RETINAL DETACHMENT - Semantic Scholar...RETINAL DETACHMENT •Separation of the neurosensory retina...
Transcript of RETINAL DETACHMENT - Semantic Scholar...RETINAL DETACHMENT •Separation of the neurosensory retina...
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RETINAL DETACHMENT
PROF. DR. ŞENGÜL ÖZDEK
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Histoloji
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Anatomy
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RETINAL DETACHMENT
• Separation of the neurosensory retina from
retinal pigment epithelium.
• Incidence 1 / 10.000, Risk is 3% until the age
of 80
• Bilaterality 10%
• Most common: 40-70 year-old
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TYPES
• RHEGMATOGENOUS RD
• TRACTIONAL RD (PDR, VENOUS OCCLUSIVE
DISEASE…)
• EXUDATIVE RD (ECLAMPSIA, KMM)
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• Vitreous pressure
• Passive fluid flow from vitreous to
choroid
• RPE tight junctions
• RPE active ion transport
• Bruch membrane (flow from RPE to
choroid)
• Concentration gradients (ionic,
osmotic)
The powers holding retina in place
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RRD
Develops in three stages
• Posterior vitreous detachment
• Retinal break / tear
• Retinal detachment
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Posterior Vitreous Detachment
Stronger adhesions:
• Vitreous base
• Around the optic nerve head
• Macula
• Retinal big vessels
• Around the retinal degenerations areas
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ACUTE PVD
After development of synchisis
in some persons, small breaks
occur in posterior vitreous
cortex and liquefied vitreous
passes to retrohyaloid space
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ACUTE PVD
• The remaining solid vitreous collapse down and retrohyaloid space filled with sinchitic fluid: PVD
• Sensorial retina lacks protection
• Sensorial retina is vulnerable to vitreoretinal traction
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PVD
• More in elderly, myopics, aphakic /
pseudophakic patient and people exposed to
trauma
• Mostly asymptomatic
• Photopsia (flashes of light)
• Gliotic tissue which adheres to the posterior
hyaloid membrane where papilla and vitreous
opacities: Floaters (flight of fly)
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Acute PVD Complications
• Retinal Tear
• Macular Hole
• Epiretinal Membrane
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Acute PVD’s Complications
• Vessel avulsion
• Vitreous hemorrhage
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Peripheral retinal degenerations
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Lattice degeneration (lattice = wire netting)
• Most important peripheral
degeneration
• It is a band-shaped retinal thinning, in
front of the equator, parallel to the
ora serrata, which contains lines in the
form of wire netting.
• atrophy starts from the inner limiting
membrane and spreads to the other
lines
• In the middle of degeneration vitreous
is liquefied but at the edge of
degeneration vitreous is attached
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Retinal break
Horseshoe tears
Holes
Disinsertion ( dialysis )
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HORSE-SHOE TEAR
The most common reason for RD
• The apex located toward to
central
• Photopsia + Floaters +
• If accompanied by the rupture
of blood vessels: blurred
vision
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Retinal Holes
• Asymptomatic
• Within lattice dehgeneration areas
• Punched out circular holes
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Mechanism of RD
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DISINSERTION (DIALYSIS)
• In severe blunt trauma
• Usually in inferior temporal
quadrant
• Severe photopsia
• Detachment may not occur for
many years in young patient if
vitreous can remain gel
formation
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PVR
• Proliferative Vitreoretinopathy (PVR)
• The proliferation of RPE cells and gliotic cells
• Long term RD
• Giant and a multible number of breaks
• Penetrating injury
• Vitreous hemorrhage
• Fast wound healers
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PVR Stages
Grade A : Vitreous haze, pigment clumbs in vitreous and inferior surface of the retina ( tobacco dust )
Grade B : creases on the face of inner retina, decreased mobility of vitreous gel and retina, irregular tear edges, tortuosity of blood vessels
Grade CP: behind equator local, diffuse or peripheral retinal creases, subretinal cords
Grade CA: Same appearance in front equator and cords in condensed vitreous
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Myopia - RD
• 10% of the general population: Myopic
• 40% of all RDs occur in myopic eyes.
• Lattice deg. is more common in -6.0 -9.0 myopes
• Vitreous degeneration and PVD are more common
in myopes
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Trauma - RD
• 10% of RD occurs following trauma.
• The most common cause of RD in children
• Severe blunt trauma: retinal dialysis, macular
hole
• Penetrating injury: Both tractional and RRD.
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RD Symptoms
• The first sings of acute PVD are fotopsia and
floaters
• Peripheral visual field defect: like a black curtain
one side of the eye
• After macula is affected, VA will decrease to
hand motions only
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RRD signs • IOP: 5 mmHg lower
• Retinal break
• Detached Retina has a convex
configuration and an opaque
appearance
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Treatment • PROPHYLAXIS IS VERY IMPORTANT
– Acute PVD’s Symptoms: Photopsia, floaters:
peripheral retinal examination!
– Myopia or trauma or family history or fellow
eye history of RD: detailed fundus
examination!
– Symptomatic or dangerous peripheral
retinal degenerations and retinal tears: laser
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Retinal Detachment Surgery
1. External buckling: Peripheral or local
scleral buckling: Classic Technique
2. İnternal retinopexy: PPV-tamponade
– laser or cryo to tears
– Gas-Silicone oil
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Scleral Buckle • Silicone band or with local sponge • Intraoperative cryotherapy around the
tear • Drainage of Subretinal fluid. • IV Air-Gas
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Internal retinopexy: Tamponade
• Gas: SF6, C3F8
• Air
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PPV • Associated Vitreous Hemorrhage,
• PVR,
• Multible/giant tears
• Macular holes
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Tractional RD
1. PDR: Proliferative diabetic retinopathy
2. ROP prematurity of retinopathy
3. Penetrating trauma
4. Sickle cell anemia, Vein occlusions, PFV
• Retina is immobile, surface is concave.
• Tractions may cause tears... COMBINED FORM RD
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Traksiyonel RD
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Trauma
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PFV
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ROP
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ROP Stage 5: Total RD-Leukocoria
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Tractional RD
• Photopsia and floaters (-)
• Vision loss occurs slowly
• Treatment: PPV
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Exudative RD
• Malign hypertension
• Hypertensive crisis/Eclampsia
• Vascular: Coats desease
• Tm: CMM, Metastases, choroidal hemangioma
• Uveitis: Vogt-Kayanagi-Harada
• Central serous chorioretinopathy
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Exudative RD
• Exudative RD: fluid leaks from retinal
vessels and RPE
• there is no tear and traction.
• May move with gravity and head
movements
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Exudative RD
• Vision is very low in the morning due to the liquid which reason to detachment becomes the subject of gravity. When patient seats, vision begins to improve.
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SSKR
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Exudative RD
• No Photopsia,
• Floaters (+/-): becauase of vitritis
• Visual field defect suddenly
• No surgical treatment.
• Treatment of the underlying condition.