1. PATHOGENESIS AND SIGNS OF RETINAL DETACHMENT (RD)
1. Rhegmatogenous RD
Fresh
Longstanding
Proliferative vitreoretinopathy (PVR)
2. Diabetic tractional RD
3. Exudative RD
4. Differential diagnosis RD

2. Definition and classification
Break - full-thickness defect in sensory retina
Hole - caused by chronic retinal atrophy
Tear - caused by dynamic vitreoretinal traction
Morphology of tears
a. Complete U-tear
b. Linear
c. Incomplete L-shaped
d. Operculated
e. Dialysis

3. Retinal detachment (RD)
Separation of sensory retina from RPE by subretinal fluid (SRF)
Rhegmatogenous - caused by a
retinal break
Non-rhegmatogenous - tractional or
exudative

4. Indirect ophthalmology
Condensing lenses
Technique
The higher the power, the less the
magnification, the shorter the working
distance but the greater the field of view
Keep lens parallel to patient’s iris plane
Avoid tendency to move towards patient
Ask the patient to move eyes and head
into optimal positions for examination

5. Fundus drawing Place chart upside down Draw what you see Technique
Colour code
Breaks
Detached retina
Vitreous
opacity
Thinning
Exudate
Lattice
Retinal
pigment
Place chart upside down
Draw what you see

6. Pathogenesis of rhegmatogenous RD
Two components for retinal break formation
Acute posterior vitreous detachment (PVD)
Predisposing peripheral retinal degeneration
Possible sequelae of acute PVD
Uncomplicated PVD (85%)
Retinal tear formation and
haemorrhage (10-15%)
Avulsion of retinal vessel and
haemorrhage (uncommon)

7. Predisposing peripheral degenerations

8. Retinal breaks not requiring treatment
e - Asymptomatic dialysis
surrounded by pigment
g - Small asymptomatic holes
near ora serrata
h - Small inner layer holes in
retinoschisis
f - Breaks in both layers of
retinoschisis

9. Complications of lattice degeneration
No complications - in most cases
RD associated with atropic holes, particularly in young myopes
RD associated with tractional tears in eyes with acute PVD
Indications for prophylaxis
RD in fellow eye
Extensive lattice in high myopia

10. PROPHYLAXIS OF RHEGMATOGENOUS
RETINAL DETACHMENT
1. Retinal breaks
2. Predisposing degenerations
Lattice
Snailtrack
White-without-pressure
3. Treatment modalities
Laser photocoagulation
Cryotherapy
4. Benign peripheral degenerations

11. pulled away from the underlying choroid
small areas of the retina torn =>
retinal tears or retinal breaks
retinal cells deprived of oxygen
if not promptly treated => permanent vision loss

12. Fresh rhegmatogenous RD - signs
Annual incidence - 1:10,000 of population
Eventually bilateral in 10%
Convex, deep mobile elevation
extending to ora serrata
Slightly opaque with dark blood vessels
Loss of choroidal pattern
Retinal breaks
Longstanding rhegmatogenous RD - signs
Frequently inferior with small holes
Very thin retina
Secondary intraretinal cysts
Demarcation lines (high-water marks)

13. Proliferative vitreoretinopathy
Grade A (minimal)
Grade B (moderate)
Grade C (severe)
Vitreous haze and
tobacco dust
Retinal wrinkling and
stiffness
Rolled edges of tears
Rigid retinal folds
Vitreous condensations
and strands
Signs of diabetic tractional RD
Concave, shallow immobile elevation
Highest at sites of vitreoretinal traction
Slow progression and variable fibrosis
Does not extend to ora serrata

14. Pathogenesis of diabetic tractional RD (1)
Antero-posterior
traction RD
Preretinal
haemorrhage

15. Pathogenesis of diabetic tractional RD (2)
A-P traction
Bridging traction
Preretinal
haemorrhage

16. Pathogenesis and Causes of Exudative RD
Damage to RPE by subretinal disease
Passage of fluid derived from choroid into subretinal space
1. Choroidal tumours
Primary
Metastatic
2. Intraocular inflammation
Harada disease
Posterior scleritis
3. Systemic
Toxaemia of pregnancy
Hypoproteinaemia
4. Iatrogenic
RD surgery
Excessive retinal photocoagulation
5. Miscellaneous
Choroidal neovascularization
Uveal effusion syndrome

17. Signs of exudative RD Convex, smooth elevation
May be very mobile and deep with
shifting fluid
Subretinal pigment (leopard spots)
after flattening

18. SYMPTOMS
floaters
light flashes
shadow or curtain over a portion of visual field
blur in vision

19. Can occur as a result of:
trauma
advanced diabetes
an inflammatory disorder, such as sarcoidosis
shrinkage of the jelly-like vitreous that fills the inside of the eye

20. Factors that may increase risk of retinal detachment:
aging - more common in people older than 40
previous retinal detachment in one eye
family history of retinal detachment
extreme nearsightedness
previous eye surgery
previous severe eye injury or trauma

21. TREATMENTS Retinal tears: laser surgery (photocoagulation)
freezing (cryopexy)
Retinal detachment:
pneumatic retinopexy
scleral buckling
vitrectomy

22. SCLERAL BUCKLING

23. VITRECTOMY

24. Technique of cryotherapy
Surround lesion with single row of
cryo-applications
Preferred for treatment of large
areas

25. PRINCIPLES OF RETINAL DETACHMENT SURGERY 1. Scleral buckling
Configuration of buckles
Preliminary steps
Localization of breaks
Cryotherapy
Insertion of local explant
Encircling procedure
Drainage of subretinal fluid
Causes of early failure
2. Pneumatic retinopexy
3. Vitrectomy
Giant tears
Proliferative vitreoretinopathy (PVR)
Diabetic tractional RD

26. Configuration of scleral buckles
Segmental
circumferential
Radial
Encircling
augmented by radial
sponge
Encircling
augmented by solid
silicone tyre

27. Drainage of subretinal fluid
Indications
Difficulty in localizing break
Immobile retina
Longstanding RD
Inferior RD
Complications
Haemorrhage
Retinal incarceration

28. Pneumatic retinopexy RD with superior breaks (a) Cryotherapy
Indications
RD with superior breaks
Pneumatic retinopexy
Technique
(a) Cryotherapy
(b) Gas injection
(c) Postoperative positioning
(d) Flat retina

29. Vitrectomy for diabetic tractional RD
Vitrectomy for PVR
Dissection of star folds and peeling of membranes
Injection of expanding gas or silicone oil
Vitrectomy for diabetic tractional RD
Release of circumferential
traction
Release of antero-
posterior traction
Endophotocoagulation