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Retinal Detachment. Abdulkrim Alkharashi , MD. RD History:. Causes of primary RD:-. Theory of distension. Theory of hypotony. Theory of exudation. Theory of retinal breaks. RD History: cont. Beer – 1817 first to detect RD clinically.

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Retinal detachment

Retinal Detachment

AbdulkrimAlkharashi , MD


Rd history
RD History:

  • Causes of primary RD:-

  • Theory of distension.

  • Theory of hypotony.

  • Theory of exudation.

  • Theory of retinal breaks.


Rd history cont
RD History: cont.

  • Beer – 1817 first to detect RD clinically.

  • Von Helmholtz – 1851 invented the ophthalmoscope.

  • Coccius – 1853 first to find retinal breaks (r.b.).

  • De Wecker – 1870 first suggested that r.b. were the causes of  RD.


Rd history cont1
RD History: cont.

  • Leber – 1882 found r.b. in 70% of RD, vit. deg. and collapse  traction  r.b.  RD. Changed to pre-retinal memb.  r.b. (in PVR).

  • Jules Gonin – 1919 Father of RD surgery. Performed the first RD operation to close r.b. – Ignipuncture of Thermocautery.


RD:

  • Rhegmatogenous – Greek thegma = rent

  • Tractional

  • Exudative


Rd epidemiology
RD Epidemiology:

  • Incidence 1: 10,000 / year.

  • In aphakics: 1– 3%.

  • In the second eye (-): 5%.

  • In the second eye (+): 10%.

  • 99% of untreated symptomatic RD  blindness.

  • 5 – 15% of population with retinal break(s)  7% of these develop new break(s).


Rhegma rd
Rhegma. RD:

  • Pre-requisite:-

  • Some degree of vitreous liquifaction.

  • Retinal break: - tear

    - hole

    - dialysis

  • Eye movements (Edie’s currents)

  • PVD, V-R traction


PVD_______________________________

  • Due to loss of hyaluronic acid  collapse of vit. collagen with liquefaction.

  • Rare before 30 yrs.

  • Increases with age (63% in > 70 yrs.)

  • Most PVDs are asymptomatic. 2nd eye in 1 yr.

  • 15% of acute PVD have a retinal tear (pathologic).

  • Increases significantly after cataract extraction: pathologic vs. physiologic PVD.


RD

  • PVD

  • 13-19% of PVD have vit. Hem.

  • PVD + hem.  70% with tears.

  • PVD + no hem.  2-4% with tears.


Rd f u
RD F/U:

  • Acute PVD:-

  • Examine periphery.

  • + vit. Hem.

    - rest, patching  examine.

  • U/S.


Rd risk factors
RD Risk Factors:

Lattice and other peripheral deg.:

  • Present in 8% of the population. In SA – 9.1%

  • As a cause of RD in 20-30%.

  • In RDs with L.D.:-

    30-45%  Atrophic holes.

    55-70%  A tear at edge of L.D.


Rd risk factors cont
RD Risk Factors: cont.

High myopia:

  • > 6 D.

  • 60 yr. myope risk of RD is 2.4% whereas normal risk 0.06%


Rd risk factors cont1
RD Risk Factors: cont.

Cataract surgery:

  • Increases PVD: Does it convert physiological PVD to a pathological one?

  • 1.3% RD in aphakes.

  • ICCE > ECCE.

  • Risk of RD increased with:-

    - P.C. otomy: 1.3%.

    - Vit. loss.

  • 50% of RDs in 1st year.


Rd risk factors cont2
RD Risk Factors: cont.

Glaucoma:

  • In general population – 1% COAG.

  • In RD patients – 4-7% COAG.

  • > in pigment dispersion synd.

    ? myopia.

  • Miotics & RD.


Rd risk factors cont3
RD Risk Factors: cont.

RD in fellow eye or F/H of RD.

Trauma.


Rd symptoms
RD Symptoms:

  • PVD – flaches & floaters.

  • Painless loss of peripheral VF.

  • Painless loss of central vision.


Rd examination
RD Examination:

  • VA.

  • IOP.

  • SLE – blood, pigment (Shafer’s sign) in the vitreous.

  • Careful binocular indirect ophthalmoscopy with scleral indentation.

  • C.L. exam.


Rd types of breaks
RD Types of Breaks:

  • Fresh (acute) tear either:-

    Symptomatic tear.

    Tear with retinal hem. at the edge.

    A new tear in that location.

  • Flap (horseshoe) tear.

  • An operculated hole.

  • Atrophic holes.


Rd ddx
RD DDX:

  • Exudative RD:-

  • Neoplasms.

  • Inflammations – VKH, ICSC, post. Scleritis.

  • Cong. Anomalies – optic pit, morning glory, choroidalcoloboma, nanophthalmos, uveal effusion syndrome


Rd ddx cont
RD DDX: cont.

  • Traction RD.

  • Retinoschisis – senile, juvenile.

  • Choroidal detachment.


Rd treatment
RD Treatment:

  • Prophylactic Rx:-

  • Olny selected breaks require Rx.

  • A symptomatic tear – caused by PVD or vit. Traction in the eye of a pt. C/O photopsias +/- floaters.


Indications for prophylactic treatment of retinal tears and holes in symptomatic patients
Indications for Prophylactic Treatment of Retinal Tears and Holes in Symptomatic Patients:

Flap tears Frequently (always)

Operculated holes Sometimes

Atrophic holes No

Macular holes Rarely

Lesion Treatment

_____________________________________


Rd treatment1
RD Treatment: Holes in Symptomatic Patients:

  • Prophylactic Rx to breaks:-

  • Cryotherapy.

  • Photocoagulation.

  • Surround it ant. & post.

  • Macular pucker.

  • Tears at margins of Rx scar.


Rd treatment cont
RD Treatment: cont. Holes in Symptomatic Patients:

  • Principles of Surgery:-

  • Emergency.

  • Localization of break(s).

  • Creation of C-R adhestion around the break(s).

  • Closure of break(s).

  • Relief of V-R traction.


Rd treatment cont1
RD Treatment: cont. Holes in Symptomatic Patients:

  • LA/GA

    Surgical techniques:-

  • Scleral buckle.

  • Orbital balloon.

  • Pneumatic retinopexy.

  • Primary vitrectomy + GFX, Long-term tamponade.


Rd prognosis va
RD prognosis & VA: Holes in Symptomatic Patients:

  • 90-95% - Anatomic success.

  • Overall 40-50%  20/50 or >

    25%  20/60 – 20/100

    25%  20/200 or <


Rd prognosis va cont
RD prognosis & VA: cont. Holes in Symptomatic Patients:

  • If macula off < 1 wk – 75%  20/70 or >.

  • If macula off 1-8 wk – 50%  20/70 pr >.

  • If macula on 90%  Preop. VA  pucker, CME, recurrent RD.


Rd prognosis
RD Prognosis: Holes in Symptomatic Patients:

Excellent prognosis (nearly 100%):

  • Detachments due to dialysis or to small or round holes.

  • Detachments with demarcation lines.

  • Detachments with minimal subretinal fluid.


Rd prognosis cont
RD Prognosis: cont. Holes in Symptomatic Patients:

Slightly poorer prognosis (95%):

  • Aphakic detachments.

  • Total detachments.

  • Detachments with associated detachment of the nonpigmented epithelium of the pars plana.

  • Detachments caused by flap tears.


Rd prognosis cont1
RD Prognosis: cont. Holes in Symptomatic Patients:

Poor prognosis (50 to 70%):

  • Detachments with associated choroidal detachment

  • Detachments with breaks larger than 180.

  • Detachments with PVR.

  • Detachments in patients with stickler’s syndrome.

  • Detachments caused by acute retinal necrosis.


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