Ocular Abnormality- Retinal Detatchments

Front 1

What is the prevalence of retinal detachments?

Back 1

• Relatively rare (9 per 100000 cases)

• Detachment bilateral in 10-30% of cases

Front 2

When does retinal detachment incidence increase?

Back 2

Incidence increases with age

Front 3

What is the prognosis of retinal detachment?

Back 3

Good with early detection

Front 4

How is retinal detachment classified?

Back 4

Primary

rhegmatogenous = break

Secondary

tractional or exudative

Front 5

What are the symptoms of retinal detatchment?

Back 5

• Sudden onset of or an increase in the number of floaters (tobacco dust).

• Sudden shower of floaters like small insects.

• Sudden onset flashes of light or a change in the pattern of flashes normally seen or flashes of light that do not go away.

• Sudden change in vision.

• Any loss of peripheral vision when one eye is covered.

• The appearance of a curtain or discolouration over your vision

Front 6

What is a retinal detachment?

Back 6

Separation of the neurosensory retina from the retinal pigment epithelium (RPE) by subretinal fluid (SRF).

Front 7

What is a Tractional detachment?

Back 7

Detachment of vitreous by fibro-proliferative strands

Front 8

What is a Exudative or serous detachment?

Back 8

Accumulation of fluid under retina without an associated retinal break

Front 9

What is a Rhegmatogenous detachment?

Back 9

Accumulation of liquefied vitreous / fluid under retina following a retinal break.

Front 10

What are the symptoms with Tractional Retinal Detachment?

Back 10

• Usually asymptomatic unless encroaching on posterior pole

• Sudden abrupt loss of visual acuity

Front 11

What are the signs with Tractional Retinal Detachment?

Back 11

• Vitreal strands and membranes

• Concave, smooth-surfaced detachment

• Dense and immobile detachment

• RAPD

• Visual field defect

Front 12

What should you do with a Tractional Retinal Detachment?

Back 12

Needs rapid referral to eye casualty, normally ring eye casualty and send direct that day.

Front 13

What is Exudative Retinal Detachment in association with?

Back 13

Occur in association with subretinal disorders that damage the RPE layer

• choroidal neoplasms

• posterior scleritis

• congenital optic disc anomalies (optic pits, morning glory syndrome)

• Coat's disease

Front 14

What would be seen with a Exudative Retinal Detachment?

Back 14

• Photopsiae ( flashing lights) are not usually noticed.

• May have sudden visual field defect.

• Metamorphopsia if near to fovea.

Front 15

What is this?

Back 15

Coats disease

Front 16

What is coats disease?

Back 16

Coats’ disease is an abnormality of the blood vessels in the retina.

Bloody vessels may leak which means that fluid can leave the vessels, becoming trapped within, and sometimes underneath, the retina causing it to lift up.

Front 17

What ia the prevalence of Rhegmatogenous Retinal Detachment?

Back 17

• 1:10,000 of the population each year

• Both eyes involved 10% - Not at the same time

Front 18

What causes Rhegmatogenous Retinal Detachment?

Back 18

• Dynamic vitreoretinal traction

• Predisposing retinal degeneration

• High myopia

Front 19

What are the predisposing retinal detachment factors

Back 19

• Lattice degeneration - present in 40% of RD

• Retinal thinning

• Overlying area of vitreous liquefaction (vitreous is abnormal)

• Usually occurs from the ora to the equator

• Snail track degeneration

• “ White without pressure”

Front 20

What is Lattice degeneration.

Back 20

The peripheral retina becomes atrophic in a lattice pattern and may develop tears, breaks, or holes, which may further progress to retinal detachment.

• Appears as a linear track circumferentially

• Found in 6-10% of general population – develops early

Front 21

What is Lattice degeneration associated with?

Back 21

Associated RPE hyperplasia

Front 22

What would be seen with lattice degeneration?

Back 22

• Yellow glistening flecks

• Sclerosed vessels

• Chorioretinal atrophy may be present

• Atrophic holes and flap retinal tears may be present

Front 23

Lattice degeneration

Back 23

Front 24

How does Rhegmatogenous Retinal Detachment occur?

Back 24

• Posterior vitreous detachment (PVD)

• Dynamic vitreoretinal traction occurs at abnormal adhesions

• This can → vitreous haemorrhage

• Traction → energy transmission to retina

• To relieve traction, a break forms

• RD caused by collection of subretinal fluid

• Common cause of failure following RD surgery

Front 25

What is Proliferative Vitreoretinopathy?

Back 25

Proliferative vitreoretinopathy (PVR) is a disease that develops as a complication of rhegmatogenous retinal detachment.

PVR occurs in about 8–10% of patients undergoing primary retinal detachment surgery and prevents the successful surgical repair of rhegmatogenous retinal detachment.

Front 26

What causes Proliferative Vitreoretinopathy?

Back 26

Caused by contraction of the membranes of the inner retinal surface (epiretinal membranes ERM)

Front 27

What are the clinical signs of Proliferative Vitreoretinopathy?

Back 27

Clinical sign are retinal folds

Front 28

Name the types of breaks that can occur.

Back 28

• Horseshoe or U-shaped tear

• Operculated

• Atrophic hole

• Dialysis

• Macular hole

- Idiopathic; myopia; Commotio retinae

Front 29

What is a Dialysis break?

Back 29

• Involves splitting of vitreous base

• Usually infero-temporal

• Can be spontaneous or traumatic

Front 30

What is this?

Back 30

Horse shoe break

Front 31

What is this?

Back 31

Treatment prophylaxis with retinopexy

Front 32

What is Operculated Retinal Holes?

Back 32

• Round red hole with associated floating plug of tissue.

• The fresher the break the more likely the development of retinal detachment.

Front 33

What might surround Operculated Retinal Holes?

Back 33

Cuff of whitish oedema

Front 34

How would you manage Operculated Retinal Holes?

Back 34

• Symptomatic – same day referral

• Asymptomatic - review 6 months

Front 35

What are Atrophic Retinal Holes?

Back 35

• A round retinal break without accompanying vitreo-retinal traction

Front 36

What percentage of the population is Atrophic Retinal Holes present in?

Back 36

2-3%

Front 37

How would you manage Atrophic Retinal Holes?

Back 37

• Keep in mind that retinal detachment may occur

• An isolated, asymptomatic atrophic retinal hole with no associated cuff of oedema - review in 12 months

– ENSURE that patient is educated correctly regarding symptoms of retinal detachment and comment in your notes you have done so.

• Any atrophic hole with cuff of oedema and associated symptoms should be same day referral

Front 38

What would increase the chances of getting an retinal detachment?

Back 38

• Risk factors

• Increased age Age

• Myopia (High)

• Acute PVD

• Family history of a retinal detachment or break

• Previous retinal detachment or break

• History of recent trauma, surgery or inflammation

• Predisposing conditions

• Vitreoretinal degenerations

Front 39

What symptoms may be presented with retinal detachment?

Back 39

• Photopsia

• Floaters

• Shadow in field of vision

• 60% of patients with RD have ALL symptoms

• Round asymptomatic holes may be associated with asymptomatic retinal detachments in young myopia

Front 40

When would photopsia be more noticeable?

Back 40

• More noticeable with eye movements and in dim illumination.

• Projected into temporal peripheral field most commonly.

Front 41

What should you ask if floaters are reported with retinal detachment?

Back 41

• Recent or long-standing

• Last day, week,month significant?

• Which eye?

• What do they look like?

• How many are there?

• Any flashes?

• Any shadows, curtains?

Front 42

What should you ask if photopsia is reported?

Back 42

• Describe the flashes?

• How long do they last?

• Which eye?

• When do you notice them?

Front 43

How would the VAs be affected with retinal detachments?

Back 43

Normal unless macular detached or SRF approaching macula.

Front 44

How would the visual fields be affected with retinal detachments.

Back 44

• Peripheral

• Maybe normal

Front 45

How would the pupil reactions be affected with retinal detachment?

Back 45

RAPD may be present

Front 46

How would the IOPs be affected with retinal detachments?

Back 46

5mmHg in affected eye

Front 47

How would you evaluate the perihipheral retina?

Back 47

• Dilated fundus examination

• Superfield or SuperVitreo

Front 48

What might you see in the anterior vitreous?

Back 48

Pigment or blood in anterior vitreous

Front 49

What is this?

Back 49

Shafers sign

Front 50

What is shafers sign?

Back 50

Shafer's sign alludes to the clinical finding of pigment cells in the vitreous.

Front 51

How would the retina appear upon examination with a retinal detachment?

Back 51

• Slightly opaque & corrugated

• Convex configuration and a slightly opaque

• Loss of the underlying choroidal pattern

• Retinal blood vessels appear darker than in flat

• Out of focus compared to flat retina

Front 52

What symptoms would require a same day referral?

Back 52

• Sudden increase in number of floaters, patient may report as "numerous".

• "too many to count" or “sudden shower or cloud of floaters”.

• Cloud, curtain or veil over the vision.

• Retinal detachment with good vision.

• Vitreous or pre-retinal haemorrhage.

• Pigment 'tobacco dust' in anterior vitreous.

• Retinal tear/hole with symptoms.

Front 53

What signs would require referral ASAP next available clinic appointment?

Back 53

• Retinal detachment with poor vision (macula off).

• Retinal hole/tear without symptoms.

• Lattice degeneration with symptoms of recent.

• flashes and/or floaters? Check for PVD first!

Front 54

What is this?

Back 54

Macula off detachments

Front 55

What would require discharge with SOS advice (verbal advice and a leaflet)?

Back 55

• Uncomplicated PVD without signs

• Signs of lattice degeneration without symptoms listed previously

Front 56

What is this?

Back 56

Weiss ring

Front 57

What are the treatments for retinal detachment?

Back 57

Localisation & closure of breaks:

• Relief of vitreoretinal traction

• Buckling or vitrectomy

• Neuroretinal-RPE adhesion

Photocoagulation or cryotherapy:

• Internal tamponade

• Air; longer acting gases; Silicone oil

Front 58

What is this?

Back 58

Scleral Buckle

Front 59

What is Retinoschisis?

Back 59

Splits or cysts within the neurosensory retina

Front 60

Name the types of Retinoschisis?

Back 60

Primary

• Senile (level of OPL)

• Juvenile/congenital (level of RNFL)

Secondary to other conditions

• Trauma, proliferative retinopathies, vitreous traction

Front 61

What is Senile Retinoschisis?

Back 61

• Bilateral in 33%

• Usually infero-temporal

• Usually hyperopic

• Dome elevation of inner

• retinal layers

• White dots (snowflakes) on inner limiting membrane

• Inner leaf has beaten metal appearance

• Sheathing of peripheral vessels

Front 62

What is Juvenile Retinoschisis?

Back 62

• X-linked recessive

• Splits in NFL

• Bilateral

• Foveal (cystoid changes BUT not CMO) or peripheral

• Associated with systemic diseases

• Poor visual prognosis

• Predisposes to RD, esp infero-temporally

Front 63

What would be seen with Retinoschisis?

Back 63

• Px Exam Symmetrical location no pigment cells in vitreous.

• Scotoma Absolute with Retinoschisis, relative scotoma with RD.