Type - 4

PVR Grade C - Type - 5

PVR Grade C - Type-6
(Anterior Loop Traction)

Retinoschisis

o Acquired -Senile, Degenerative-Split-OPL & INL
o Congenital - Juvenile, Heriditary, Developmental-
Splits in NFL
3. Secondary -
Trauma, Battered Baby Syndrome
Fundus Disease: PDR, Regressed ROP, Sickle Cell Retinopathy, Occlusive Vascular Disease, Chronic RD, Optic Nerve Pit, Peripheral Uveitis, Tumours, Phakomatosis, Good Pasture's Synd.

Typical or Acquired Retinoschisis - OPL

Reticular or Congenital Retinoschisis- NFL

Acquired Retinoschisis

o More Common - 4% to 20% above 40 Yrs
o Equally affects M & F
o Splitting occurs in OPL & INL- Cystoid Degeneration.
o Typical RS- Bullous
o Reticular RS -Flat, Cystoid Degn.
o Starts in Periphery Inferotemporal / Supratemporal
o Outer Surface is smooth does not Undulate
o White with Pressure (WWP) sign on Outer Layer
o Outer Layer has multiple Reddish round spots Fish Egg
o Inner Layer - Pitted Appearance on its back
o Test - Indirect Ophthalmoscopic Perimetry

Optic Nerve Pit

DD of RRD / Retinoschissis

o Degenerative Retinoschisis : Typical- Outer Plexiform or Reticular Type - Nerve Fibre Layer (Less Common)
o Demarcation Lines or RPE Abnormalities not seen in Schisis cavity
o Bubbling Shiny Appearance- Cystoid Degeneration.
o Snowflake Frosty appearance- Muller Cell Foot Plate
o Schisis Cavity is Dome Shaped -Thin Smooth Inner Wall
o Schisis inner wall moves like Jelly -RD Undulates
o RS asymptomatic No TabacoDust / Haemorrhage
o Outer Layer develops Atrophic Holes Degenerative Retinoschisis


DD of RRD / Exudative RD
o Breakdown of Blood-Retinal barrier
o Serous Fluid bet RPE & Photoreceptors

Signs
o No Retinal Breaks
o Smooth "Blister Like"
o No Corrugations of Retinal Surface
o Shifting Subretinal Fluids

Forces Predisposing to Ex RD
o Inflammatory Disorders
Harada's Dis, Sympathetic Ophthalmia, Ischaemia- Toxemia & Malignant HT,
o Retinal Vascular Disorders Coats'Disease, Hemangioma, Sick RPE as in ARMD & CSR, Reduced Flow through Bruch's Membrane
o Tumours - Melanoma, Ch Hemangioma, Metastases
o Hemorrhage

Retinal Vascular Disorder - Coats' Dis. Hemangioma

"Sick" RPE Pump & Bruch's Mem - Drusen

Choroidal Inflammation- Harada's Dis, Post. Scleritis, Sym. Ophthalmitis

Choroidal Tumours - Melanomas Hemangiomas

Exudative RD - Sub-Retinal Hge

Ex RD - Sub-Retinal Exudation / Hge
Exudative RD

DD of RRD / Traction RD
o Charactristic Concave Configuration
o Vitreous Membranes / PVR Changes
o Massive Subretinal Hem / Choroidal Tumours / RD must be differentiated

TRD

TRD - PDR

Forces Predisposing to TRD

o Vascular Proliferative Retinopathy PDR, Sickle Cell Retinopathy, BRVO, ROP
o Proliferative Vitreoretinopathy PDR
o Scar Tissue Formation Penetrating Injury

DD of RRD / Uveal Effusion

CAUSES of Uveal Effusion:
o Ocular Hypotony
o Inflammation - Uveitis, Scleritis, Orbital Cellulitis, Laser or Cryotherapy, Surgical or Non-Surgical Trauma
o Compromised Uveal, Scleral, Vortex Venous drainage
o Dural Arteriovenous Fistula
o Thickened Sclera - Nanophthalmos

DD of RRD / Uveal Effusion
Idiopathic Uveal Effusion Syndrome (IUES)
o Exudative detachment of Peripheral Choroid, Ciliary Body, Peripheral Retina, or Macula in Normal sized eye. - Unlike Nanophthalmos
o Healthy Middle Aged Males
o Mild to Moderate Hyperopes
o Second eye involvement- Weeks to Years
o No Anterior Chamber Involvement
o Prolonged Remission & Exacerbation of Ex RD
o Secondary Leopard-Spot pattern of RPE
o Reduced Vision -due to Chronic RD

DD of RRD / Choroidal Effusion
o Shifting of Sub Retinal Fluid
o Protein content 2 to 3 times of plasma
o Pathogenesis not known
o Thickened Sclera - Obstructing Venous Outflow
o Vortex Vein Hypoplasia

Shifting of Fluid - Choroidal Effusion

Treatment for Choroidal Effusion
o Idiopathic Form do not respond to Steroids
o Or Surgical SRFD, Scleral Buckling
o Thickened Sclera - Segmental Partial or Full Thickness "Window" Scleral Resection
o Nanophthalmos: Vortex Vein Decompression

DD of RRD / Choroidal Detachment
o Accumulation of Serous or Hemorrhagic Fluid between Choroid & Sclera
o Normal apposition of Choroid & Sclera & Normal Fluid Transit in Supra-Choroidal space Depends on balance between Hydrodynamics & Oncotic Forces
o Pressure in Supra-Choroidal space is lower than IOP - Hydrostatic Forces

Causes of Serous Choroidal Detachment
o Hypotony or Vortex Vein Compression-
Scleral Buckling, Thick Sclera, Increased Ophthalmic venous Pressure
o Altered Hydrostatic Forces
o Abnormal Vascular Permeability
Surgical & Non-surgical Trauma, Ocular / Periocular Inflammation, Ischaemia
o 3% after Cataract Sx,
o 68% Transient Serous CD after LASER PRP
Signs of Serous Choroidal Detachment
o Subtle AC Shallowing - Ciliary Body Rotation
o Highly Elevated Smooth, Solid Orange Brown Lobes in the Retropupillary area
o Absence of Retinal Breaks
o Elevation of Pars plana
o Smooth Lobular Contour of Elevation
o USG- Suprachoroidal Serous Fluid- Rules out RD & Neoplasm
o Hypotonic & Inflammed Eye
o Often there is Exudative RD

Hemorrhagic Choroidal Detachment
o Trauma
o Immediate or Delayed Complication of Ocular Surgery

Signs of Immediate Suprachoroidal Hemorrhage
Signs:
o Abrupt Rise of IOP
o Shallowing of AC
o Iris Prolapse
o Dark Red-Brown Elevation behind Pupil
o Expulsive Hemorrhage

Delayed Suprachoroidal Hge
Glaucoma Filtering Sx - Myopes & Aphakics
Symptoms: Pain, Nausea, & Vomiting
Signs:
o Raised IOP
o Flat AC
o Loss of Red Reflex
o Dark Lobes behind Pupil
o Vitreous Hemorrhage may be associated
o B-Scan - Suprachoroidal Echogenic Clot

Treatmant of Choroidal Detachment
o No T/T for Post surgical & Post Laser Choroidal Detachment
o Hypotony: Look for Wound Leak
o Inflammation: Steroids
o Shallow Ac:, Risk of PAS:, & Endothelial Damage : Drianage of Choroidal Detachment & Reform Anterior Chamber

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