surgical retina for lecture dimc
TRANSCRIPT
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SURGICAL RETINA
D r. J a m s h e d A h m e dM B B S., M C P S., F C P S ( O P H T H )
ASSISTANT PROFESSOR
Department of Ophthalmology
Dow International Medical Collegehttp://www.youtube.com/watch?v=VHzJIUfO3ck
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Retinal Detachment(R.D)
R.D. is a separation of the sensory retina from theretinal pigment epithelium(R.P.E) by sub retinalfluid(S.R.F)
Two main types
1)Rhegmatogenous or Primary R.D
2)Nonrhegmatous or SecondaryR.D
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Types
Two main types
1. Rhegmatogenous or Primary R.D
2. Nonrhegmatous or Secondary R.D Tractional R.D.
Exudative(Serous)R.D
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Rhegmatogenous R.D
In Greek word,Rhegma meaning a rent or fissure
http://www.youtube.com/watch?v=9Lxu3cUguM0&feature=related
is a condition in which fluid from vitreous cavitypasses through a full thickness retinal defect into the sub retinal space to cause separation ofthe neural retina from the underlyingR.P.E
It affects about 1:10,000 of the population eachyear
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Pathogenesis
Acute posterior Predisposing
vitreous retinal degenerations
detachment AphakiaTrauma retinal break
degenerated vitreous passes via this breakbetween sensory retina and RPE collected as SRF
Retinal detachment
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Clinical Features
History age: Common age group is 40-70 years
No age is bar
Sex: 60 % case comprises by males
Hereditary: although a no.of pedigree shows
familial detachments, most cases aresporadic
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Symptoms :
Classic premonitory symptoms present in 60% ofpatients with Spontaneous rheg.R.D are
1) Flashes of lights(Photopsia)
2) floaters- may be Solitary ring shaped opacity(Weiss Ring)
Cobwebs Sudden shower of minute red colored or dark spots
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Contd
3) localized relative loss in field of vision-early
less aware of superior than inferior field defect
highly specific for localization ofR.D
cause -spread of SRF behind the equator
perceived by the patient as black curtain
4) sudden painless loss of vision in case of large or
centralR
.D
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Contd
Blurring of distant vision
40-45% R.D occurs in myopic patients
History of trauma:(Surgical/Accidental)
Surgical details
a)Aphakia
b) Pseudophakia with vitreous loss
Ocular Trauma
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Contd
History of previous ocular disease similar problem in other eye
glaucoma
more in pigment dispersion syndromeMiotic drugs
uveitis, vitreous hemorrhage, diabetic
retinopathy Cytomegalovirus retinitis
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Contd
History of systemic diseases eg.
Diabetes,tumors,angiomatosis of C.N.S,sickle
cell disease,leukemia and EclampsiaMarfan's syndrome,
Family history
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Signs
1) VisualAcuity less ifR.D extend up to fovea
2) Confrontation test;Visual field defect
3) External examination
4)Anterior segment examination Cornea is usually clear but descemet's folds
if hypotony
Mild flare and cells inAnterior chamber
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Signs
5) Pupillary reaction
Relative afferent pupillary
defect in extensiveR
.D6) Posterior segment
Tobacco dust in retrolental
vitreous, haemorrhages
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Signs
7) Fundus Examinationa Loss of normal fundal glowb)Retinal breaks: Present in about 70% of
the eyes with tobaccodust.
appears as reddiscontinuities in theretinal surface
Upper temporal quadrantis the commonest site forretinal break
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Signs
Breaks may be in the form of holes,tears or
dialysis
Shape may be variable
Can locate primary break by the shape of theR.D
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Shape of R.D in relation to primary break
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Signs
Retinal signs depends on
duration ofR.D
A) Fresh R.D
Detached retina has a
convex configuration,
slightly opaque and
corrugated appearance,undulates freely with eye
movements.
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Signs
loss of underlying choroidal pattern
retinal blood vessels appears darker so color
contrast vein and artery is less SRF extends up to ora serrata except caused
by macular hole
pseudo hole in posterior pole detachment
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Signs
B) Long standing retinal detachment
retinal thinning secondary to atrophy
secondary intraretinal cysts if more than 1 year sub retinal demarcation lines
present after 3 months.
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Signs
Macula
pigment of the macula may become more
evident as a yellow colour due to intraretinaloedema or sub retinal fluid
macular involvement is high in superior or
temporal break or if in equatorial region
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Signs
Apparent holes in macula are relatively common
Macular breaks leading toR.D are common instaphyloma of high myopia or following trauma
Associated retinal degenerations,
Intraocular pressure-low
Systemic evaluation
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Signs
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Differential diagnosis
Includes R.D from other causes and retinoschisis
1) Tractional R.D
Symptoms Photophobia and floaters usually absent
Visual field defect progressive
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Contd
Signs concave configuration ,
breaks absent
SRF - shallower, seldomextends to ora serrata
highest elevation at sites
of vitreo-retinal traction
severely reduced retinalmobility , shifting fluid
absent
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Contd
2) ExudativeRD : Symptoms
photopsia is absent
VF defects develop suddenly
and progress rapidly
Signs-
convex configuration
breaks are absent smooth surface, SRF deep, shifting fluid phenomenon present
Leopard spots in resolved RD
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Contd
Degenerative retinoschisis : Symptoms
photopsia and floaters absent
VF defects absolute scotoma
Signs
Elevation is convex, thin, smooth , relativelyimmobile
Demarcation lines and secondary cyst absent
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Management
Diagnosis/Treatment
Diagnosis
1. Clinical Feature
2. Investigations
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USG- B scan
RoutineTC, DC, Hb, ESR, Blood sugar,
Urine R/M
ERG (Brightflash)
Investigations
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Prophylaxis: Retinal Breaks
INDICATIONS
A. Characteristics of break
B. Predisposing Peripheral retinal degenerations
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High risk Breaks
1)Tears more dangerous than holes
2) Large break
3)Symptomatic tears4) Superior breaks
5) Equatorial breaks
6) Sub clinical R.D
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Other Considerations
Break with or without symptoms:
Aphakia
Myopia
One eyed
Family History
Systemic Diseases e.g. Marfan Syndrome,
Stickler Syndrome, Ehlers DanlosSyndrome
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Prophylaxis
Predisposing Peripheral retinal
degenerations (Lattice/Snail track)
R.D in the fellow eye Aphaka or pseudophakia
High Myopia
Strong family history of R.D
Systemic diseases
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Prophylaxis Contd.
White without pressure with fellow eye -
giant retinal tears
Fellow eye aphakic retinal detachment (
360 degree cryotherapy 4 weeks prior to
cataract surgery)
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Prophylaxis
Treatment Options
C seals the retina with the RPE and choroid
around the break,C 2-3 rows of nearly confluent laser burns
around e.g. break in lattice.
C
firm chorioretinal scar forms in 7-10 days.
Laser photocoagulation
Transcleral cryotherapy
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Cryotherapy/Laser
Therapy
Location of lesion
Clarity of the media
Pupil size
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Retinal Detachment Surgery
Historical Review:1920:T/t of R.D began in rational lines,
Jules Gonin-first man to appreciate the pathologicalsignificance and therapeutic effect of closing retinal
breaksT/t of R.D by sealing of the retinal breaks andevacuating the inter retinal fluid by puncture with agalvanocautery.
1930 : Rosengren tried intravitreal air injection in
upper half detachments.
1933: Deutschmann tried cryopexy for R.D
.
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History contd..
1949 Custodis : concept of ScleralBuckling
1957 Schepens : refined scleral buckling techniqueand devised encircling operation in 1960.
1949: Goldman devised three mirror funduscontact lens
1950 Schepens : Indirect ophthalmoscope1962 Cibis introduced silicon oil to tamponade
Lincoff and co-workers: Silicon sponge explant andcryotherapy
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History contd
1964 Lincoff revived Cryotherapy
1940 AmslerSRF distribution to find
probable hole, later in 1971 Lincoffprovided detail description.
1985 Gilbert and McLeod successfully tried
D-ACE procedure for upper half bullous R.D
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Preoperative considerations &
patient counseling
IfRRD threatening to detach the macula;surgery urgently necessary
Ifmacula is involved prompt surgery within 2-3 days
recovers reasonable central vision
macula off> 2 months postoperative Va usually poor
Ifmacula is not involved, most eyes maintain preop VA
Simple pathology and principles ofsurgery has to explained
Anatomic success does not equal visual success,
occassionally second surgery may be needed
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Anaesthesia
C Local or general anesthesia
Advantages of LA Shorter operating time
Quicker postoperative recovery
Decreased morbidity and mortality
C Peribulbar / retrobulbar
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Purpose of R.D surgery
To close the retinal hole
To relieve any vitreoretinal traction.
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Treatment options: RRD
C Permanent scleral buckle, with/withoutdrainage- radial, segmental or encirclage
C Temporary scleral buckle- Lincoff balloon, absorbable buckles
C Pneumatic retinopexyC Primary vitrectomy
C Combinations of aboveC Observation rarely
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Scleral buckling
C Purpose: to close retinal breaks
: to reduce VR traction
C Explants: material sutureddirectly onto the sclera
Implants: intrascleral placementof buckle
C Explant configuration1. Radial
2. Segmental circum
3. Encirclage
C Explant size1. Buckle width/length
2. Buckle height
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Scleral buckling
Indications for radial buckle
- Large U-tears
- relatively posterior
breaks
Indications for segmental buckle
- single or closely
spaced breaks