Retinal Detachment Slide

Retinal
Detachment
Anatomy of the peripheral retina
Salmon, J. and Kanski, J., n.d. Kanski's clinical ophthalmology. 9th ed. elseiver, pp.654-687.
The peripheral cortical vitreous is loosely attached
to the internal limiting membrane (ILM) of the
sensory retina.
Sites of stronger adhesion in the normal eye :

● Vitreous base (very strong).
● Optic disc margins (fairly strong).
● Perifoveal (fairly weak).
● Peripheral blood vessels (usually weak).
Part 1
POSTERIOR VITREOUS
DETACHMENT.
● Separation of the cortical vitreous, along with

the delineating posterior hyaloid membrane
(PHM), from the neurosensory retina posterior
to the vitreous base.
● Occurs due to vitreous gel liquefaction with age

(synchysis) to form fluid-filled cavities and
subsequently condensation (syneresis).
● Prevalence increases with age.
● Predisposing : aphakia, pseudophakia with

open posterior capsule, inflammatory disease,
trauma, vitreous hemorrhage, and axial myopia.
Signs.
● On slit lamp : crumpled
translucent membrane in the
mid-vitreous cavity behind
which the cavity is optically
clear
● Haemorrhage indicated by
the presence of red blood
cells in the anterior vitreous or (C) Weiss ring on retroillumination; (D) Weiss ring on
slit lamp biomicroscopy
Symptoms. as (usually small) focal
intragel collections, or
preretinally
● Early stages : asymptomatic
● ● Separation from the optic
Flashing lights (photopsia)
● Floaters (myodesopsia) nerve head margin (the area
● Blurred vision of Martegiani) occurs with
appearance of Weiss Ring.
Colin A, M., 2019. Basic and Clinical Science Course Chapter 12 Retina and Vitreous. San Fransisco: American Academy of
Ophthalmology, pp.355-381.
Investigation.
• B-scan ultrasound can demonstrate the
extent of PVD.
• OCT can show separation of the

posterior vitreous face and retina.
(B) ultrasound B-scan; (C) OCT showing macular PVD
Posterior Vitreous Detachment
● Management
• Reexamination of the patient 2–4 weeks following presentation may be

appropriate, because as the PVD evolves over time, new retinal breaks may occur.
• Large vitreous hemorrhage  complete examination, bilateral ocular patching

and bed rest, with the patient’s head elevated 45° or more for a few days
• If the cause of the hemorrhage cannot be found, the patient should be reexamined
at frequent, regular intervals, and early vitrectomy should be considered to
reduce the risk of retinal detachment.
Part 2
Lesions That Predispose Eyes to
Retinal Detachment
Meridional Folds,
Enclosed Ora
Lattice Vitreoretinal Bays,
Degeneration Tufts and Peripheral
Retinal
Excavation
a vitreoretinal interface small, peripheral, focal areas of folds of redundant retina

abnormality elevated glial hyperplasia
associated with vitreous or
zonular attachment and traction.
LATTICE DEGENERATION
● A vitreoretinal interface abnormality, bilateral in one-third to one-

half of affected patients, commonly in myopic eyes
● May predispose eyes to retinal breaks and detachment.
● 20%–30% of all eyes that present with rhegmatogenous RD.
● Retinal detachments secondary to atrophic holes typically occur

in young patients with myopic eyes and no vitreous detachment;
they are generally asymptomatic.
Clinical features of lattice
degeneration :
(A) Small island of lattice with an

arborizing network of white
lines (arrow) using wide-field
photography;
(B) Lattice associated with
‘snowflakes’;
(C) Lattice associated with
pigmentary changes;
(D) Small holes within lattice seen
on scleral indentation
Vitreoretinal Tufts
• Peripheral retinal tufts are small, peripheral, focal areas of elevated glial
hyperplasia associated with vitreous or zonular attachment and traction.
• Tractional tufts are classified according to anatomical, pathogenetic, and

clinical distinctions into the following groups:
1. Noncystic retinal tufts

2. Cystic retinal tufts
3. Zonular traction retinal tufts
Vitreoretinal Tufts
Color photograph of a gross eye specimen Color photograph of a gross eye specimen shows a
shows a cluster of white surface nodules small zonular traction tuft (arrow)
with characteristic gross appearance and with cystic base. Note that the tuft points anteriorly
location of noncystic retinal tufts. toward.
Meridional Folds, Enclosed Ora Bays, and
Peripheral Retinal Excavations
• Meridional folds are folds of redundant retina, usually located superonasally.

Occasionally, tears associated with PVD occur at the most posterior limit of the folds
• Retinal tears can also occur at or near the posterior margins of enclosed ora bays,
which are oval islands of pars plana epithelium located posterior to the ora serrata.
• Tears may occur at the site of peripheral retinal excavations, which represent a
mild form of lattice degeneration. Peripheral retinal excavations often aligned with
meridional folds.
Meridional Folds, Enclosed Ora Bays, and Peripheral Retinal Excavations
Color photograph of a gross eye specimen shows a meridional complex, consisting of an atypical and large dentate process (arrow)
that is continuous with a ciliary process of the pars plicata and an area of enclosed pars plana and ora bay (asterisk). Slightly
posterior to the complex is a small area in the same meridian that appears to be excavated but is in fact a cyst (small arrow).
Part 3
Lesions That DO NOT Predispose Eyes to Retinal
Detachment
Retinal Pigment Peripheral

Epithelial Cystoid
Hyperplasia Degeneration
Paving-Stone Retinal Pigment

Degeneration Epithelial
Hypertrophy
Paving-Stone
Degeneration
• “paving stones”  atrophy of the RPE and
outer retinal layers, attenuation or absence
of the choriocapillaris, and adhesions
between the remaining neuroepithelial
layers and Bruch membrane
• Most common  inferior quadrants,

anterior to the equator
Gross appearance of paving-stone degeneration
Part 4
Retinal Breaks
• Defined as any full-thickness defect in the neurosensory retina  liquid from the
vitreous cavity to enter the potential space  RRD
• Retinal breaks may be classified as :

• flap, or horseshoe, tears
• Giant retinal tears
• Operculated holes
• Retinal dialyses
• Atrophic retinal holes
• Traumatic breaks
Traumatic Breaks
● Blunt trauma can cause retinal breaks by direct contusive injury to the globe
through 2 mechanisms:
○ coup, adjacent to the point of trauma,
○ contrecoup, opposite the point of trauma.
Traumatic retinal detachments in young patients may be shallow and often

show signs of chronicity, including multiple demarcation lines, subretinal
deposits, and intraretinal schisis.
Schematic
illustration of retinal
tears and holes.
Part 1, Retinal breaks at borders of the vitreous
base.
Part 2, Retinal breaks with areas of abnormal

vitreoretinal interface (lattice degeneration)
Part 3, Retinal breaks associated with abnormal

vitreoretinal attachments.
Retinal tears. (A) Large U-tear; (B) operculated tear (arrow); (C) atrophic hole
(arrow) with subretinal fluid; (D) retinal dialysis (arrow heads); (E) giant retinal
tear;
Part 5
Prophylactic Treatment of Retinal Breaks
• The goal  the creation of a chorioretinal adhesion around each break to

prevent fluid from entering the subretinal space.
• The ophthalmologist weighs numerous factor : symptoms, family history,

residual traction, size and location of the break, phakic status, refractive error,
status of the fellow eye, presence of subretinal fluid, and availability of the
patient for follow-up evaluation.
• Prophylaxis is sometimes contraindicated in eyes with more than 6.00

diopters (D) of myopia and more than 6 clock-hours of lattice degeneration
Prophylactic Treatment of Retinal Breaks.
Symptomatic Retinal Breaks
● Numerous clinical studies have demonstrated that acute, symptomatic breaks are at
greater risk of progressing to retinal detachment, especially if there is associated
vitreous hemorrhage.
● Acute symptomatic flap tears are commonly treated prophylactically.
● Acute operculated holes are less likely to cause detachment because there is no
residual traction on the adjacent retina, and they usually are not treated.
● Atrophic holes are often incidental findings in a patient who presents with an acute
PVD  treatment not recommended
Part 6
Retinal Detachment
• Retinal detachments are classified as rhegmatogenous, tractional, and exudative. The most
common are rhegmatogenous retinal detachments (RRDs). The term is derived from the
Greek rhegma, meaning “break.”
Rhegmatogen Exudative or
Tractional
Retinal Secondary
Detachments Detachments detachments
Rhegmatogenous Retinal Detachment
● Incidence of 12.6 per 100,000 persons in a primarily white

population
● Risk factors : myopia, family history, fellow-eye retinal tear or
detachment, recent vitreous detachment, trauma, peripheral high-
risk lesions, and vitreoretinal degenerations. Use of
fluoroquinolones (controversial)
● In 90%–95% of RRDs, a definite retinal break can be found, often
with the help of Lincoff rules
• A Shafer sign, descriptively termed
“tobacco dust” due to its small clumps
of pigmented cells, is frequently present
in the anterior vitreous.
• Fixed folds resulting from proliferative

vitreoretinopathy (PVR) almost always
indicate an RRD.
‘Tobacco dust’ in the anterior vitreous
Identification of retinal breaks
Lincoff’s rules
Colin A, M., 2019. Basic and Clinical Science Course Chapter 12

Retina and Vitreous. San Fransisco: American Academy of
Fresh retinal detachment
• The RD has a convex configuration
and a slightly opaque and corrugated
appearance as a result of retinal
oedema
• There is loss of the underlying
choroidal pattern and retinal blood
vessels appear darker than in flat
retina.
• SRF extends up to the ora serrata,
except macular hole in which fluid is
initially confined to the posterior pole
(A) Temporal detachment with macula on; (B) superior bullous
detachment with large tear; (C) typical corrugated appearance of
detached retina with macula off; (D) macular hole surrounded by SRF
confined to the posterior pole
Proliferative Vitreoretinopathy
(PVR)
● Caused by epiretinal and subretinal
membrane formation, contraction of which
leads to tangential retinal traction and
fixed retinal fold formation.
● Occurs following surgery for

rhegmatogenous RD or penetrating injury,
may also occur in eyes with
rhegmatogenous RD that have not had
previous retinal surgery.
Development of proliferative vitreoretinopathy (PVR). (A) Extensive vitreous syneresis; (B)
total retinal detachment without PVR; shrunken vitreous is condensed and attached to the
equator of the retina; (C) early PVR with anteriorly retracted vitreous gel and equatorial
circumferential retinal folds; (D) advanced PVR with a funnel-like retinal detachment bridged
by dense vitreous membranes
Proliferative vitreoretinopathy (PVR). (A) Early retinal wrinkling in minimal
grade B; (B) marked grade B with rolled retinal break edges; (C) grade C
with upper temporal tear; (D) grade C with prominent star fold
Salmon, J. and Kanski, J., n.d. Kanski's clinical ophthalmology. 9th ed. elseiver, pp.654-687
Colin A, M., 2019. Basic and Clinical Science Course Chapter 12 Retina and Vitreous. San Fransisco: American Academy of Ophthalmology, pp.355-381.
Management of Rhegmatogenous
Retinal Detachment.
The principles of surgery for retinal detachment are as follows:
• Find all retinal breaks.
• Create a chorioretinal irritation around each break. Close the retinal breaks.
This process usually involves 1 of 3 approaches:

(1) scleral buckling
(2) vitrectomy
(3) pneumatic retinopexy.
Colin A, M., 2019. Basic and Clinical Science Course Chapter 12 Retina and Vitreous. San
Fransisco: American Academy of Ophthalmology, pp.355-381.
• For acute, macula-on
retinal detachments with
symptoms, surgery is
performed urgently.
• In contrast, in eyes with

chronic retinal
detachments with
pigmented demarcation
lines, treatment may be
delayed or it may not be
needed, if the eye continues
Chronic retinal detachment. Patient presented with an asymptomatic large
to be monitored closely retinal detachment with a pigmented and atrophic demarcation line.
Colin A, M., 2019. Basic and Clinical Science Course Chapter 12 Retina and Vitreous. San
Fransisco: American Academy of Ophthalmology, pp.355-381.
Pneumatic Retinopexy
 Procedure in which an intravitreal gas
bubble together with cryotherapy or laser
are used to seal a retinal break and
reattach the retina.
 The most frequently used gases are sulfur

hexafluoride (SF6) and the longer-acting
perfluoropropane (C3F8)
 Relatively quick, minimally invasive, ‘office-

based’ procedure
Indication.
The classic indications for pneumatic retinopexy include :
• confidence that all retinal breaks have been identified

• retinal breaks that are confined to the superior 8 clock-hours
• a single retinal break or multiple breaks within 1–2 clock-hours
• the absence of proliferative vitreoretinopathy (PVR) grade C or D
• a cooperative patient who can maintain proper positioning
clear media
A, A small, expansile gas bubble is injected into the

vitreous cavity. B, The bubble enlarges. The patient
is positioned so the gas bubble occludes the retinal
break, allowing for resorption of subretinal fluid.
Scleral buckle
A silicone band is placed outside the
eye wall to push the wall of the eye closer
to the retinal tear in order to close the tear.
With a freezing treatment to induce

controlled scarring around the tear and
permanently seal it.
Ryan SJ, Hinton DR, Schachat AP, et al. Retina. Elsevier 2011:100-107
Indication.
• Young, phakic patients with no posterior vitreous detachment.
• Retinal dialysis.
• Very anterior break(s)
• Patients with extensive lattice or multiple retinal breaks at the
vitreous base. SB provides 360° support to the vitreous base and
peripheral retina thereby preventing future tears.
• High myopia, middle-aged patients with minimal or no cataract.
Pars Plana Vitrectomy
• Three small incisions are made in the sclera and
instruments are manipulated to remove the vitreous
gel that fills the eye and drain the fluid from under
the retina.
• The surgeon may then use a laser or cryopexy to

seal the retinal tears or holes.
• The eye is then filled with a gas bubble or silicon oil

to hold the retina in place while it heals.
Ryan SJ, Hinton DR, Schachat AP, et al. Retina. Elsevier 2011:100-107
Indication.
Rhegmatogenous retinal Tractional retinal detachment
detachment
• Indications in diabetic RD
○ Tractional RD threatening or involving the macula.
• When retinal breaks cannot be visualized as a ○ Combined tractional–rhegmatogenous RD should be
result of haemorrhage, vitreous debris, posterior treated urgently, even if the macula is not involved.
capsular opacity, IOL edge effects.
• Indication in Penetrating Trauma
• When retinal breaks are unlikely to be closed by ○ Prevention of tractional RD. Fibrocellular proliferation
scleral buckling such as giant tears, large posterior after penetrating trauma tends to develop on the pre-
breaks and in the presence of PVR equatorial retina.
○ Late tractional RD, which may be associated with an
intraocular foreign body or retinal incarceration
Tractional Retinal Detachment
● Vitreous membranes caused by penetrating injuries

or by proliferative retinopathies such as diabetic
retinopathy can pull the neurosensory retina away
from the RPE  a tractional retinal detachment
● Can be central or peripheral and, in rare cases, can

extend from the optic nerve head to the ora serrata.
● Traction may tear the retina and cause a combined

tractional and rhegmatogenous retinal detachment.
Tractional retinal detachment associated with anterop

and bridging traction
Colin A, M., 2019. Basic and Clinical Science Course Chapter 12 Retina and Vitreous. San Fransisco: American
Academy of Ophthalmology, pp.355-381.
Signs.
• The RD has a concave configuration and
breaks are absent.
• Retinal mobility is severely reduced and
shifting fluid is absent.
• If a break occurs in a tractional RD it Localized tractional detachment
assumes the characteristics of a secondary to preretinal fibrosis;
rhegmatogenous RD and progresses
rapidly (combined tractional–
rhegmatogenous RD)
B-scan ultrasonography
Treatment.
Treatment may require a
combination of vitrectomy and a
scleral buckling procedure to
release the traction and seal the
break.
Exudative Retinal
Detachment
● Characterized by the accumulation of SRF
in the absence of retinal breaks or
traction.
● Occurs when either retinal blood vessels

leak or the RPE is damaged, allowing fluid
to pass into the subretinal space
● Neoplasia and inflammatory diseases are

the leading causes of large exudative Color fundus photograph of an exudative retinal detachment
that resulted from metastatic breast carcinoma
detachments.
Salmon, J. and Kanski, J., n.d. Kanski's clinical ophthalmology. 9th ed. elseiver, pp.654-687
Symptoms. Signs.
• Both eyes may be involved • The RD has a convex configuration, as with a
simultaneously. rhegmatogenous RD, but its surface is smooth
• There is no vitreoretinal traction and not corrugated.
 photopsia is absent • The detached retina is very mobile and exhibits
• Floaters may be present if there the phenomenon of ‘shifting fluid’
is associated vitritis.
• A visual field defect may
develop suddenly and progress
rapidly.
(A) Inferior collection of subretinal fluid

with the patient sitting; (B) the subretinal
fluid shifts upwards when the patient
assumes the supine position
• The cause of the RD, such as a
choroidal tumour, may be
apparent in fundus.
• Patient may have an associated
systemic disease responsible for
the RD (e.g. Harada disease,
toxaemia of pregnancy).
Exudative retinal detachment caused by a

choroidal melanoma
‘Leopard spots’ consisting of scattered areas of

subretinal pigment clumping may be seen after
the detachment has flattened.
‘Leopard spot’ pigmentation
Treatment.
• Treatment depends on the cause.
• Some cases resolve spontaneously,
whilst others are treated with
systemic corticosteroids. (Harada
disease and posterior scleritis).
• Bullous central serous
chorioretinopathy, the leak in the
RPE can be sealed by laser
photocoagulation.
Differential Diagnosis of
Retinal Detachment
Retinoschisis
• Reticular degenerative retinoschisis, the splitting occurs in the nerve

fiber layer. The very thin inner layer may be markedly elevated. The
outer layer appears pockmarked and the retinal vessels sclerotic.
Approximately 23% of cases have holes in the outer wall that may be
large and have rolled edges.
Colin A, M., 2019. Basic and Clinical Science Course Chapter 12 Retina and Vitreous. San Fransisco: American Academy of Ophthalmology, pp.355-381
Retinoschisis with large, irregular
outer-schisis-layer holes (outlined
by arrowheads) and yellow dots
on the inner surface.
Thankyou
Algorithm.
Brinton DA, Wilkinson CP. Retinal detachment: principles and practice. 3rd ed. New York: Oxford
University Press/American Academy of Ophthalmology,2009.
Tamponading agents.
• Expanding gases
○ Sulfur hexafluoride (SF6) doubles its volume if used at a 100%

concentration and lasts 10–14 days.
○ Perfluoroethane (C2F6) triples its volume at 100% and lasts 30–35 days.
○ Perfluoropropane (C3F8) quadruples its volume at 100% and lasts 55–
65 days.
• Silicone oils • Heavy liquids

1000 cs silicone is easier to inject and to remove (perfluorocarbons) have high specific
whilst 5000 cs is more viscous but may be less prone gravity and thus settle inferiorly in the
to emulsification. vitreous cavity.
Perfluoro-n-octane is most commonly
used as it allows good visibility and low
viscosity.

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Retinal

Sites of stronger adhesion in the normal eye :

● Separation of the cortical vitreous, along with

● Occurs due to vitreous gel liquefaction with age

● Prevalence increases with age.

● Predisposing : aphakia, pseudophakia with

• OCT can show separation of the

(B) ultrasound B-scan; (C) OCT showing macular PVD

• Reexamination of the patient 2–4 weeks following presentation may be

• Large vitreous hemorrhage  complete examination, bilateral ocular patching

a vitreoretinal interface small, peripheral, focal areas of folds of redundant retina

● A vitreoretinal interface abnormality, bilateral in one-third to one-

● May predispose eyes to retinal breaks and detachment.

● 20%–30% of all eyes that present with rhegmatogenous RD.

● Retinal detachments secondary to atrophic holes typically occur

(A) Small island of lattice with an

• Tractional tufts are classified according to anatomical, pathogenetic, and

1. Noncystic retinal tufts

• Meridional folds are folds of redundant retina, usually located superonasally.

Retinal Pigment Peripheral

Paving-Stone Retinal Pigment

• Most common  inferior quadrants,

Gross appearance of paving-stone degeneration

• Retinal breaks may be classified as :

○ coup, adjacent to the point of trauma,

○ contrecoup, opposite the point of trauma.

Traumatic retinal detachments in young patients may be shallow and often

Part 2, Retinal breaks with areas of abnormal

Part 3, Retinal breaks associated with abnormal

Prophylactic Treatment of Retinal Breaks

• The goal  the creation of a chorioretinal adhesion around each break to

• The ophthalmologist weighs numerous factor : symptoms, family history,

• Prophylaxis is sometimes contraindicated in eyes with more than 6.00

● Acute symptomatic flap tears are commonly treated prophylactically.

● Incidence of 12.6 per 100,000 persons in a primarily white

• Fixed folds resulting from proliferative

Colin A, M., 2019. Basic and Clinical Science Course Chapter 12

● Occurs following surgery for

This process usually involves 1 of 3 approaches:

• In contrast, in eyes with

 The most frequently used gases are sulfur

 Relatively quick, minimally invasive, ‘office-

• confidence that all retinal breaks have been identified

A, A small, expansile gas bubble is injected into the

With a freezing treatment to induce

• The surgeon may then use a laser or cryopexy to

• The eye is then filled with a gas bubble or silicon oil

● Vitreous membranes caused by penetrating injuries

● Can be central or peripheral and, in rare cases, can

● Traction may tear the retina and cause a combined

Tractional retinal detachment associated with anterop

● Occurs when either retinal blood vessels

● Neoplasia and inflammatory diseases are

(A) Inferior collection of subretinal fluid

Exudative retinal detachment caused by a

‘Leopard spots’ consisting of scattered areas of

• Reticular degenerative retinoschisis, the splitting occurs in the nerve

○ Sulfur hexafluoride (SF6) doubles its volume if used at a 100%

• Silicone oils • Heavy liquids

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