Rhegmatogenous Retinal Detachment

Nawat Watanachai 2012

Little QUIZ (10min)

1. how to differentiate RRD/TRD/ERD from fundus findings?

2. risk of PVR 3. contraindication for pneumatic

retinopexy 4. compare PPV vs SBP for RRD 5. compare laser vs cryo retinopexy

Retinal Detachment: Definition separation of the inner layers of the

retina from the underlying retinal pigment epithelium (RPE, choroid)

RD: Pathophysiology

3 basic mechanisms: 1. Rhegmatogenous retinal detachment (RRD) 

2. Exudative retinal detachment (ERD)

3. Traction retinal detachments (TRD)

The Vitreous

Water 98-99% water 1-2%

collagen type II fibres* salts, sugars glycosaminoglycan, hyaluronic acid

very few cells mostly phagocytes hyalocytes of Balazs (surface/ hyaluronate)

refractive index of 1.336

The Vitreous *

Condense and attach more atOptic disc rimAlong blood vesselsMaculaPeripheral retinal abnormalities

○ Chorioretinal scar○ Lattice degeneration and others

Ora serrata (Vitreous base: 2mmA, 4mmP)

Vitreous degeneration/ syneresis

Posterior Vitreous Detachment

Posterior Vitreous detachment

Weiss ring

Posterior vitreous detachment Prevalence increase with

AXL age

○ < 10% at < 50 yrs○ 30% at 50-70 yrs ○ >60% at > 70 yrs

Other associateCataract Sx, within 2 yrs after surgery

○ ICCE 84% = ECCE c PC tear76% ○ ECCE c intact PC40%○ PE 30%

inflammation / uveitis trauma syndromes

Posterior vitreous detachment

Symptomsmost asymptomaticphotopsia

○ physical stimulate of vitreoretinal tractionfloaters

○ Weiss ring and V.condensation in the posterior hyaloid surface

○ vitreous opacity eg. blood , glia cell VH rupture of retinal vessel

Vitreo-retinal adhesion

-Chronic traction hyperpigmented area-Acute traction retinal break/ tear

Retinal Break/ tear

Rhegmatogenous retinal detachment

- A hole, tear, or break in the neuronal layer

- allowing fluid from the vitreous cavity to seep in between and separate sensory and RPE layers

RB and PVD*

acute symptomatic PVD 15% retinal tear

PVD with VH 50-70 % retinal tear

PVD without VH 10-12 % retinal tear

Risks of RRD 1 *

Posterior vitreous detachment Peripheral retinal lesions

enclosed oral baysmeridional foldscystic retinal tuftlattice degeneration

Myopia Senile retinoschisis Cataract extraction Trauma

Risks of RRD 2 *

Intraocular inflammation/infection-Acute retinal necrosis syndrome

-Cytomegalovirus retinitis

-Ocular toxocariasis

-Ocular toxoplasmosis

-Pars planitis

Risks of RRD 3 *

Choiroid/ retinal coloboma Lens coloboma Stickler syndrome Goldmann-Favre syndrome Marfan syndrome Homocystinuria Ehlers-Danlos syndrome

Mortality/Morbidity*

1: 10,000 population : yr 15% of people with RD in one eye

develop RD in the other eye. (lifetime)

Risk of bilateral RD is increased (25-30%) in patients who have had bilateral cataract extraction.

History Floaters Flashing light (photopsia) Shadow in the peripheral visual field Decreased visual acuity and a wavy

distortion of objects (metamorphopsia)

History Detachments anterior to the equator are

very unlikely to affect the VF Detachment posterior to the equator can

be isolated with visual field testing, but many patients aware of a defect only when it involved the posterior pole and macula.

Photopsia and floaters not helpful in locating the position of the retinal tear or detachment

visual field defect very specific for locating the detachment.

History

FHx of RRD History of trauma previous surgery

cataract extraction/ esp c cpx (-L-’)intraocular foreign body removalretinal procedures

Physical examination VA/ VF IOP : hypotony of >4-5 mm Hg less than

the fellow eye is common Vitreous

tobacco dust (Shafer’s sign), pathognomonic for a retinal tear in 70% of cases with no previous eye disease or surgery.

Physical examination

Indirect ophthalmoscopy with scleral depression

A 3-mirror contact lens examination with a slit-lamp

marked elevation of the retina, which appears gray with dark blood vessels that may lie in folds.

Physical examination

Retinal detachment

Which one is this case?1. Rhegmatogenous retinal detachment (RRD) 

2. Exudative retinal detachment (ERD)

3. Traction retinal detachments (TRD)

Is this RRD/ TRD or ERD *

symptoms RRD TRD ERD

floaters ++ +/- +/-

flashing ++ - -

Progression of VA

loss

acute chronic Subacute/ chronic

Fluctuation of vision

- +/- +

Is this RRD/ TRD or ERD *

signs RRD TRD ERD

Shaffer’s sign

+ - -

PVD ++ - +/-

VH +/- +/- -

RD contour convex concave bullous

RD surface corrugate Ridge/ wavy smooth

shifting +/- - ++

associated Myopia/ trauma/ Sx

DM CTD

Workup for diagnosis Lab study – unhelpful Imaging – not necessary in most cases

Poor visualization B-scanWeird cases

○ IOFB/parasite

CLINICAL FEATURES

Early Long standing

CLINICAL FEATURES:early

Earlyretina lost transparency and assumes a

gray, translucent appearancefine, irregular corrugations usually present

○ result of intraretinal edema

Recent rhegmatogenous retinal detachment showing loss of the normal retinal transparency and irregular corrugations

CLINICAL FEATURES : early

fine details of the choroidal vasculature obscured by overlying detached retina

within days of RRDouter retinal degeneration starts to occurphotoreceptor damage related to height and

duration circulation of inner retina not affected

CLINICAL FEATURES : early

If retina reattached within a weekmost of cellular changes reversible

RPE cells underlying RRD released into SRF and may pass through RB into vitreous cavitytobacco dust 70% of case

CLINICAL FEATURES :early

Lincoff and Geiser reported 4 guidelines for locating RB causing RRD *determined by

○ location of causative break○ anatomic barriers (optic n.,ora serrata,

existing chorioretinal adhesions)○ effect gravity on SRF in upright

position

Note : only for fresh RD with 1 RB

ป๋�า harvey lincoff ณ NEI

Lincoff rule

total or superior RD that cross midlineprimary hole usually

within 1 clock hr. of 12-o'clock meridian

If detachment extends more inferiorly on either nasal or temporal sideRB usually on same

side of 12-o'clock meridian

Lincoff rule

superotemporal RDRB lies near superior edge of detached retina

superior nasal or temporal RDRB lies within 1.5 clock hr. of the highest border 98%

Lincoff rule

inferior RDhigher side indicates

which side of the disc an inferior hole lies 95% of the time

inferior detachment is bullousprimary hole lies

above horizontal meridian

CLINICAL FEATURES:long standing

LONG-STANDINGprogressive atrophy of all retinal layers smooth contour and semitransparentsome cases, cystic spaces atrophy and depigmentation of underlying

RPE

CLINICAL FEATURES :LONG-STANDING

RRD ≥ 3 mo.RPE metaplasia at border of detachment

Most RRD surrounded by demarcation line eventually progress; nonetheless, surgical repair of these eyes has an excellent prognosis

CLINICAL FEATURES :LONG-STANDING RRD > 6 mo.

Subretinal fibrosis

CLINICAL FEATURES :LONG-STANDING

RRD > 1 yearintraretinal cystcan resolve if retinal reattach

CLINICAL FEATURES :LONG-STANDING

very long-standing extensive capillary nonperfusion lead to

peripheral retinal NVIOP can rise

○ TM impeded by pigment clumps or the outer segments of photoreceptors

PROLIFERATIVE

VITREORETINOPATHY

occurs ~ 10% of all RRD which ¼ require additional surgical intervention

most common cause of failure to repair risk factor

aphakia , preop PVR , extensive RD , uveitis , excessive cryo, GRT, massive VH

ClassificationRD with vitreoretinopathy1983*

GradeGrade NameName SignsSigns

AA MinimalMinimal vitreous haze ,pigment clumpvitreous haze ,pigment clump

BB ModerateModerate wrinkling inner retinal surface,roll edge RB , wrinkling inner retinal surface,roll edge RB , retinal stiffness , vessel tortous retinal stiffness , vessel tortous

CC MarkedMarked full thickness fix retinal fold full thickness fix retinal fold

C1,C2,C3C1,C2,C3

DD Massive Massive full thickness fix retinal fold 4 quadrants full thickness fix retinal fold 4 quadrants D1 wide ,D2 narrow D1 wide ,D2 narrow D3 close not seen optic disc D3 close not seen optic disc

Classification of PVR 1991*

gradegrade featuresfeatures

AA vitreous haze ,pigment clump,pigment cluster inferior vitreous haze ,pigment clump,pigment cluster inferior retinaretina

BB wrinkling inner retinal surface,roll and irregular edge RB , wrinkling inner retinal surface,roll and irregular edge RB , retinal stiffness , vessel tortous ,retinal stiffness , vessel tortous ,vitreous mobility , vitreous mobility ,

CP1-12CP1-12 posterior to equator : focal , diffuse ,or circumferential full posterior to equator : focal , diffuse ,or circumferential full thickness fold , subretinal strandsthickness fold , subretinal strands

CA1-12CA1-12 anterior to equator : focal ,diffuse ,or circumferential full anterior to equator : focal ,diffuse ,or circumferential full thickness fold , subretinal strandsthickness fold , subretinal strands

Management RRD Retinal repositioning

Push the retina-eyewall○ Pneumatic retinopexy○ Scleral buckle procedure○ vitrectomy

Remove SRF/ perfluorocarbon liquidRemove fibrous membrane/traction

Seal the break(s)CryoretinopexyLaser retinopexy

Temponade the retinaGas/ silicone oil

Retinal Repositioning

○Pneumatic retinopexy○Scleral buckle procedure

Scleral balloon

○vitrectomy

Pneumatic retinopexy *

intravitreal gas tamponade RB temporary100%C3F8 4X at 72 hrs

SRF will resolve Need laser / cryo to permanently close the

RB

Pneumatic retinopexy*

ContraindicationsBreak > 1 clock hr Break inferior 4 clock hrPVR grade C,DCloudy ocular mediaUncontrolled or severe glaucomaCan’t maintain position

Pneumatic retinopexy

Relative contraindicationsExtensive lattice degenerationAphakia or pseudophakia

Results PR

50-80% reattach with single PR 60-98% reattach with reoperation

Scleral buckle

Indent sclera with solid silicone Segmental versus Encircling Buckles

Scleral buckle : Segmental *

usually reserved for RRD < 1 clock hourposterior breaks

primary advantage easy of placementminimal refractive error changeavoid effects of large encircling elements

however, for most large posterior breaks , all MH prefer closure with gas and vitrectomy

Scleral buckle : Segmental

not provide retinal support elsewhere vitreoretinal traction away from

segmental element not supported, which may result in formation of new RB

because of limited support , some surgeon prefer encircling when possible

Scleral buckle :encircling

particularly indicated in *multiple breaks in different quadrantsAphakia/ pseudophakiaHigh/pathologic myopiadiffuse vitreoretinal pathologic eg. extensive

lattice degeneration or vitreoretinal degenerations

PVR ≥ grade B

Scleral buckle

Intraoperative complicationsCorneal clouding

○ epithelial edema from IOP risingMiosis

○ hypotony , inflammationScleral perforateDrainage complications

○ retinal incarcerate/perforate○ choroidal hemorrhage

Scleral buckle

Post-op complicationsGlaucomaAnterior segment ischemiaInfection/extrusionCD

○ vortex vein obstrution○ drainage procedure

CME

Scleral buckle Post-op complications

Macular puckerMotility disturbanceChange refractive error

○ greater in phakic eye○ Myopic or hyperopic?

ERD○ cause unknown

Scleral buckle

macula off VA ≥ 20/50 ~ 40-60% duration of macula detachment relate

with final VA VA ≥ 20/40 71% if detach < 10 daysVA ≥ 20/40 27% if detach 11days-6 weeksVA ≥ 20/40 14% if detach > 6 weeks

Temporary balloon

Lincoff’s balloon external device indent

sclera to allow cryotherapy or laser induce choriorertinal adhesion

especial useful ininferior RD when PR not

possible

Vitrectomy

Remove vitreousRemove vitreoretinal traction on RB

FAX Injection of gas or liquid silicone Avoid complication from SB Complete tamponade of vitreous cavity

Vitrectomy

Advantagesbetter intraoperative control in difficult

situationimprove visualization of peripheral breakInternal drainage avoid complication of

external drainage

Vitrectomy

Advantageshigh intraoperative reattach rateremove of vitreous opacityremove capsular opacityinternal photocoagulation / cryotherapy RBdrainage suprachoroidal fluid if present

Vitrectomy

Advantagesless post-op change refractive errorlower incidence of post-op double visionlower incidence of ERDavoid hazard of scleral perferation

Vitrectomy

Disadvantagesdelay visual restitution from gas tamponadeposition after operationair travel avoid

Vitrectomy

Disadvantageshigher rate of cataract in phakic eyehigher rate of iatrogenic breakhigher rate of post-op IOP risinghigher rate of post-op new/miss breakspecial equipmenthigher cost

Vitrectomy

Results Anatomical reattach 64-100% Functional results

VA ≥ 20/50 63%Compare with SB VA ≥ 20/50 39-56%

Seal the break(s)

Diathermy (obsolete) Laser cryo

Laser photocoagulation

usually cannot seal RB if presence SRF may be use to create barrier to prevent

progression of RD esp. useful in

chronic inferior RDsystemic illness contraindicate to surgery

Laser photocoagulation

slit-lamp biomicroscope with contact lens

laser indirect ophthalmoscope (LIO)

endolaser

Laser photocoagulation*

Slit-lampbetter magnified Safer in inexpertise

operatorLess need of corneal

care during laserLess pain

LIOsignificant cataracts,

PCO, mild VH more easily treated with LIO

indentationNeed more skillnot be readily

available Any patient position

A.posteriorly located retinal tear B.treat by laser photocoagulation

Laser photocoagulation *

Compared with diathermy and cryopexyless breakdown of blood–ocular barrierthermal effect confined predominantly to

retina and pigment epitheliumlittle or no effect on choroid or sclerainduces adhesive effect between retina &

pigment epithelium within 24hr

Cryoretinopexy

RD with very shallow fluid can be cure by cryoretinopexy alone

using cryoprobe and indirect ophthalmoscope testing cryoprobe prior to make sure probe is

freezing

Cryoretinopexy

freezing or whitening of RPE will noticed first, followed by delineation of edges of retinal tear and whitening of retina

excessive freezing or ice crystal formation should be avoided

Cryoretinopexy

histologic response depends on whether RPE alone or RPE and overlying detached retina together are frozenonly RPE froze once retina reattached

○ pigment epithelial hyperplasia ○ loss of retinal outer segments ○ normal microvillous interdigitations seen between

retina and RPE are missing

Cryoretinopexy

If both RPE and overlying retina frozencellular connections between retina and RPE

consisting of desmosome formation between retinal glia and pigment epithelium or direct contact between retinal glia and Bruch's membrane

Cryoretinopexy

Disadvantage dispersion of pigment epithelial cells, which can

result in subretinal pigmentary changes after reattachment

dispersion of viable pigment epithelial cells capable of causing PVR following cryopexy

Cryoretinopexy

Some study suggest cryopexy is risk factor of post-op PVR whereas others not show an associationminimize cryotherapy-induced pigment epithelial cell

dispersion by ○ not over treating ○ avoiding unnecessary scleral depression of treated

areas localization and examination with scleral

depression should be performed before cryopexy

Cryoretinopexy : disadvantage

induce choroidal congestion &hyperemia although not permanentmay complicate drainage of SRF through

treated areas

breakdown of BRBcause post-op CME and ERD