Rhegmatogenous Retinal Detachment (Manag

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Rhegmatogenous Retinal DetachmentMANAGEMENT : 

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

REFERENCES : 

REFERENCES 1. Ophthalmology -Myron Yanoff & J.S Duker 2. Principles & Practice of Ophthalmology,1994 Albert and Jakobiec 3. Stallard’s Eye Surgery-7th. Edition 4. American Academy of Ophthalmology (Retina and Vitreous) 5.Clinical Ophthalmology 4th. Edition Jack J. Kanski 6. Retina - Stephen J. Ryan

Management : 

Management Diagnosis/Treatment Diagnosis Clinical Feature Investigations

Slide 4: 

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

Prophylaxis: Retinal Breaks : 

Prophylaxis: Retinal Breaks INDICATIONS A. Characteristics of break B. Predisposing Peripheral retinal degenerations

High risk Breaks : 

High risk Breaks 1) Tears more dangerous than holes 2) Large break 3) Symptomatic tears 4) Superior breaks 5) Equatorial breaks 6) Sub clinical R.D

Other Considerations : 

Other Considerations Break with or without symptoms: Aphakia Myopia One eyed Family History Systemic Diseases e.g. Marfan Syndrome, Stickler Syndrome, Ehlers Danlos Syndrome

Prophylaxis… : 

Prophylaxis… Predisposing Peripheral retinal degenerations (Lattice/Snail track) R.D in the fellow eye Aphaka or pseudophakia High Myopia Strong family history of R.D Systemic diseases

Prophylaxis Contd…. : 

Prophylaxis Contd…. White without pressure with fellow eye - giant retinal tears Fellow eye aphakic retinal detachment ( 360 degree cryotherapy 4 weeks prior to cataract surgery)

Prophylaxis Treatment Options : 

Prophylaxis Treatment Options 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

Cryotherapy/Laser Therapy : 

Cryotherapy/Laser Therapy Location of lesion Clarity of the media Pupil size

Retinal Detachment Surgery : 

Retinal Detachment Surgery Historical Review: 1920:T/t of R.D began in rational lines, Jules Gonin-first man to appreciate the pathological significance and therapeutic effect of closing retinal breaks T/t of R.D by sealing of the retinal breaks and evacuating the inter retinal fluid by puncture with a galvanocautery. 1930 : Rosengren tried intravitreal air injection in upper half detachments. 1933: Deutschmann tried cryopexy for R.D .

History contd.. : 

History contd.. 1949 Custodis : concept of Scleral Buckling 1957 Schepens : refined scleral buckling technique and devised encircling operation in 1960. 1949: Goldman devised three mirror fundus contact lens 1950 Schepens : Indirect ophthalmoscope 1962 Cibis introduced silicon oil to tamponade Lincoff and co-workers: Silicon sponge explant and cryotherapy

History contd… : 

History contd… 1964 Lincoff revived Cryotherapy 1940 Amsler–SRF distribution to find probable hole, later in 1971 Lincoff provided detail description. 1985 Gilbert and McLeod successfully tried D-ACE procedure for upper half bullous R.D

Preoperative considerations & patient counseling : 

Preoperative considerations & patient counseling 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

Anaesthesia : 

Anaesthesia Local or general anesthesia Advantages of LA Shorter operating time Quicker postoperative recovery Decreased morbidity and mortality Peribulbar / retrobulbar

Purpose of R.D surgery : 

Purpose of R.D surgery To close the retinal hole To relieve any vitreoretinal traction.

Treatment options: RRD : 

Treatment options: RRD Permanent scleral buckle, with/without drainage - radial, segmental or encirclage Temporary scleral buckle - Lincoff balloon, absorbable buckles Pneumatic retinopexy Primary vitrectomy Combinations of above Observation rarely

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 or suture

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

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 Fish mouthing 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 sub retinal 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 : 

VITRECTOMY Historical Review Till 1960, believed that vitreous body should not be violated 1970, Machemer and Parel introduced the first vitrectomy machine and vitrectomy performed in diabetic patient

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

Contd… : 

Contd… Corneal decompensation Hypotony Endophthalmitis (1 in 2000) Anterior Hyaloidal fibrovascular proliferation Fibrin deposition in the anterior chamber (D.M)

Tamponading Agents : 

Tamponading Agents Purpose: To achieve intra operative retinal flattening by internal drainage of SRF and fluid gas exchange. To produce internal closure of retinal breaks during the post operative period.

Tamponade… : 

Tamponade… Ideal tamponading Agents: High surface tension Optically clear Biologically inert

Expanding Gases : 

Expanding Gases Sulphur hexafluoride( SF6) Doubles its volume and lasts 10-14days. Perfluoroethane(C2F6) Triples its volume and lasts 30-35 days Perfluoropropane(C3F8) Quadruples its volume and lasts 66-65 days

Tamponade… : 

Tamponade… Heavy Liquid Perfluorocarbons Indications: To stabilize the posterior retina To unfold a giant retinal tear To remove posteriorly dislocated lens fragments or intraocular lens implants

Tamponade… : 

Tamponade… Silicon oil: Low specific gravity More controlled intraoperative manipulations Prolonged post operative intraocular tamponade

Slide 42: 

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