Retinal Detachment (Investigation

Category: Entertainment

Presentation Description

No description available.


Presentation Transcript

An Approach To Retinal Detachment : 

An Approach To Retinal Detachment Dr Gyanendra Lamichhane ,Dr.R.N.Byanju, Dr.I.Kansakar Lumbini Eye Institute Bhairahawa, Nepal

Slide 2: 

USG- B scan Routine TC, DC, Hb, ESR, Blood sugar, Urine R/M ERG (Bright flash) Investigations

Prophylaxis: Treatment of breaks : 

Prophylaxis: Treatment of breaks seals the retina with the RPE and choroid around the break, 2-3 rows of nearly confluent laser burns around e.g. break in lattice; firm chorioretinal scar forms in 7-10 days. Laser photocoagulation Transcleral cryotherapy

Treatment options for RRD : 

Treatment options for RRD Permanent scleral buckle, with/without drainage - radial, segmental or encirclage Temporary scleral buckle - Lincoff balloon, absorbable buckles Pneumatic retinopexy - Routine - with drainage of SRF or intravit. Liquid Primary vitrectomy Combinations of above Laser barrage Observation rarely

Anaesthesia : 

Anaesthesia Local or general anesthesia - advantages of LA: shorter operating time, quicker postoperative recovery, and decreased morbidity and mortality Peribulbar or retrobulbar

Preoperative considerations & patient counselling : 

Preoperative considerations & patient counselling If RRD threatening to detach the macula; surgery urgently necessary If macula is involved prompt surgery within 2-3 days recovers reasonable central vision macula off > 2 months postoperative Va usually poor If macula is not involved, most eyes maintain preop Va Simple pathology and principles of surgery has to explained Anatomic success does not equal visual success, occassionally second surgery may be needed

Scleral buckling : 

Scleral buckling Purpose: to close retinal breaks : to reduce VR traction Explants: material sutured directly onto the sclera Implants: intrascleral placement of buckle Explant configuration 1. Radial 2. Segmental circum 3. Encirclage Explant size 1. Buckle width/length 2. Buckle height

Scleral buckling… : 

Scleral buckling… Indications for radial buckle - Large U-tears - relatively posterior breaks Indications for segmental buckle - single or closely spaced breaks < 1clock hour - anterior breaks - wide breaks e.g. dialyses Indications for encirclage • multiple breaks in different quadrants; • aphakia • pseudophakia • myopia • diffuse vitreoretinal pathology, such as extensive lattice degeneration or vitreoretinal degeneration • proliferative vitreoretinopathy • extensive RD without detectable breaks, particularly in eyes with hazy media

Scleral buckling technique : 

Scleral buckling technique Examination with scleral indentation Conjunctival peritomy- conj. & tenon’s reflected, recti muscle/s hooked & traction suture placed Sclera inspected for thinning, staphyloma or anomalous vortex veins Precise localization of retinal breaks with ink marker, suture or O’ Connor localiser

Scleral buckling contd… : 

Scleral buckling contd… Insertion of local explant; appropriate size Calipers to measure separation of sutures; mark sclera Sutures placed a minimum 2mm farther apart than the width of explant Mattress suture; 5-0 non-absorbable SRF drainage

Rationale 1. To allow elevation of buckle without elevating the IOP 2. To allow the retina to settle on the elevating the buckle : 

SRF drainage Immobile retina Longstanding RD with viscous SRF Inferior RD with equatorial tears Bullous RD with difficulty localizing breaks Rationale 1. To allow elevation of buckle without elevating the IOP 2. To allow the retina to settle on the elevating the buckle

Scleral buckling… : 

Scleral buckling… Cryotherapy under direct visualization with indirect Freeze until retina just turns white, surround entire break by 2mm margin Tighten the suture over explant, rechecking its correct position over the break. The buckling effect should extend for 30° on either side of the tear and extend anteriorly to the ora serrata D-ACE technique for bullous RDs and breaks behind the equator

Scleral buckling - encirclage : 

Scleral buckling - encirclage Strap of appropriate diameter passed under 4 recti 2 ends are secured by a sleeve (Watzke) Buckle positioned such that the posterior edge of the break lies on the posterior crest of the buckle If no specific pathologic factor to be supported, the encircling element should buttress the posterior margin of the vitreous base.

Encirclage … : 

Encirclage … Strap secured by placing holding sutures SRF drainage: Just above or below the horizontal meridian, temporally/nasally : radial sclerotomy – needle puncture Strap tightened; internal indentation directly visualised; ideal ht. 2mm Radial sponge for large U-tears/fishmouthing and segmental tyre to support several breaks

Buckling failure : 

Buckling failure Missed break/s Buckle of inadequate size, height and incorrect positioning Fishmouthing Missed iatrogenic break caused during SRF drainage PVR; most common cause, can open old breaks or create new ones, typically 4-6 postop weeks Persistent VR traction & new break formation Reopening of break due to inadequate chorioretinal reaction or late buckle failure. Early failure Late failure

Complication - Intraoperative : 

Complication - Intraoperative Scleral Perforation presentation of blood, pigment, and/or subretinal fluid through the suture tract. Drainage Complications retinal incarceration - support with a buckle if large choroidal / subretinal hemorrhage - close quickly with either the buckle or a sclerotomy suture

Complications - Postoperative : 

Complications - Postoperative Glaucoma : with/without pupillary block Explant exposure/infection/extrusion Choroidal detachment (choroidal edema) Maculopathy : CME, macular pucker, Pigmentary Diplopia Changes in refractive error : most in encirclage

Vitrectomy in RRD : 

Vitrectomy in RRD Inability to visualize the break due to opacities Inability to close breaks due to - Very large breaks - Posterior break including a macular hole - PVR with severe VR traction

Vitrectomy… : 

Vitrectomy… 1. Ocular manipulation less; buckle small or not required 2. Retinopexy is more controlled; applied after retinal reattachment 3. Internal tamponade ensures closure of retinal break postoperatively. Advantage

Complications : Vitreous surgery : 

Complications : Vitreous surgery Intraoperatively Posterior/peripheral retinal breaks Choroidal haemorrhage (rare) Postoperatively Retinal breaks, RRD Elevated IOP : gas overfill, steroid use, inflammatory, angle closure, neovascular Progressive nuclear sclerosis Corneal decompensation Hypotony Endophthalmitis (1 in 2000)

authorStream Live Help