Rhegmatogenous Retinal Detachment (Patho

Rhegmatogenous Retinal Detachment : 

Rhegmatogenous Retinal Detachment Dr Gyanendra Lamichhane Lumbini Eye Institute Bhairahawa ,Nepal

References: : 

References: Clinical ophthalmology-Kanski 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

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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 Affects about 1:10,000 of the population each year.

History : 

History 1851 Von Helmholtz-invented direct ophthalmoscope Coccius –first detected retinal breaks 1919Jules Gonin-first operation

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Types of retinal tears

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

Pathogenesis : 

Pathogenesis -decreased conc of hyaluronic acidliquification of vitreous & loss of support of collagen fiberscollapse of vitreous cavityfluid subhyloid spacePVD -vitreoretinal traction where vitreous remains attachedretinal break-horseshoe-shaped .

Predisposing conditions : 

Predisposing conditions Posterior vitreous detachment Peripheral fundus leisons Myopia Aphakia & pseudophakia Inadvertent scleral perforation Intraocular inflammation-infection Colobomas of choroid & retina Marfan’s syndrome Goldmann-favre syndrome

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 eg. 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 months.

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

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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

Thank You : 

Thank You