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RETINAL DETACHMENT PROF. DR. ŞENGÜL ÖZDEK

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  • RETINAL DETACHMENT

    PROF. DR. ŞENGÜL ÖZDEK

  • Histoloji

  • Anatomy

  • RETINAL DETACHMENT

    • Separation of the neurosensory retina from

    retinal pigment epithelium.

    • Incidence 1 / 10.000, Risk is 3% until the age

    of 80

    • Bilaterality 10%

    • Most common: 40-70 year-old

  • TYPES

    • RHEGMATOGENOUS RD

    • TRACTIONAL RD (PDR, VENOUS OCCLUSIVE

    DISEASE…)

    • EXUDATIVE RD (ECLAMPSIA, KMM)

  • • Vitreous pressure

    • Passive fluid flow from vitreous to

    choroid

    • RPE tight junctions

    • RPE active ion transport

    • Bruch membrane (flow from RPE to

    choroid)

    • Concentration gradients (ionic,

    osmotic)

    The powers holding retina in place

  • RRD

    Develops in three stages

    • Posterior vitreous detachment

    • Retinal break / tear

    • Retinal detachment

  • Posterior Vitreous Detachment

    Stronger adhesions:

    • Vitreous base

    • Around the optic nerve head

    • Macula

    • Retinal big vessels

    • Around the retinal degenerations areas

  • ACUTE PVD

    After development of synchisis

    in some persons, small breaks

    occur in posterior vitreous

    cortex and liquefied vitreous

    passes to retrohyaloid space

  • ACUTE PVD

    • The remaining solid vitreous collapse down and retrohyaloid space filled with sinchitic fluid: PVD

    • Sensorial retina lacks protection

    • Sensorial retina is vulnerable to vitreoretinal traction

  • PVD

    • More in elderly, myopics, aphakic /

    pseudophakic patient and people exposed to

    trauma

    • Mostly asymptomatic

    • Photopsia (flashes of light)

    • Gliotic tissue which adheres to the posterior

    hyaloid membrane where papilla and vitreous

    opacities: Floaters (flight of fly)

  • Acute PVD Complications

    • Retinal Tear

    • Macular Hole

    • Epiretinal Membrane

  • Acute PVD’s Complications

    • Vessel avulsion

    • Vitreous hemorrhage

  • Peripheral retinal degenerations

  • Lattice degeneration (lattice = wire netting)

    • Most important peripheral

    degeneration

    • It is a band-shaped retinal thinning, in

    front of the equator, parallel to the

    ora serrata, which contains lines in the

    form of wire netting.

    • atrophy starts from the inner limiting

    membrane and spreads to the other

    lines

    • In the middle of degeneration vitreous

    is liquefied but at the edge of

    degeneration vitreous is attached

  • Retinal break

    Horseshoe tears

    Holes

    Disinsertion ( dialysis )

  • HORSE-SHOE TEAR

    The most common reason for RD

    • The apex located toward to

    central

    • Photopsia + Floaters +

    • If accompanied by the rupture

    of blood vessels: blurred

    vision

  • Retinal Holes

    • Asymptomatic

    • Within lattice dehgeneration areas

    • Punched out circular holes

  • Mechanism of RD

  • DISINSERTION (DIALYSIS)

    • In severe blunt trauma

    • Usually in inferior temporal

    quadrant

    • Severe photopsia

    • Detachment may not occur for

    many years in young patient if

    vitreous can remain gel

    formation

  • PVR

    • Proliferative Vitreoretinopathy (PVR)

    • The proliferation of RPE cells and gliotic cells

    • Long term RD

    • Giant and a multible number of breaks

    • Penetrating injury

    • Vitreous hemorrhage

    • Fast wound healers

  • PVR Stages

    Grade A : Vitreous haze, pigment clumbs in vitreous and inferior surface of the retina ( tobacco dust )

    Grade B : creases on the face of inner retina, decreased mobility of vitreous gel and retina, irregular tear edges, tortuosity of blood vessels

    Grade CP: behind equator local, diffuse or peripheral retinal creases, subretinal cords

    Grade CA: Same appearance in front equator and cords in condensed vitreous

  • Myopia - RD

    • 10% of the general population: Myopic

    • 40% of all RDs occur in myopic eyes.

    • Lattice deg. is more common in -6.0 -9.0 myopes

    • Vitreous degeneration and PVD are more common

    in myopes

  • Trauma - RD

    • 10% of RD occurs following trauma.

    • The most common cause of RD in children

    • Severe blunt trauma: retinal dialysis, macular

    hole

    • Penetrating injury: Both tractional and RRD.

  • RD Symptoms

    • The first sings of acute PVD are fotopsia and

    floaters

    • Peripheral visual field defect: like a black curtain

    one side of the eye

    • After macula is affected, VA will decrease to

    hand motions only

  • RRD signs • IOP: 5 mmHg lower

    • Retinal break

    • Detached Retina has a convex

    configuration and an opaque

    appearance

  • Treatment • PROPHYLAXIS IS VERY IMPORTANT

    – Acute PVD’s Symptoms: Photopsia, floaters:

    peripheral retinal examination!

    – Myopia or trauma or family history or fellow

    eye history of RD: detailed fundus

    examination!

    – Symptomatic or dangerous peripheral

    retinal degenerations and retinal tears: laser

  • Retinal Detachment Surgery

    1. External buckling: Peripheral or local

    scleral buckling: Classic Technique

    2. İnternal retinopexy: PPV-tamponade

    – laser or cryo to tears

    – Gas-Silicone oil

  • Scleral Buckle • Silicone band or with local sponge • Intraoperative cryotherapy around the

    tear • Drainage of Subretinal fluid. • IV Air-Gas

  • Internal retinopexy: Tamponade

    • Gas: SF6, C3F8

    • Air

  • PPV • Associated Vitreous Hemorrhage,

    • PVR,

    • Multible/giant tears

    • Macular holes

  • Tractional RD

    1. PDR: Proliferative diabetic retinopathy

    2. ROP prematurity of retinopathy

    3. Penetrating trauma

    4. Sickle cell anemia, Vein occlusions, PFV

    • Retina is immobile, surface is concave.

    • Tractions may cause tears... COMBINED FORM RD

  • Traksiyonel RD

  • Trauma

  • PFV

  • ROP

  • ROP Stage 5: Total RD-Leukocoria

  • Tractional RD

    • Photopsia and floaters (-)

    • Vision loss occurs slowly

    • Treatment: PPV

  • Exudative RD

    • Malign hypertension

    • Hypertensive crisis/Eclampsia

    • Vascular: Coats desease

    • Tm: CMM, Metastases, choroidal hemangioma

    • Uveitis: Vogt-Kayanagi-Harada

    • Central serous chorioretinopathy

  • Exudative RD

    • Exudative RD: fluid leaks from retinal

    vessels and RPE

    • there is no tear and traction.

    • May move with gravity and head

    movements

  • Exudative RD

    • Vision is very low in the morning due to the liquid which reason to detachment becomes the subject of gravity. When patient seats, vision begins to improve.

  • SSKR

  • Exudative RD

    • No Photopsia,

    • Floaters (+/-): becauase of vitritis

    • Visual field defect suddenly

    • No surgical treatment.

    • Treatment of the underlying condition.