Rhegmatogenous Retinal Detachment

Rhegmatogenous Retinal Detachment: 

Rhegmatogenous Retinal Detachment Dr. Deepak Khadka, MD Geta Eye Hospital, Kailali , Nepal

References: : 

References: Retinal detachment by American Academy of Ophthalmology Retinal Detachment –Diagnosis and Management by William Edmunds Benson Ophthalmology by Myron Yanoff Principles & practice of ophthalmology-Albert & Jakobiec,Vol-2 Retina-Stephen J. Ryan Clinical ophthalmology-Jack J Kanski

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Retinal Detachment (R.D) R.D. is a separation of the sensory retina from the retinal pigment epithelium(R.P.E) by sub retinal fluid(S.R.F) Four types: 1)Rhegmatogenous or Primary R.D 2)Tractional R.D 3)Combined Tractional & Rhegmatogenous RD 4)Exudative RD

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Rhegmatogenous R.D In Greek word, Rhegma meaning a rent or fissure A condition in which fluid from vitreous cavity passes through a full thickness retinal break into the sub retinal space Most common RD

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Affects about 1:10,000 of the population each year. The inclusion of traumatic RD slightly increases this figure. M:F ratio 61% vs. 39% - trauma Incidence of bilateral RD- 5% without predisposing lesion -10% with predisposing lesion

What keeps retina attached?: 

What keeps retina attached? RD occurs when liquefied vitreous passes through a retinal break to the potential space between sensory retina and RPE. However the vast majority of patients with retinal breaks never develop RD.

Theories of retinal attachment:: 

Theories of retinal attachment: Acid Mucopolysaccharide theory: Biological glue Prevents vitreous from gaining access to SR space RPE cells sheath theory: Strong adhesion between photoreceptor outer segments and RPE sheaths. Mechanical peeling – stretches and deforms the sheaths Electron microscopy – actin containing sheaths

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Hydrostatic pressure theory: SRF actively pumped by RPE creating a low hydrostatic pressure as compared to vitreous. Main resistance to diffuse water from vitreous to choroid is retina hence it helps flattening it. All the arguments supports important role of RPE and choroid in retinal attachments however removal of RPE and choroid in eye wall resection rarely cause RD.

Factors that causes RD: 

Factors that causes RD Major factors Retinal breaks Vitreous liquefaction and detachment Vitreoretinal traction Intraocular fluid currents

Retinal breaks: : 

Retinal breaks: Break - full-thickness defect in sensory retina Hole - caused by chronic retinal atrophy not associated with persistent VR traction. Tear - caused by dynamic vitreoretinal traction, usually produced by PVD Dialysis – large breaks that occurs along ora serrata.

Vitreous liquefaction and detachment:: 

Vitreous liquefaction and detachment : Ageing Myopia Surgical and Non surgical trauma Intraocular inflammation Others Hyaluronic acid concentration support to collagen fibers Aggregation of collagen Cavities of liquefied Vitreous cortex Hole in thin vitreous cortex Liquefied vitreous into Retro hyaloid space PVD

PVD cont…d: 

PVD cont…d PVD Symptomatic – 15% Asymptomatic – 85% Retinal tear seen in: 15% symptomatic PVD 50 – 70% with vitreous hemorrhage 10 – 12% without vitreous hemorrhage

Traction on the retina:: 

Traction on the retina: Range from simple action of gravitational force on vitreous gel to prominent fibrocellular membranes. Gravitational force - high percentage of superior retinal tears (80%) Rotational eye movements - the important causes of ongoing VR traction.

Traction on the retina: cont…d: 

Traction on the retina: cont…d VR traction caused by eye movements Eye ball rotation Retina at the site of VR adhesion exerts force on the Vit. gel causes adjacent vitreous to rotate Exerts equal and opposite force to retina Retinal break or extension of RD

Liquid currents:: 

Liquid currents: Rotatory eye movement Liquid currents in the vitreous to push against the gel adjacent to the break Dissect beneath the edge of retinal break into the SR space Subsequent eye movements Inertia effect on SR fluid Forces extension of RD

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Characteristics of Rhegmatogenous RD: -presence of liquefied vitreous gel -tractional forces that can precipitate a retinal break -presence of retinal break

Predisposing conditions: 

Predisposing conditions

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Typical lattice degeneration Present in about 8% of general population Present in about 40% of eyes with RD Spindle-shaped islands of retinal thinning Network of white lines within islands Variable associated RPE changes Small round holes within lesions are common Overlying vitreous liquefaction Exaggerated attachments around margin of lesion Retina Vitreous

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Snailtrack degeneration Indications for prophylaxis - presence of holes Sharply demarcated, frost-like bands which are longer than lattice Large round holes which carry high risk of RD

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White-without-pressure Indications for prophylaxis - giant tear in other eye Translucent grey appearance of retina Occasional giant tear formation along posterior margin of lesion

Myopia: 

Myopia 42% of all RD occurs in myopes. Myopia incidence of lattice degeneration High incidence of PVD Thin retina – retinal breaks Macular hole Retinal detachment

Aphakia / pseudophakia: 

Aphakia / pseudophakia 2-5% have subsequent RD. vitreous loss – 7% RD. If myopia > 10D – 40% likelihood of RD after ICCE. Aphakic detachments are commonly total, macula is often detached, and the retina more often has fixed retinal folds. Usually flap tears along the posterior vitreous base. Breaks are very small and difficult to find.

Aphakia / pseudophakia cont…d: 

Aphakia / pseudophakia cont…d Why high incidence of RD in Aphakia? Diffusion of Hyaluronic acid from the eye due to removal of lens liquefaction and collapse of vitreous body. Loss of adhesions of the vitreous to the posterior capsule at Weiger’s ligament increased traction on the retina when eye moves (endopthalmodonesis) Low incidence of RD after ECCE but due to Yag Capsulotomy rates incidence has increased.

Glaucoma: 

Glaucoma May be genetic relationship between chronic open angle glaucoma and RD. 4 – 7% patient with RD have chronic open angle glaucoma. Pigment dispersion syndrome – prone to RD. Miotics drugs in glaucoma therapy can cause RD. Congenital glaucoma – increased incidence of RD.

Trauma: 

Trauma Leading cause of RD in children and adolescents. Vast majority are males. Blunt trauma Compression of eye along AP axis Expansion of equatorial plane Slow compression Rapid compression No deleterious effect Insufficient time for vitreous to stretch Traction at vitreous base Dialysis Linear tear at Posterior V. base Avulsion of V. base Retinal necrosis Macular hole 20% of posterior segment penetrating injuries cause RD holes

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Proliferative retinopathies like DM, BRVO, Sickle cell RD, ROP etc Infections: patient with endopthalmitis after cataract have 90% incidence of RD, 50% RD in patients with ARN. Inherited disorders: hereditary hyaloidoretinopathies, congenital retinoschisis, ED syndrome, Marfan’s syndrome.

Pathophysiology of Rhegmatogenous Retinal Detachment:: 

Pathophysiology of Rhegmatogenous Retinal Detachment:

Early RD:: 

Early RD: First few days protein synthesis, intraretinal edema Folding of the outer retina Retinal transparency and corrugations Loss of horizontal orientation of discs of photoreceptors RPE cells are larger (initially) Some RPE cells separate (later) Float through SRF Vitreous: Shaffer’s sign Proliferates through retinal surface Subretinal white dots PVR changes

Long standing RD: 

Long standing RD Longer the duration More atrophy with necrosis and dropout of all cell layer RPE atrophy and depigmentation PVR No PVR Extensive atrophy Semitransparent and smooth retina Subretinal cysts RD of at least 3 mo. duration Metaplastic RPE proliferation Demarcation line 23% localized 77% detaches through demarcation lines

Subretinal fluid: 

Subretinal fluid Recent onset RD Lower concentration of protein than plasma Watery fluid in fresh detachments Quick absorption Hyaluronic acid Longer duration RD Protein concentration Osmolality of SRF increases Viscous fluid Longer time for absorption after RD surgery

Intraocular Pressure: 

Intraocular Pressure IOP Low High normal Misdirection of aqueous posteriorly Passes through retinal break Absorbed by RPE and Choroid RD itself Hyperplasic RPE and outer segments of photoreceptors Anterior chamber Uveitis Trabecular obstruction Glaucoma Schwartz syndrome

Retinal recovery after reattachment: 

Retinal recovery after reattachment Reattachment of retina <1 week duration Retinal recovery is rapid Within hours of surgery Protein synthesis Photoreceptor regeneration begins ERG recordable within 5 hrs Continue to improve for 12 weeks Intraretinal edema within hrs Nearly complete within 9 days VA continues to improve for a year or longer Reattachment after 1 mo. Morphological recovery is poor

PVR : 

PVR In many RD; glial or pigment epithelial cells or both, proliferate on either or both surfaces of the retina or on vitreous strands- a process known as Proliferative Vitreo-retinopathy.

PVR cont…d: 

PVR cont…d Metaplastic RPE (contains actin filaments and myoblastic like) Extensive membranes RPE cells pulls collagen Towards themselves VR traction Contracts Multiple fixed folds On both surface of retina Fixed folds, irregular retinal folds Rolled edges of tear Trans vitreal membranes Equatorial folds Fixed folds 10% detached retina has signs of PVR 25% of these progresses enough to require vitrectomy

Classification of PVR: 

Classification of PVR Grade Features A Vitreous haze, vitreous pigment clumps, pigment clusters on inferior retina B Wrinkling of inner retinal surface, retinal stiffness, vessel tortuosity, rolled and irregular edge of retinal break, decreased mobility of vitreous CP 1-12 Posterior to equator: focal, diffuse, or circumferential full thickness folds*, subretinal strands* CA 1-12 Anterior to equator: focal, diffuse, or circumferential full thickness folds*, subretinal strands*, anterior displacement,* condensed vitreous with strands * Expressed in number of clock hours involved.

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Proliferative vitreoretinopathy Vitreous haze and tobacco dust Grade A (minimal) Rigid retinal folds Vitreous condensations and strands Grade C (severe) Retinal wrinkling and stiffness Rolled edges of tears Grade B (moderate)

Clinical Features: 

Clinical Features History Age: Common age group is 40-70 years. No age is bar Sex: 60 % case comprises by males RD in fellow eye

Symptoms :: 

Symptoms : Flashes of lights (Photopsia) Floaters- may be Solitary ring shaped opacity(Weiss Ring) Cobwebs Sudden shower of minute red colored or dark spots

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3) localized relative loss in field of vision- cause -spread of SRF behind the equator less aware of superior than inferior field defect highly specific for localization of R.D perceived by the patient as black curtain

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4) sudden painless loss of vision – in case of large or central R.D 5) 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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History of previous ocular disease glaucoma Miotic drugs Chronic POAG more in pigment dispersion syndrome uveitis, vitreous hemorrhage, diabetic retinopathy Cytomegalovirus retinitis

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History of systemic diseases e.g. Diabetes, Tumors, Angiomatosis of C.N.S Sickle cell disease, Eclampsia Marfan's syndrome Family history

Signs: 

Signs Visual Acuity less if R.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 in Anterior chamber

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5) Pupillary reaction Relative afferent pupillary defect in extensive R.D 6) Posterior segment Tobacco dust in retrolental vitreous, haemorrhages

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Fundus Examination a Loss of normal fundal glow b) Retinal breaks: Present in about 70% of the eyes with tobacco dust. appears as red discontinuities in the retinal surface Upper temporal quadrant is the commonest site for retinal break

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Macula pigment of the macula may become more evident as a yellow colour due to intraretinal oedema or sub retinal fluid macular involvement is high in superior or temporal break or if in equatorial region

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Apparent holes in macula are relatively common Macular breaks leading to R.D are common in staphyloma of high myopia or following trauma Associated retinal degenerations Intraocular pressure-low Systemic evaluation

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Breaks may be in the form of holes, tears or dialysis Shape may be variable Can locate primary break by the shape of the R.D

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Shape of R.D in relation to primary break

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Retinal signs depends on duration of R.D Fresh R.D Detached retina has a convex configuration, slightly opaque and corrugated appearance,undulates freely with eye movements.

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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

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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 mo.

Differential diagnosis: 

Differential diagnosis Tractional R.D Symptoms Photophobia and floaters usually absent Visual field defect progressive Signs concave configuration , breaks absent SRF - shallower, seldom extends to ora serrata highest elevation at sites of Vitreo-retinal traction severely reduced retinal mobility , shifting fluid absent

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2) Exudative RD : 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

Differentiating features between RRD and Retinoschisis: 

Differentiating features between RRD and Retinoschisis RRD Retinoschisis Dome Convex, corrugated Convex, smooth Laterality Unilateral Usually Bilateral Field defect Relative Absolute Chronic changes Demarcation lines No demarcation line Breaks Present Absent or small inner leaf defects Response to laser No uptake Good uptake

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3) Degenerative retinoschisis : Symptoms – photopsia and floaters absent VF defects – absolute scotoma Signs – Elevation is convex, thin, smooth , relatively immobile Demarcation lines and secondary cyst absent

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4) Choroidal Detachment 5)Uveal Effusion Syndrome

Differentiating features between RRD and choroidal detachment: 

Differentiating features between RRD and choroidal detachment RRD Choroidal detachment Color Pale Darker (brownish), normal color Dome Convex corrugated Convex smooth Breaks Present Absent Ora serrata Visible with indentation Easily visible Maximal extent Anterior: ora serrata Posterior: unlimited Anterior: ciliary body Posteriorly: vortex veins

An approach in assessing RD: 

An approach in assessing RD Visual symptoms: asymptomatic; flashes, floaters, curtain field defect, decrease VA POH: Refractive error, surgery, trauma, laser treatment. PMH: connective tissue syndromes, diabetes, hypertension FH: retinal problems/ detachments, connective tissue syndromes Dx: use of miotics

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VA: pinhole and BCVA Pupils: RAPD (if extensive RD) Cornea: clarity for surgery, DM folds if hypotony AC: cells, flare (mild activity is common) Lens: cataract, PC rent, Aphakia, Yag capsulotomy Tonometry: IOP may be low, normal or high

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Fundus: RD: location, extent, age (atrophy, intraretinal cysts, demarcation lines), PVR (vitreous haze, retinal stiffness, retinal folds), retinal break (s): location, associated degenerations. Macula: on or off, hole Other eye: degeneration, breaks , other disease Indirect fundoscopy with indentation of both eyes.

Differentiating features of RD:: 

Differentiating features of RD: RRD ERD TRD History Aphakia, trauma, myopia Hypertension, eclampsia, renal failure DM, ROP, Penetrating trauma Retinal break 90-95% cases No break, coincidental No primary break, may develop secondary break Extent of detachment Extends to ora early Gravity dependent Frequently doesn’t extend to ora Retinal mobility Undulating bullae or folds Smoothly elevated bullae, usually without folds Taut retina, concave, peaks to traction points

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RRD ERD TRD Retinal elevation Low to moderate Seldom severe Varies may be extremely high to app. lens Elevated to a level of focal traction Evidence of chronicity Demarcation lines, intraretinal cysts, atrophic retina Usually none Demarcation lines Pigment in the vitreous 70% cases Not present Present in trauma cases Vitreous changes Syneretic, PVD, traction on flap tear Usually clear except in uveitis VR traction Subretinal fluid clear May be turbid and shift Clear, no shift

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RRD ERD TRD Choroidal mass None May be present none IOP Frequently low varies Usually normal Examples Retinal break Uveitis, metastatic tumor, malignant melanoma, coat’s disease, VKH syndrome, etc PDR, ROP, Toxocara, sickle cell disease, post traumatic VR traction

Thank You: 

Thank You