CASE PRESENTATION

HISTORY

• A 35 Year old lady presented in OPD with:

• Sudden in vision right eye 1-week
• Curtain infront of right eye 1-week
HOPI

• The patient was in the usual state of health 1 week back she had a decrease in vision in her right eye
which was:
• Sudden
• Painless
• Progressive
• Associated with curtain/black shadows
• Flashes

• No history of
• Micropsia
• Macropsia
• Halos
• Color vision defect
PAST OCULAR HISTORY

• The Patient has been using glasses of -7.50D for the last 20-years.
• No History of:
• Surgery
• Ocular trauma
• Intravitreal Injections
• Lasers
• Any previous eye disease
PAST MEDICAL HISTORY

• The patient was:

• Non-diabetic
• Normotensive
• And did not have any kind of systemic disease
OCULAR EXAMINATION

OD OS

VA CF 6/60

BCVA CF 6/6

Pupils RRR RRR

EOM Full Full

SLIT LAMP EXAMINATION

OD OS
AT(IOP) 06 12
ADNEXA Normal Normal
CONJUNCTIVA Normal Normal
CORNEA Clear Clear
A/C Deep & Quiet Deep & Quiet
LENS Clear Clear
FUNDUS • Tobacco dusting in ant.
Vitreous
Normal
• Elevated retina from 2-8’ o
clock with break at 2’ o clock
DIAGNOSIS • Right Rhegmatogenous bullous Retinal Detachment
RHEGMATOGENO
US RETINAL
DETACHMENT
INTRODUCTION

• Rhegmatogenous retinal detachment (RRD) is defined as the separation of the

neurosensory retina from the retinal pigment epithelium (RPE) secondary to a ‘rhegma’
or break.
• Rhegmatogenous RD affects about 1 in 10 000 of the population each year, with both eyes
eventually affected in about 10%.
• Subclinical detachment <2DD
• Clinical detachment >2DD
RISK FACTORS

• conditions associated with early PVDs:

• pseudo-phakia
• aphakia
• high myopia (>−6.00 diopters [D])
• Hereditary collagen–vascular disorders like Stickler’s and Marfan’s syndromes.

• Other causes of RRDs, not necessarily related to premature PVD development, include:
• proliferative retinopathy
• trauma, and viral retinitis associated with immunodeficiency.
• (Nd:YAG) laser capsulotomy
RETINAL BREAKS

• Retinal breaks develop in most cases as a result of traction at sites of vitreoretinal

adhesion and occur in up to about 1 in 5 eyes with symptomatic PVD.
• Timing. Breaks are usually present at or soon after the onset of symptoms of PVD
• Location. Tears associated with PVD are usually located in the upper retina and are more
commonly temporal than nasal.
• Morphology. Retinal breaks may be flat or associated with a surrounding cuff of SRF. If fluid
extends more than one-disc diameter from the edge of a break, an RD is said to be present.
 U-tears (horseshoe) Operculated tears Retinal holes Dialysis Giant retinal tear

The flap is completely

dialysis is a
It consists of a flap, its torn away from the variant of
circumferential tear
apex pulled anteriorly retina round or oval, usually U-tear, by definition
along the ora serrata and
by the vitreous, the base This may be aided by smaller than tears and involving 90° or more
is usually a
remaining attached to the presence of carry a lower risk of RD of the retinal
consequence of blunt
the retina preretinal blood at the circumference.
ocular trauma.
site.
IDENTIFICATION OF RETINAL BREAKS

• Distribution of breaks
• 60% superotemporal quadrant
• 15% superonasal
• 15% inferotemporal
• 10% inferonasal.

• Configuration of SRF SRF spread is governed by

• gravity,
• by anatomical limits (ora serrata and optic nerve)
• the location of the primary retinal break.
Lincoff’s Rule: It works on gravity principle

A shallow inferior RD in which the SRF

is slightly higher on the temporal side,
points to a primary break located
inferiorly on that side
A primary break located at 6 o’clock will
cause an inferior
RD with equal fluid levels

In a bullous inferior RD, the primary

break usually lies
above the horizontal meridian
If the primary break is A subtotal RD with a When the SRF crosses the
located in the upper nasal superior wedge of the vertical midline above, the
quadrant the SRF will attached retina primary break is near to 12
revolve around the optic points to a primary break o’clock, the lower edge of
disc and then rise on the located in the periphery the
temporal side until it is nearest RD corresponding to the
level with the primary its highest border side of the break
break
SYMPTOMS

• The symptoms of RRD include

• flashes,
• floaters,
• curtain-like shadow over the visual field.
SIGNS

• Relative afferent pupillary defect (Marcus Gunn pupil) is present in an eye with an extensive RD.
• Intraocular pressure (IOP) is often lower by about 5 mmHg compared with the normal eye.
• Schwartz–Matsuo syndrome: in which RRD is associated with an apparent mild anterior uveitis,
often due to dialysis secondary to previous blunt trauma in a young man.
• Iritis
• ‘Tobacco dust’ consisting of pigment cells is commonly seen in the anterior vitreous
• Retinal breaks
 Fresh retinal detachment Longstanding retinal detachment

• convex configuration Retinal thinning secondary to atrophy is a characteristic

• slightly opaque finding and should not lead to a misdiagnosis of retinoschisis.
• corrugated appearance as a result of retinal edema

• Intraretinal cysts may develop if the RD has been present

• SRF extends up to the ora serrata for about 1 year.
• disappear afterretinal reattachment.

Subretinal demarcation lines (‘high water’ or ‘tide’ marks)

Macular pseudohole. Because of the thinness of the foveal
• caused by proliferation of RPE cells at the junction of flat
retina, the impression of a macular hole may be given if the
and detached retina
The posterior pole is detached.
• taking about 3 months to develop.

B-scan ultrasonography shows good mobility of the retina

and vitreous.
FRESH RETINAL DETACHMENT LONGSTANDING RETINAL
DETACHMENT
 PROLIFERATIVE
VITREORETINOPATHY
• Proliferative vitreoretinopathy (PVR) is caused
by epiretinal and subretinal membrane formation,
• contraction of which leads to tangential retinal
traction and fixed retinal fold formation
MANAGEMENT

• Bed rest and bilateral patching

• Bed rest may help restrict the forces related to head and ocular movements.
• Large eye movements increase vitreous traction and detachment forces on the edge of the
retinal hole, creating a subretinal vacuum and facilitating increased subretinal fluid.
• Bilateral patching 24-48 hours before surgery may decrease saccadic ocular movements and
reduce inertial force induced by ocular movements.
• which decreases retinal detachment height and prevents macula ON retinal detachment from
converting to macula OFF retinal detachment.
• Positioning
• The detached retina should be in the lowermost
position to address the force of gravity.
• In superior retinal detachments, the patient
should maintain a supine position with no pillows
and the foot end raised (i.e., the Trendelenburg
position).

• In inferior retinal detachments, an upright or sitting

position is preferred.
• Indications for urgent surgery :
• An acutely symptomatic RD should be surgically repaired as soon as possible, particularly if the macula
is not Involved.
• Presence of a superior or large break, from which SRF is likely to spread more rapidly and advanced
syneresis as is found in high myopia.
• Patients with dense fresh vitreous hemorrhage in whom visualization of the fundus is impossible should
also be operated on as soon as possible if B-scan ultrasonography shows an underlying RD.
• Depending on the extent of retinal detachment and location of retinal breaks,
management can be:

• Laser barrage/ delimiting laser photocoagulation

• Pneumatic retinopexy
• Scleral buckle
• Vitrectomy
DELIMITING LASER PHOTOCOAGULATION/
LASER BARRAGE
• Delimiting laser photocoagulation can be used in:
• subclinical retinal detachments that
• extend at least 1 disc diameter from the nearest break
• and no more than 2 disc diameters posterior to the equator
• with no visual field loss.

• Preferred in young patients in whom the vitreous is not liquified or when the patient
cannot be operated on due to other reasons.
PNEUMATIC RETINOPEXY

• Pneumatic Retinopexy is the injection of a gas bubble into the vitreous cavity
• The common indications include:
• Retinal break(s) within the superior 8 clock hours (8 to 4 o’clock)
• Single or multiple breaks within 1 clock hour
• No or minimal media opacity and all the breaks should have been identified
• Patient should be able to maintain positioning for 5-8 days after the procedure
• absence of proliferative vitreoretinopathy (PVR) grade CP or CA according to the updated
Retina Society Classification
• Intravitreal gas bubble together with cryotherapy or laser are used to seal a retinal break
and reattach the retina without scleral buckling.
• A concomitant anterior chamber paracentesis is generally required to normalize the
elevated IOP that results from the gas injection.
• With direct pneumatic occlusion of the causative retinal breaks in acute detachments,
subretinal fluid is often completely resorbed within 6–8 hours.
• The most frequently used gases are:
• A prospective multicenter randomized clinical trial comparing pneumatic retinopexy with
scleral buckling demonstrated successful retinal reattachment in 73% of patients who
underwent pneumatic retinopexy and in 82% of those who received scleral buckling
procedures; this difference was not statistically significant.

• COMLICATIONS
• Subretinal gas migration
• anterior chamber gas migration
• Endophthalmitis
• Cataract
• Recurrent retinal detachment from the formation of new retinal breaks.
SCLERAL BUCKLING
• Scleral buckling closes retinal breaks through external scleral indentation.
• The purpose is to close retinal breaks by opposing the RPE to the sensory retina and to
reduce dynamic vitreoretinal traction at sites of local vitreoretinal adhesion.
• Common indications are:
• Young patients
• Phakic eyes
• High myopia
• Absence of a PVD
• The absence of advanced proliferative vitreoretinopathy (PVR) changes. RRD with PVR grade
C1 can be treated with SB
• RRD secondary to breaks anterior to the equator
• RRD secondary to retinal dialysis
• The explants are made from soft or hard silicone. The entire break should ideally be
surrounded by about 2 mm of buckle.
• The explants can be classified into four types:
• Bands and strips
• Implants and Wedges
• Tires
• Sponges
• Bands and strips:
• They are used for encircling the eyeball all around, thus supporting the vitreous base.
• The most commonly used bands include band numbers 240 and 42.
• The 240 band is flat on both sides and measures 2.5mm in width and 0.6mm in height.

• The 42 band has one side flat (shiny looking) and the other side convex (dull looking) and
measures 4.0mm in width and 1.25mm in height. While suturing, care must be taken that the
flat side is placed towards the sclera.
• Tires:
• They are used as a circumferential segmental buckle to support the break(s).
• The radius of curvature of these tires is similar to that of the globe.
• One of their sides has a groove that measures 2.5 mm.
• It is provided for fixing the 240 band for simultaneous 360-degree encirclage.
• The other side of these tires can be either
• convex or
• concave.
• The convex ones are used to manage RRD secondary to retinal dialysis as the convex
curvature supports the vitreous base. The most commonly used tire is number 286,
measuring 7.0 mm in width.
• The concave ones can further be of two types:
• symmetrical and
• asymmetrical.
• The symmetrical tires groove in the center and
manage RRD secondary to lattice(s) and atrophic
hole(s). The most commonly used symmetrical tire
is number 277, which measures 7.0mm in width.
• On the contrary, the groove in asymmetrical tires does
not pass through the center. They are used to manage
RRD secondary to horse-shoe tears (HST). The most
commonly used asymmetrical tire is number 276,
measuring 7.0mm in width.
• They are placed such that the slender side is positioned
anteriorly under the muscle insertion while the hefty
side is positioned posteriorly.
• This arrangement ensures that the anterior slender side
of the tire doesn’t budge against the muscles, thus
reducing the chances of anterior segment ischemia,
while the posterior, hefty side supports the break(s).
• Sponges: They are mainly used as radial buckles to support posterior break(s).
• However, they can also be used as circumferential buckles.
• They are cylindrical in shape and need to be cut lengthwise into two halves with equal
thickness, and the convex side is placed towards the globe to produce a high indentation.
• As the air cells get exposed to the surface after the sponge is cut, they can absorb fluid
and harbor bacteria, which can cause infection.
• Buckle configuration can be
• radial
• segmental
• Circumferential
• encircling

• depending on the size, configuration, and number of breaks.

• Technique: The conjunctiva is incised (peritomy) to facilitate access, following which
retinal breaks are localized.
• Then cryotherapy is applied.
• An explant of appropriate dimensions and orientation is then sutured to the sclera and the
position of the buckle is checked in relation to the break
DRAINAGE OF SUBRETINAL FLUID

• Drainage of SRF via the sclera (e.g. the D-ACE: Drainage- Air-Cryotherapy-Explant)
surgical technique is advocated by many practitioners, citing more rapid retinal
reattachment in the presence of deep or longstanding viscous SRF.
• Others prefer to avoid external drainage because of the potential complications associated
with the technique, such as retinal perforation or incarceration in the drainage site and
choroidal hemorrhage and would rather perform a pars plana vitrectomy as a primary
option.
COMPLICATIONS OF SCLERAL BUCKLING
• Diplopia
• Cystoid macular edema
• Anterior segment ischaemia
• Buckle extrusion, intrusion, or infection
• Elevated IOP
• Choroidal detachment
• Surgical failure
• Missed breaks
• Buckle failure
• ‘Fish-mouthing’ describes the phenomenon of a tear, typically a large superior equatorial U-tear in a
bullous RD, to open widely following scleral buckling, requiring further operative treatment.
• Proliferative vitreoretinopathy
CONTRAINDICATIONS

• The various contraindications for SB include:

• Scleromalacia or severe scleral thinning

• Advanced PVR changes
• Dense vitreous hemorrhage or significant cataract which precludes fundus view
• Previous glaucoma surgery
• RRD secondary a giant retinal tear
• RRD secondary to retinal breaks posterior to the equator
PARS PLANA VITRECTOMY

• Many simple rhegmatogenous RD can be treated successfully by scleral buckling

techniques.
• PPV has greatly improved the prognosis for more complex detachments.
INDICATIONS
• Rhegmatogenous retinal detachment
• When retinal breaks cannot be visualized
• When retinal breaks are unlikely to be closed by scleral buckling

• Tractional retinal detachment

• Tractional RD threatening or involving the macula
• Vitrectomy is always combined with anti-VEGF agents and/or internal pan-retinal
photocoagulation to prevent postoperative neovascularization that may cause vitreous
hemorrhage or rubeosis iridis.
• Extramacular tractional RD may be observed without surgery because, in many cases, it
remains stationary for a long time provided proliferative retinopathy has been controlled.
• Combined tractional–rhegmatogenous RD should be treated urgently, even if the macula is not
involved because SRF is likely to spread quickly.

• Indications in penetrating trauma

• Prevention of tractional RD.
TAMPONADING AGENTS
• These achieve intraoperative retinal flattening in combination with internal drainage of
SRF
• Expanding gases: Although air can be used, an expanding gas isovolumetric(non-
expansile) concentration (e.g. 20–30% for SF6 and 12–16% for C3F8). is usually preferred in
order to achieve prolonged tamponade.
• Postoperative positioning of the patient is used to maximize the effective vector and
maintain surface tension around the break.
• Sulfur hexafluoride (SF6) doubles its volume if used at a 100% concentration and lasts 10–14
days.
• Perfluoroethane (C2F6) triples its volume at 100% and lasts 30–35 days.
• Perfluoropropane (C3F8) quadruples its volume at 100% and lasts 55–65 days.
• Silicone oils have low specific gravity – they are lighter than water and thus buoyant.
• They are commonly used for both intraoperative retinal manipulation and prolonged postoperative
intraocular tamponade and are particularly helpful in the management of proliferative vitreoretinopathy.
• 1000 cs silicone is easier to inject and remove whilst 5000 cs is more viscous but may be less prone to
emulsification.
• Heavy liquids (perfluorocarbons) have high specific gravity and thus settle inferiorly in the vitreous
cavity
• Perfluoro-n-octane is most commonly used as it allows good visibility and low viscosity.
• It acts as an intraoperative mechanical device that can be used to flatten the posterior retina, open retinal
folds, and improve visualization of additional membranes.
• Although primarily developed for RD surgery, other indications include:
• hemostasis (by localizing bleeding), expression of
• liquefied blood from behind the retina, and
• anterior floating of dislocated lens fragments or
• intraocular lens (IOL).

• Cases of retinal toxicity and inflammation have been reported.

GOALS OF SURGERY

• To separate the posterior hyaloid from the retinal surface.

• To remove the epiretinal tissue in order to release the central and/or peripheral retinal
traction.
• To close retinal breaks if present.
COMPLICATIONS

• Intraoperative complications
• Posterior retinal breaks.
• Peripheral retinal breaks.
• Rarely choroidal hemorrhage.

• Postoperative complications
• Retinal breaks and rhegmatogenous RD.
• Retinal fold Inflammation, particularly in patients with diabetes.
• Raised intraocular pressure

• Cataract
• Band keratopathy
RAISED INTRAOCULAR PRESSURE

• Overexpansion of intraocular gas

• Silicone oil-associated glaucoma.
• Early glaucoma may be caused by direct pupillary block by silicone oil
• This occurs particularly in an aphakic eye with an intact iris diaphragm.
• In aphakic eyes this can be prevented by performing an inferior (Ando) iridectomy at the time
• of surgery to allow free passage of aqueous to the anterior chamber.
• Late glaucoma is caused by emulsified silicone in the anterior chamber causing trabecular
obstruction and scarring.
• The risk may be reduced by early oil removal, though glaucoma can still occur.
• A long tube seton may be required