Retinal Detachment

EKO KUNARYAGI
Vitreous Body
Attachments of the
vitreous body
Anatomy of retina
Definition
Retinal detachment refers to the separation of the neurosensory retina
from the underlying retinal pigment epithelium, to which normally it is
loosely attached.
Classification

This can be classified into:

Rhegmatogenous retinal detachment results from a tear,
i.e.,a break in the retina.
Tractional retinal detachment results from traction, i.e., from
vitreous strands that exert tensile forces on the retina
Exudative retinal detachment is caused by fluid. Blood,
lipids, or serous fluid accumulates between the neurosensory
retina and the retinal pigment epithelium. Coatsdisease is
atypical example.
Cont.

Primary retinal detachment usually results from a tear.

In rare cases, secondary retinal detachment may also result from a
tear due to other disorders or injuries. Combinations of both are also
possible but rare.
Proliferative vitreoretinopathy frequently develops from a chronic
retinal detachment.
 Epidemiology
Rarely encountered in ophthalmologic practice, clinically highly
significant as they can lead to blindness if not treated immediately.
Rhegmatogenous retinal detachment (most frequent form):
Approximately 7% of all adults have retinal breaks. The incidence of
this finding increases with advanced age.
The peak incidence is between the fifth and seventh decades of
life. This indicates the significance of posterior vitreous detachment
(separation of the vitreous body from inner surface of the retina; also
age-related) as a cause of retinal detachment.
The annual incidence of retinal detachment is one per10000
persons; the prevalence is about 0.4% in the elderly.
Cont.

There is a known familial disposition, and retinal detachment

also occurs in conjunction with myopia.
The prevalence of retinal detachment with emmetropia (normal
vision) is 0.2% compared with 7% in the presence of severe
myopia exceeding -10 diopters.
Exudative, tractional, and tumor-related retinal detachments are
encountered farless frequently.
Etiology

Rhegmatogenous retinal detachment.

This disorder develops from an existing break in the retina. Usually
this break is in the peripheral retina, rarely in the macula. Two
types of breaks are distinguished:
Round breaks: A portion of the retina has been completely torn
out due to a posterior vitreous detachment.
Horse shoe tears: The retina is only slightly torn.
Not every retinal break leads to retinal detachment. This will
occur only where the liquefied vitreous body separates, and
vitreous humor penetrates beneath the retina through the tear. The
retinal detachment occurs when the forces of adhesion can no
longer with stand this process.
Cont.

Tractional forces (tensile forces) of the vitreous body (usually vitreous

strands) can also cause retinal detachment with or with out
synchysis.
In this and every other type of retinal detachment, there is a dynamic
inter play of tractional and adhesive forces. Whether the retina will
detach depends on which of these forces is stronger.
Cont.
Cont.

Tractional retinal detachment.

This develops from the tensile forces exerted on the retina by
preretinal fibrovascular strands especially in proliferative retinal
diseases such as diabetic retinopathy.
Exudative retinal detachment.
The primary cause of this type is the break down of the inner or
outer bloodretina barrier, usually as a result of a vascular
disorder such as Coats disease. Subretinal fluid with or without
hard exudate accumulates between the neurosensory retina and
the retinal pigment epithelium.
Symptoms

Retinal detachment can remain asymptomatic for along time.

In the stage of acute posterior vitreous detachment:
Flashes of light (photopsia) and floaters
Black points that move with the patients gaze.
A posterior vitreous detachment that causes a retinal tear may
also cause avulsion of a retinal vessel.
Blood from this vessel will then enter the vitreous body.
The patient will perceive this as blackrain, numerous slowly
falling small black dots.
Cont.

Another symptom is a dark shadow in the visual field.

This occurs when the retina detaches.
The patient will perceive a falling curtain or a rising wall,
depending on whether the detachment is superior or inferior.
A break in the center of the retina will result in a sudden and
significant loss of visual acuity, which will include
metamorphopsia (image distortion) if the macula is involved.
Clinical examination

Best corrected visual acuity

Visual field screening (confrontation)
Direct / indirect ophthalmoscopy
Slit lamp fundus examination
Retinal drawing or photodocumentation
Ultrasonography
Differential diagnosis

Normal eye with sudden loss vision

Degenerative retinoschisisis the primary disorder that should be
excluded as it can also involve rhegmatogenous retinal detachments in
rare cases.
A retinal detachment may also be confused with a choroidal
detachment.
Fluid accumulation in the choroid, due to inflammatory choroidal
disorders such as Vogt-Koyanagi-Harada syndrome, causes the
retinal pigment epithelium and neurosensory retina to bulge outward.
Treatment
Retinal breaks with minimal circular retinal detachment can be treated
with argon laser coagulation
The scars resulting from argon laser therapy are sufficient to prevent
any further retinal detachment.
Cont.

More extensive retinal detachments are usually treated with a retinal

tamponade with an elastic silicone sponge that is sutured to the
outer surface of the sclera, also-called budding procedure.
It can be sutured either in a radial position (perpendicular to the limbus)
or parallel to the limbus.
This indents the wall of the globe at the retinal break and brings the
portion of the retina in which the break is located back into contact with
the retinal pigment epithelium.
The indentation also reduces the traction of the vitreous body on the
retina.
Cont.

An artifical scar is created to stabilize the restored

contact between the neurosensory retina and retinal
pigment epithelium.
This is achieved with a cryoprobe. After a successful
operation, this scar prevents recurring retinal
detachment.
Cont.

Where there are several retinal breaks or the break

can not be located, a silicone cerclage is applied to
the globe as a circumferential buckling procedure.
The procedures described up until now apply to
uncomplicated retinal detachments, i.e., without
proliferative vitreoretinopathy.
 Suturing a retinal tamponade with silicone sponge
may also beat tempted initially in a complicated
retinal detachment with proliferative
vitreoretinopathy.
If this treatment is unsuccessful, the vitreoretinal
proliferations are excised, and a vitrectomy is
performed in which the vitreous body is replaced
with Ringers solution, gas, or silicone oil. These fluids
tamponade the eye from within.
Prophylaxis

High-risk patients above the age of 40 with a

positive family history and severe myopia should
be regularly examined by an ophthalmologist,
preferably once a year.
Clinical Course and Prognosis

About 95% of rhegmatogenous retinal detachments can be treated

successfully with surgery.
Where there has been macular involvement (i.e.,the initial
detachment included the macula), a loss of visual acuity will remain.
The prognosis for the other forms of retinal detachment is usually poor,
and they are often associated with significant loss of visual acuity.
Terimakasih