RETINAL DETACHMENT

Dr. Abdirizak yusuf olow

MBBS-Somali international university
Senior clerkship at the university of Nairobi(UoN)
Clinical internship at MBALE RR HOSPITAL-
uganda
OBJECTIVES
 INTRODUCTION TO RETINAL DETACHMENT
 ANATOMY OF THE RETINA
 EPIDEMIOLOGY OF RD
 TYPES OF RD
 RISK FACTORS OF RD
 SYMPTOMS AND SIGNS
 DIAGNOSIS
 MANAGEMENT
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
 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.

 RD refers to separation of the neurosensory retina (NSR)

from the retinal pigment epithelium (RPE). This results in

the accumulation of sub retinal fluid(SRF) in the
potential space between the NSR and RPE.
Anatomy of the peripheral retina

 Pars plana:
The ciliary body starts 1 mm from the limbus and extends posteriorly
for about 6 mm. The anterior 2 mm consist of the pars plicata, the
remaining 4 mm the flattened pars plana
 Ora serrata:
The ora serrata is the junction between the retina and ciliary body. In
retinal detachment (RD), fusion of the sensory
retina with the retinal pigment epithelium (RPE) and choroid
limits forward extension of subretinal fluid (SRF) at the ora.
However, there is no equivalent adhesion between the choroid and
sclera, and choroidal detachments may progress anteriorly to
involve the ciliary body (ciliochoroidal detachment).
Anatomy of the peripheral retina:
 Vitreous base:
The vitreous base is a 3–4 mm wide zone straddling the
ora serrata, throughout which the cortical vitreous is
strongly attached. Following posterior vitreous
detachment (PVD), the posterior hyaloid face remains
attached at the vitreous base. Pre- existing retinal holes
within the attached vitreous base do not lead to RD.
Blunt trauma may cause an avulsion of the vitreous base,
with tearing of the non-pigmented epithelium of the pars
plana along the base’s anterior border and of the retina
along the base’s posterior border.
The ora serrata and normal anatomy
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 middle aged 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

non myopic ones.

three types of retinal detachment:
 There are three types of retinal detachment:
1. rhegmatogenous (Greek rhegma – break)
2. tractional
3. 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.
 RD requires a full-thickness defect in the sensory
retina, which permits fluid derived from
synchytic (liquefied) vitreous to gain access to
the subretinal space. RRD, as opposed to the
presence merely of a cuff of subretinal fluid
(SRF) surrounding a retinal break, is said to be
present when fluid extends further than one optic
disc diameter from the edge of the break.
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
Causes of exudative RD
 Choroidal tumours
 Inflammation
 Iatrogenic causes include retinal detachment surgery

and panretinal photocoagulation

 Hypertensive choroidopathy
 Idiopathic, such as uveal effusion syndrome
Types
 Tractional retinal detachment:
 It occurs when fibrous or fibrovascular tissue, pulls the

sensory retina from the retinal pigment epithelium.

 the NSR is pulled away from the RPE by contracting

vitreoretinal membranes in the absence of a retinal break.

 The main causes of tractional RD are proliferative

retinopathy such as diabetic and retinopathy of

prematurity, and penetrating posterior segment trauma
Risk factors
 Severe myopia
 Retinal tear
 Family history
 Other eye diseases or disorders, such as retinoschisis,

uveitis, degenerative myopia, or lattice degeneration

 Eye injury
 Tumors
 Systemic diseases such as diabetes & sickle cell disease
 Complications from cataract surgery
Sign and symptoms
 Warning signs
 lashes 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

 Intraocular pressure (IOP)
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
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 of the 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
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.

 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 patient’s non-operative eye
prior to surgery
 Assess the patient’s support systems and the possible effect

of impaired vision on lifestyle and ability to perform

ADLs(activities of daily living) 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 patient 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 patient 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 patient is
positioned so that the detachment is dependent or
inferior.
 For example , if the outer portion of the left retina is
detached , the patient 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

c) 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 patient 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