Retinal Detachment (History

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Rhegmatogenous Retinal Detachment(History & Clinical Evaluation) : 

Rhegmatogenous Retinal Detachment(History & Clinical Evaluation) Dr Gyanendra Lamichhane Dr.R.N.Byanju Dr.I.Kansakar Lumbini Eye Institute Bhairahawa , Nepal

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Contd.. References: Clinical Ophthalmology - Kanski Retinal detachment by American Academy of Ophthalmology Retinal Detachment –Diagnosis and Management by William Edmunds Benson Ophthalmology by Myron Yanoff

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Contd.. 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) Two main types 1)Rhegmatogenous or Primary R.D 2)Nonrhegmatous or Secondary R.D

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Contd… Secondary R.D sub divided in to two types: Tractional R.D. Exudative(Serous) R.D Rhegmatogenous R.D In Greek word,Rhegma meaning a rent or fissure

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Contd… Rhegmatogenous R.D is a condition in which fluid from vitreous cavity passes through a full thickness retinal defect in to the sub retinal space to cause separation of the neural retina from the underlying R.P.E It affects about 1:10,000 of the population each year

Pathogenesis : 

Pathogenesis Acute posterior Predisposing vitreous retinal degenerations detachment Aphakia Trauma retinal break degenerated vitreous passes via this break between sensory retina and RPE collected as SRF Retinal detachment

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Contd… Major factors associated with development of R.D are : Neural retinal break Vitreous liquefaction and detachment

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Contd… c) Vitreoretinal traction d) Intra ocular fluid currents associated with movement of liquid vitreous and sub retinal fluid Retinal breaks are caused by an interplay between dynamic vitreoretinal traction and predisposing retinal degenerations.

Clinical Features : 

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 are sporadic

Symptoms : : 

Symptoms : Classic premonitory symptoms present in 60% of patients with Spontaneous rheg.R.D are 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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Contd… 3) localized relative loss in field of vision-early less aware of superior than inferior field defect highly specific for localization of R.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 central R.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 syndrome Miotic 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 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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Contd… 5) Pupillary reaction Relative afferent pupillary defect in extensive R.D 6) Posterior segment Tobacco dust in retrolental vitreous, haemorrhages

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Contd… 7)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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Contd 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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Contd… 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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Contd… 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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Contd 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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Contd 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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Contd… 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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Differential diagnosis : 

Differential diagnosis Includes R.D from other causes and retinoschisis 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, seldom extends to ora serrata highest elevation at sites of vitreo-retinal traction severely reduced retinal mobility , shifting fluid absent

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Contd… 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

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Contd… 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

Thank You : 

Thank You

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