RETINAL DETACHMEN

TPresented by: Yogesh kumar tiwari

MSc.Nsg.1st year CON,AIIMS

Moderator:Mrs. Ujjwal Dahiya Lecturer,CON,AIIMS

Introduction• The role of vision in our lives is difficult to define,

because it is so deeply personal and intimate• Whenever there is a failure in the vision, its not

only the eyes, that are said to be in darkness but the whole life is in darkness.

• Loss of vision means loss of independence. Among the various causes of blindness ,retinal detachment is one which is an ocular emergency.

Definition

Retinal detachment is a disorder of the eye in which the retina peels away from its underlying layer of support tissue.

A detached retina is a serious and sight-threatening event.

And unless the retina is reattached soon, permanent vision loss may result.

Anatomy of eyeball

Retina The retina is the inner most layer of the eye. It is composed of nerve tissue. The optical system of the eye focuses light on the retina much like light is focused on the film in a camera.

Layers of retina The retina is composed of 10 layers

Pigmented epithelium

Photoreceptors; bacillary layer (outer and

inner segments photoreceptors)

External (outer) limiting membrane

Outer nuclear

Layers of retina Outer plexiform

Inner nuclear

Internal limiting membrane

Inner plexiform layer

Ganglion cell layer

Nerve fiber layer

Layers of retina

How does retina forms images ?

Vitreous Humour Comprises a large portion of the eyeball

It is a clear gel that occupies the space behind the lens and the retina

Epidemiology The incidence of retinal detachment in otherwise normal

eyes is around 5 new cases in 100,000 persons per year Detachment is more frequent in middle aged or elderly

populations, with rates of around 20 in 100,000 per year The lifetime risk in normal individuals is about 1 in 300 Retinal detachment is more common in people with

severe myopia (above 5–6 diopters), in whom the retina is more thinly stretched. In such patients, life time risk rises to 1 in 20.

About two thirds of cases of retinal detachment occur in myopics. Myopic retinal detachment patients tend to be younger than non myopic ones.

Type

• There are three types of retinal detachment:• rhegmatogenous• tractional• exudative

Types Rhegmatogenous retinal detachment –It occurs due

to a break in the retina (called a retinal tear)

Retinal breaks are divided into three types – holes, tears and dialyses.

TypesExudative, serous, or secondary

retinal detachment –It occurs due to inflammation, injury or vascular abnormalities

Fluid accumulating underneath the retina without the presence of a hole, tear, or break.

Rare

Types Tractional retinal detachment –It occurs

when fibrous or fibrovascular tissue, pulls the sensory retina from the retinal pigment epithelium.

Risk factors

• Severe myopia

• Retinal tear

• Family history

•Other eye diseases or disorders, such as

retinoschisis, uveitis, degenerative myopia, or lattice

degeneration

Risk Factors…• Eye injury

• Tumors

• Systemic diseases such as diabetes & sickle cell

disease

• Complications from cataract surgery

Sign and symptimsWarning signs

Flashes of light (photopsia)

A sudden increase in the number of floaters

Blurred vision Seeing a shadow or a curtain

descending from the top of the eye or across

DiagnosisElicit history for any of the

following:• History of trauma• Previous ophthalmologic surgery• Previous eye conditions (eg,

uveitis and vitreous hemorrhage)

• Duration of visual symptoms and visual loss

DiagnosisPhysical examination should include the following: • Checking of visual acuity• External examination for signs of trauma and

checking of the visual field• Assessment of pupil reaction• Measurement of intraocular pressure in both eyes• Slit-lamp examination• Examination of the vitreous for signs of pigment or

tobacco dust

Diagnosis• Fundus photography or ophthalmoscopy.

Fundus photography : larger instrument than the ophthalmoscope

• Ultrasound

Significance of timely treatment

• Visual improvement is much greater when the retina is repaired before the macula is detached.

• Once the retina is reattached, vision usually improves and then stabilizes.

Treatment General principles of treatment:

1. Find all retinal breaks

2. Seal all retinal breaks

3. Relieve present (and future) vitreo retinal traction

Surgical Methods

Cryopexy and laser photocoagulation

Scleral buckle surgery

Pneumatic retinopexy

Vitrectomy

Cryopexy

Cryotherapy (freezing) is used to wall off a small area of retinal detachment

Uses nitrous oxide to freeze the tissue behind the retinal tear

This prevents fluid passing through the hole.

Laser Photocoagulation• If the retina is torn or the detachment is

slight• Laser burn the edges of the tear and halt

progression.• Stimulates the scar tissue formation to

seal the edges of the tear

Scleral buckle surgery

Surgeon sews silicone bands to the sclera (the white outer coat ofthe eyeball)

The bands push the wall of the eye inward against

the retinal hole

Cryotherapy (freezing) is applied around retinal breaks prior to placing the buckle

Scleral buckle surgery

Subretinal fluid is drained as part of the buckling procedure

The buckle remains in situ The most common side effect of a scleral

operation is myopic shift.

Myopic shift: the operated eye will be more short sighted after the operation

Scleral buckle surgery

Types of scleral buckling:

Radial scleral buckle Circumferential scleral buckle

Encircling buckles

Pneumatic retinopexyGenerally under local anesthesia

Gas bubble (SF6 or C3F8 gas) is injected into the eye after which laser or freezing treatment

The patient's head is then positioned

Have to keep their heads tilted for several days

Reseach input• Problem statement-Outcome of surgery after macula-off retinal detachment – results from MUSTARD, one of the largest databases on buckling surgery in Europe • ABSTRACT. Purpose: To evaluate the anatomical success rate of scleral buckling surgery in the

treatment of rhegmatogenous retinal detachment and to evaluate the differences in outcome between patients suffering macula-off retinal detachment and those without a macular involvement.

• Methods: As a retrospective interventional case series, Munster Study on Therapy Achievements in Retinal Detachment (MUSTARD) is one of the largest ever established of retinal detachment patients and their outcome after buckling surgery, with 4325 patients who underwent surgery between 1980 and 2001. In 53.94% (n = 2134) of 3956 patients with nontraumatic retinal detachment, the macula was involved. The main outcome measure was the achievement of dry anatomical attachment of the retina.

• Results: The success rate in patients with macula-off retinal detachment is 80.46% and thus 7.78% lower (p < 0.01) than that in those patients with their macula intact whose success rate amounted to 88.24%. The overall success rate of all 4325 MUSTARD patients was 83.98%.

• Conclusions: Scleral buckling is an established and mostly successful method for the treatment of retinal detachment. As our case series has demonstrated, even eyes with macula-off can be treated successfully by this procedure, thereby avoiding the complications of primary vitrectomy.

Pneumatic retinopexyThe surface tension of the gas/water interface

seals the hole in the retina

Combined with cryopexy or laser photocoagulation

VitrectomyTiny incision in the sclera Remove vitreousGas is often injected to into the eye During the healing process, the eye makes

fluid that gradually replaces the gas and fills the eye.

Vitrectomy

Using gas in this operation : no myopic shift after the operation

Silicon oil (PDMS), if filled needs to be

removed after a period of 2–8 months

COMPLICATIONS AFTER SURGERY

• Discomfort

• Watering

• Redness

• Swelling

• Itching

• Blurred vision

Prognosis85 percent of cases will be successfully treated with one

operation 15 percent requiring 2 or more operations After treatment patients gradually regain their vision over a

period of a few weeks, although the visual acuity may not be as good as it was prior to the detachment, particularly if the macula was involved in the area of the detachment.

Currently, about 95 percent of cases of retinal detachment can be repaired successfully

Pre operative management• Assess the visual acuity of the client’s non-operative eye

prior to surgery• Assess the client’s support systems and the possible

effect of impaired vision on lifestyle and ability to perform ADLs in the post- operative period

• Safety measures such as installing hand rails,especially if the client has limited vision in the unaffected eye

• Remove all eye makeup and contact lenses or glasses prior to surgery • Mydriatic (pupil-dilating) or cycloplegic (ciliary- paralytic)

drops and drops to lower intraocular pressure may be prescribed preoperatively.

POST – OPERATIVE MANAGEMENT

• Monitor status of the eye dressing following surgery.• Assess dressings for the presence of bleeding or

drainage• Maintain the eye patch or eye shield in place. The eye

patch or shield helps prevent inadvertent injury to the operative site

• Place the client in a semi-Fowler’s or Fowler’s position , having the client lie on the unaffected side.These positions reduce intraocular pressure in the affected eye.

• Assess the client and medicate or assist to avoid vomiting coughing , sneezing or straining as needed. These activities increase intraocular pressure

Contd…• After surgery for a detached retina,the client is

positioned so that the detachment is dependent or inferior.

For example , if the outer portion of the left retina is detached , the client is positioned on the left side . Positioning so that the detachment is inferior maintains pressure on that area of the retina, improving its contact with the choroid.

• Assess comfort and medicate as necessary for complaints of an aching or scratchy sensation in affected eye . Immediately report any complaint of sudden, sharp eye pain to the physician.

Contd…• Assess for potential surgical complications:

a. Pain in or drainage from the affected eye b. Hemorrhage with blood in the anterior chamber eye c. Flashes of light, floaters, or the sensation of a curtain

being drawn over the eye (indicators of retinal detachment) d. Cloudy appearance to the cornea (corneal edema)

• Evidence of any of the above manifestations or unusual complaints by the client should be reported to the physician at once

• Approach the client on the unaffected side.This approach facilitates eye contact and communication.

Contd…• Place all personal articles and the call bell within easy

reach . These measures prevent stretching and straining by the client

• Assist with ambulation and personal care activities as needed. Assistance may be necessary to maintain safety

• Antibiotic ,anti-inflammatory and other systemic and eye medications as prescribed . Medications are prescribed post operatively to prevent infection or inflammation of the operative site, maintain pupil constriction , and control intraocular pressure

• Administer antiemetic medication as needed. It is important to prevent vomiting to maintain normal intraocular pressures

Home care• Adequate lighting• Promote unrestricted ambulation• Removal of hazards like rugs, clutters, unnecessary

furnitures• Provision of hand rails in hallways, bathrooms• Access to radio and television• Voice activated switches• Pill organizers• Large print newspapers, magazines

Contd…• Double vision• Glaucoma• Bleeding into the vitreous, within the retina,

or behind the retina• Cataract• Drooping of the eyelid• Infection around the scleral buckle• Endophthalmitis

Prognosis Treatment failures usually involve either the failure to recognize all sites of detachment, the formation of new retinal breaks,or proliferative vitreo retinopathy Involvement of the macula portends a worse prognosisDamage to vision may occur during reattachment Surgery 10 percent of patients with normal vision experience some vision loss after a successful reattachment surgery.

Conclusion Visual impairment is more than a physiologic

deficit. It is a loss that has physical and emotional

effects on the person afflicted. So as far as possible prevent those causes of

blindness.