TREATMENT OF RETINAL DETACHMENT

TREATMENT OF RETINAL DETACHMENT By- Dr. Neeraj Agarwal

PRINCIPLESIdentification of all retinal breaks and area of tractionInduction of aseptic chorioretinal inflammation around the break to seal themRelease of any tractionDrainage of subretinal fluidEnsuring chorioretinal apposition for atleast a couple of weeks by tamponade

TechniquesCryotherapyLaser photocoagulationPneumatic retinopaxyDrainage of SRFScleral bucklingVitrectomy

CRYOTHERAPYJouleThomson EffectIt is used to produce choriretinal inflammation around the edges of the retinal break Chorioretinal adhesion take 2-6 weeks to form.

Technique

Single row of applicationTransscleralNot remove probe until it defrosted completelyPatch eye for 4hrAfter 5 day pigmentation begin to appear. Initially it is fine then it becomes coarser.

Always check that the tip will freeze and unfreeze before applying it to the eye (these machines are notoriously unreliable).

complicationsRedness and swelling of the eyelid.Temporary pain and discomfortDiplopiaFloatersGlare and sensitivity to light. Mild drop in vision (usually temporary)Haemorrhage & CME (rare)

Over-freeze causing a retinal tear and haemorrhage.

It breakdown the blood ocular barrier and may stimulate dispersion of retinal pigment epithelium cells into vitreous cavity

Some study suggest cryopexy is risk factor of post-op PVR (due to dispersion of RPE cells ) whereas others not show an association

Cause of FailureFailure to surround entire lesionFailure to apply contiguous t/tFailure to use tamponade or explant in an eye with subclinical RDNew break formation

LASERIt cause less morbidityToc for prophylaxis except in very peripheral retinal breakIt cannot be used in presence of detachment. Argon, diode, or visible spectrum diode laser induce tissue injury and therefore scarring from thermal burns on the tissues (photocoagulation)

usually cannot seal RB if presence SRFmay be use to create barrier to prevent progression of RDesp. useful inchronic inferior RDsystemic illness contraindicate to surgery

techniqueTwo rows of confluent burnTypical laser settings for argon green are 200300 mW power 0.10.2 msec duration Spot size 200500 m Repeat interval 0.1 s

Compared with Cryopexyless breakdown of bloodocular barrierthermal effect confined predominantly to retina and pigment epitheliumlittle or no effect on choroid or sclerainduces adhesive effect between retina & pigment epithelium within 24hr

Complicatios

Retinal bleeding: Press on the eye to minimise.Lens damage: Reduce the power.Macular damage: keep the laser on standby when not in use.Excessive burns: Use only laser powers that produce retinal blanching not more.

A.posteriorly located retinal tear B.treat by laser photocoagulation

PNEUMATIC RETINOPAXYIt is an OPD procedure in which an intravitreal expanding gas bubble is used to seal a retinal break and reattach the retina.It is used as an alternative to scleral bucklingThis procedure is usually reserved for t/t of uncomplicated RD

INDICATIONAll retinal breaks identifiedConfined to superior 8 clock hourSingle break or multiple breaks within 1-2 clock hoursAbsence of PVR grade B or greaterCooperative patient who can maintain proper positionClear media

Relatively quickMinimally invasiveSuccess rate is low

COMPLICATIONSSubretinal gas migrationAC gas migrationEndopthalmitisCataractRecurrent RD

TECHNIQUECryopexy or laserTransconjuctivally through pars planaPredetermined head posture that place the break in the least dependent positionAC paracentesis done to normalize elevated IOP

PNEUMATIC RETINOPEXY

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SCLERAL BUCKLINGIn this a soft silicone encircling band or sectoral buckle is sutured to scleraIn presence of extensive vitreous traction or multiple retinal break an encircling band of silicone is placed around the sclera, beneath the rectus muscles and tied after external drainage of some SRF

EXPLANTSoft or hard siliconeTo adequately seal a retinal break the entire break should ideally be surrounded by about 2mm of buckle.

Buckle ConfigurationRadial- right angle to limbus U tear, posterior breaksSegmental circumferential- parallelanterior breaks, dialysesEncircling- 360 bucklemay be augmented by local explants

TechniquePeritomy4/0 black silk suture passed under all rectiBreaks localise by IO and markedCroyotherapy appliedMattress type suture which will straddle explant. (seperation of1.5x of diameter)Check position

COMPLICATIONMyopiaAnt ocular ischemiaDiplopiaPtosisOrbital cellulitisSubretinal hemorrhageRetinal incarcerationFish mouthing

SCLERAL BUCKLING12/2/2015Retinal Detachment, Mohammed Al-Khali, 2014, St John Eye Hospital.33

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DRAINAGE OF SRF INDICATIONS-Deep SRFLong standing RDsBullous RD

TECHNIQUEPRANG- central retinal artery is occluded and complete blanching of choroidal vasculature is achieved full thickness perforation made by tip of 27 gauge hypodermic needle bent 2 mm from tip after it air injected to restore IOP

2. CUT DOWN- a radial sclerotomy of 4mm length a mattress suture is placed across lips of sclerotomy inspect and if large choroidal vessels absent gentle low cautery applied if SRF not drain then perforate with 25g needle.

Complications 1-choroidal haemorrhage 2- retinal perforation 3- retinal incarceration 4- choroidal neovascularistion 5- endopthalmitis 6- dry tap

INTERNAL TAMPONADEAirGasLiquid

GASSF6- inert gas, high Mw, low water solubility. it double its volume 10-14 dayC2F6- triple, 30-35 daysC3F8- quadruples, 55-65 days Isovolumetric concentration (20-30% for SF6, 12-16% for C3F8)

SILICONE OILIt retain its shape for extended periods so that refilling is not requiredIt dampens the tendency towards reproliferationc/c- secondary glaucoma, cataract, keratopathy8-12 weeks later removal

VITRECTOMY Indications- Rhegmatogenous- If break cant be visualized or cant be closed by scelral bucklingTractional- in diabetic RD involving or threatning the macula or combined RD.

TECHNIQUEInfusion canula is secured to sclera at inferior border of lateral rectus muscle.Sclerotomies made on 10 and 2 oclock for cutter and fibreoptic light pipe.During vitrectomy, a complete posterior vitreous separation is ensured and the peripheral cortical vitreous is carefully shaved towards the vitreous base to relieve traction on the retinal breaks.

After removal of trocar pressure is applied to each site to ensure that they are not leaking.If conjuctiva begins to swell & form bleb then there may be a leak.If leak occur then its better to suture the site on same day than resurgery on next day.

COMPLICATIONSRaised IOP- due to gas, si oilCataract- due to feathering of posterior subcapsular lens cortex (transient), si oil, delayedBand keratopathy- due to prolonged contact b/w si oil and endothelium

DEVELOPMENT OF VITRECTOMY1970- Machemer= 17 gauge (1.5mm dia) multifunctionl i/m (father of modern vitreous surgery)1974- OMalley & Heintz= 20 gauge (0.9mm)1990- De juan & Hickingbotham= 25 gauge (0.5mm) in paediatric pt. (Era of sutureless vitrectomy begin)2002- Fuji et al introduce complete 25 gauge vitrectomy system

2004- Eckardt introduces first fully integrated 23-gauge vitrectomy system, and demonstrates its safety and efficiency

25 GAUGE VITRECTOMY Transconjunctival sutureless 25-gauge vitrectomy have-favorable anatomic resultslong-term stable visual rehabilitation minimal surgically induced complications

INDICATIONS Procedures which not require extensive dissection like-RD with minimal or no pvrEpiretinal membrane peelingMaculr hole surgeryVitreous haemorrhage

LIMITATIONSPreviously scarred operated eyeHigh myopic with thin scleraDifficult to infuse Si oil through 25gDense fibrous proliferation

For uncomplicated primary rhegmatogenous RD, the preferred treatment until a few years ago was scleral buckling or encircling.If this failed, or relapse occurred, vitrectomy was the safest procedure, often the only one.Recent advances in vitrectomy technique have encouraged vitreoretinal surgeons to expand the role of primary pars plana vitrectomy in the management of uncomplicated RDs

AdvantageRemove vitreous opacities & RPE cellsCan drain SRFAbility to view small retinal break

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