RETINAL

DETACHMENT
Presented by: Yogesh kumar tiwari
MSc.Nsg.1st year
CON,AIIMS
Moderator:Mrs. Ujjwal Dahiya
Lecturer,CON,AIIMS
 Introduction
• The role of vision in our lives is difficult to define,
because it is so deeply personal and intimate
• Whenever there is a failure in the vision, its not
only the eyes, that are said to be in darkness
but the whole life is in darkness.
• Loss of vision means loss of independence.
Among the various causes of blindness ,retinal
detachment is one which is an ocular
emergency.
 Definition
 Retinal detachment is a disorder of the eye in
which the retina peels away from its
underlying layer of support tissue.

 A detached retina is a serious and sight-

threatening event.

 And unless the retina is reattached soon,

permanent vision loss may result.
Anatomy of eyeball
 Retina
 The retina is the inner most layer of the eye. It is
composed of nerve tissue.
 The optical system of the eye focuses light on the
retina much like light is focused on the film in a camera.
 Layers of retina
The retina is composed of 10 layers
Pigmented epithelium

Photoreceptors; bacillary layer (outer and

inner segments photoreceptors)

External (outer) limiting membrane

 Outer nuclear
 Layers of retina
 Outer plexiform

 Inner nuclear

 Internal limiting membrane

Inner plexiform layer

Ganglion cell layer

Nerve fiber layer

Layers of retina
How does retina forms
images ?
 Vitreous Humour
 Comprises a large portion of the eyeball

It is a clear gel that occupies the space behind

the lens and the retina
 Epidemiology
 The incidence of retinal detachment in otherwise normal
eyes is around 5 new cases in 100,000 persons per year
 Detachment is more frequent in middleaged or elderly
populations, with rates of around 20 in 100,000 per year
 The lifetime risk in normal individuals is about 1 in 300
 Retinal detachment is more common in people with
severe myopia (above 5–6 diopters), in whom the retina
is more thinly stretched. In such patients, life time risk
rises to 1 in 20.
 About two thirds of cases of retinal detachment occur in
myopics. Myopic retinal detachment patients tend to be
younger than nonmyopic ones.
 Type
• There are three types of retinal detachment:
• rhegmatogenous
• tractional
• exudative
 Types
 Rhegmatogenous retinal detachment –It occurs due
to a break in the retina (called a retinal tear)

 Retinal breaks are divided into three types – holes,

tears and dialyses.
 Types
Exudative, serous, or secondary
retinal detachment –It occurs due
to inflammation, injury or vascular
abnormalities

 Fluid accumulating underneath

the retina without the presence of a
hole, tear, or break.

 Rare
 Types
 Tractional retinal detachment –It occurs
when fibrous or fibrovascular tissue, pulls the
sensory retina from the retinal pigment
epithelium.
 Risk factors
• Severe myopia

• Retinal tear

• Family history

•Other eye diseases or disorders, such as

retinoschisis, uveitis, degenerative myopia, or
lattice degeneration
 Risk Factors…
• Eye injury
• Tumors
• Systemic diseases such as diabetes & sickle cell
disease
• Complications from cataract surgery
 Sign and symptims
Warning signs
 Flashes of light
(photopsia)
 A sudden increase in
the number of floaters
 Blurred vision
 Seeing a shadow or a
curtain descending from the
top of the eye or across
 Diagnosis
Elicit history for any of the
following:
• History of trauma
• Previous ophthalmologic surgery
• Previous eye conditions (eg,
uveitis and vitreous
hemorrhage)
• Duration of visual symptoms and
visual loss
 Diagnosis
Physical examination should include the following:
• Checking of visual acuity
• External examination for signs of trauma and
checking of the visual field
• Assessment of pupil reaction
• Measurement of intraocular pressure in
both eyes
• Slit-lamp examination
• Examination of the vitreous for signs of
pigment or tobacco dust
 Diagnosis
• Fundus photography or
ophthalmoscopy.
Fundus photography : larger
instrument than the ophthalmoscope

• Ultrasound
 Significance of timely
treatment
• Visual improvement is much greater when
the retina is repaired before the macula is
detached.

• Once the retina is reattached, vision

usually improves and then stabilizes.
 Treatment
General principles of treatment:

1. Find all retinal breaks

2. Seal all retinal breaks

3. Relieve present (and future) vitreo retinal traction

 Surgical Methods
 Cryopexy and laser photocoagulation

 Scleral buckle surgery

 Pneumatic retinopexy

 Vitrectomy
 Cryopexy
 Cryotherapy (freezing) is used to wall off a small
area of retinal detachment

 Uses
nitrous oxide to freeze the tissue behind the
retinal tear
 This prevents fluid passing through the hole.
 Laser Photocoagulation
• If the retina is torn or the detachment
is slight
• Laser burn the edges of the tear and
halt progression.
• Stimulates the scar tissue formation to
seal the edges of the tear
 Scleral buckle surgery
Surgeon sews silicone bands to the sclera
(the white outer coat ofthe eyeball)

The bands push the wall of the eye inward

against the retinal hole

Cryotherapy (freezing) is applied around

retinal breaks prior to placing the buckle
 Scleral buckle surgery
 Subretinal fluid is drained as part of the buckling
procedure
 The buckle remains in situ
 The most common side effect of a scleral
operation is myopic shift.

Myopic shift: the operated eye will be more short

sighted after the operation
 Scleral buckle surgery
Types of scleral buckling:

 Radial scleral buckle

 Circumferential scleral buckle

 Encircling buckles
 Pneumatic retinopexy
Generally under local anesthesia

Gas bubble (SF6 or C3F8 gas) is injected into

the eye after which laser or freezing treatment

The patient's head is then positioned

Have to keep their heads tilted for several

days
 Reseach input
• Problem statement-
Outcome of surgery after macula-off retinal detachment – results from MUSTARD, one of the largest
databases on buckling surgery in Europe
• ABSTRACT. Purpose: To evaluate the anatomical success rate of scleral buckling surgery in the
treatment of rhegmatogenous retinal detachment and to evaluate the differences in
outcome between patients suffering macula-off retinal detachment and those without a
macular involvement.
• Methods: As a retrospective interventional case series, Munster Study on Therapy Achievements
in Retinal Detachment (MUSTARD) is one of the largest ever established of retinal detachment
patients and their outcome after buckling surgery, with 4325 patients who underwent surgery
between 1980 and 2001. In 53.94% (n = 2134) of 3956 patients with nontraumatic retinal
detachment, the macula was involved. The main outcome measure was the achievement of dry
anatomical attachment of the retina.
• Results: The success rate in patients with macula-off retinal detachment is 80.46% and thus
7.78% lower (p < 0.01) than that in those patients with their macula intact whose success rate
amounted to 88.24%. The overall success rate of all 4325 MUSTARD patients was 83.98%.
• Conclusions: Scleral buckling is an established and mostly successful method for the treatment of
retinal detachment. As our case series has demonstrated, even eyes with macula-off can be
treated successfully by this procedure, thereby avoiding the complications of primary vitrectomy.
 Pneumatic retinopexy
 The surface tension of the gas/water interface
seals the hole in the retina

 Combined with cryopexy or laser

photocoagulation
 Vitrectomy
Tiny incision in the sclera
Remove vitreous
Gas is often injected to into the eye
During the healing process, the eye makes
fluid that gradually replaces the gas and
fills the eye.
 Vitrectomy
 Using gas in this operation : no myopic
shift after the operation

 Silicon oil (PDMS), if filled needs to be

removed after a period of 2–8 months
 COMPLICATIONS AFTER
SURGERY
• Discomfort

• Watering

• Redness

• Swelling

• Itching
• Blurred vision
 Prognosis
 85 percent of cases will be successfully treated
with one operation
 15 percent requiring 2 or more operations
 After treatment patients gradually regain their
vision over a period of a few weeks, although the
visual acuity may not be as good as it was prior
to the detachment, particularly if the macula was
involved in the area of the detachment.
 Currently, about 95 percent of cases of retinal
detachment can be repaired successfully
Pre operative management
• Assess the visual acuity of the client’s non-operative
eye prior to surgery
• Assess the client’s support systems and the possible
effect of impaired vision on lifestyle and ability to
perform ADLs in the post- operative period
• Safety measures such as installing hand rails,especially if
the client has limited vision in the unaffected eye
• Remove all eye makeup and contact lenses or
glasses prior to surgery
• Mydriatic (pupil-dilating) or cycloplegic (ciliary-
paralytic) drops and drops to lower intraocular pressure
may be prescribed preoperatively.
 POST – OPERATIVE
MANAGEMENT
• Monitor status of the eye dressing following surgery.
• Assess dressings for the presence of bleeding or
drainage
• Maintain the eye patch or eye shield in place. The eye
patch or shield helps prevent inadvertent injury to the
operative site
• Place the client in a semi-Fowler’s or Fowler’s position ,
having the client lie on the unaffected side.These
positions reduce intraocular pressure in the affected
eye.
• Assess the client and medicate or assist to avoid
vomiting coughing , sneezing or straining as needed.
These activities increase intraocular pressure
 Contd…
• After surgery for a detached retina,the client is
positioned so that the detachment is dependent or
inferior.

 For example , if the outer portion of the left retina is

detached , the client is positioned on the left side .
Positioning so that the detachment is inferior maintains
pressure on that area of the retina, improving its contact
with the choroid.

• Assess comfort and medicate as necessary for

complaints of an aching or scratchy sensation in affected
eye . Immediately report any complaint of sudden, sharp
eye pain to the physician.
 Contd…
• Assess for potential surgical complications:
a. Pain in or drainage from the affected eye
b. Hemorrhage with blood in the anterior chamber eye
c. Flashes of light, floaters, or the sensation of a curtain
being drawn over the eye (indicators of retinal
detachment)
d. Cloudy appearance to the cornea (corneal edema)
• Evidence of any of the above manifestations or unusual
complaints by the client should be reported to the
physician at once
• Approach the client on the unaffected side.This
approach
facilitates eye contact and communication.
 Contd…
• Place all personal articles and the call bell within easy
reach . These measures prevent stretching and straining
by the client
• Assist with ambulation and personal care activities as
needed. Assistance may be necessary to maintain
safety
• Antibiotic ,anti-inflammatory and other systemic and eye
medications as prescribed . Medications are prescribed
post operatively to prevent infection or inflammation of
the operative site, maintain pupil constriction , and
control intraocular pressure
• Administer antiemetic medication as needed. It is
important to prevent vomiting to maintain normal
intraocular pressures
 Home care
• Adequate lighting
• Promote unrestricted ambulation
• Removal of hazards like rugs, clutters,
unnecessary furnitures
• Provision of hand rails in hallways, bathrooms
• Access to radio and television
• Voice activated switches
• Pill organizers
• Large print newspapers, magazines
 Contd…
• Double vision
• Glaucoma
• Bleeding into the vitreous, within the retina,
or behind the retina
• Cataract
• Drooping of the eyelid
• Infection around the scleral buckle
• Endophthalmitis
 Prognosis
 Treatment failures usually involve either the failure
to recognize all sites of detachment, the
formation of new retinal breaks,or proliferative
vitreo retinopathy
 Involvement of the macula portends a
worse prognosis
 Damage to vision may occur during
reattachment Surgery
 10 percent of patients with normal vision
experience some vision loss after a successful
reattachment surgery.
 Conclusion
Visual impairment is more than a physiologic
deficit.
It is a loss that has physical and emotional
effects on the person afflicted.
So as far as possible prevent those causes of
blindness.