6.1.12 Evaluates and manages patients presenting with symptoms of retinal detachment.

Question 1

Risk Factors:

Answer 1

• Age (50+)
• High Myopia (-3D+)
• FH of retinal detachment or break (2x higher risk)
• Previous RD or break (higher risk in other eye; 10% chance)
• Systemic disease (e.g. diabetes, Marfan’s syndrome)
• Recent Ocular Surgery, Inflammation, Trauma e.g. sports like boxing
• Peripheral lesions:
  
  • Lattice degeneration, Snail track degeneration, Retinoschisis, White without pressure, Bear tracks

Question 2

Difference between RD & Retinoschisis

Answer 2

Retinoschisis is a splitting of the retinal layers, most often at the outer plexiform layer or the nerve fiber layer. By contrast, a retinal detachment is a separation of the neurosensory retina from the retinal pigment epithelium (RPE).

Question 3

Rhegmatogenous RD:

Answer 3

• RD’s are full thickness breaks in the sensory retina, allowing vitreous to enter the subretinal space. Caused by retinal breaks allowing liquefied vitreous to enter the sub-retinal space, separating the sensory retina from RPE.
  
  • A small detachment in the inferior retina results in a small superior visual field defect
• Symptoms are sudden onset photopsia, many new floaters and loss of VF described as ‘curtain’ over peripheral vision.
• Signs are RAPD, lower IOP than other eye, tobacco dust in anterior vitreous, retinal break(s), reduced VA if macula off, absent choroidal pattern under large raised areas of retina circumscribed by a wrinkled border.

Question 4

Tractional RD:

Answer 4

• TD is a physical pulling of the retina away from the RPE by contraction of fibrovascular membranes over areas of vitreoretinal adhesion.
• Symptoms are only a VF defect that slowly progresses (can be stable over time however). F+F unlikely as vitreoretinal traction gradual & not associated with PVD
• Signs are pale crinkled areas that are lighter than surrounding fundus. No breaks. The subretinal fluid on OCT/fundoscopy will be shallower than that in RD.
• Causes - Retinopathy of prematurity, Trauma, Diabetes

Question 5

Serous RD:

Answer 5

• SD is an accumulation of sub-retinal fluid with no break/traction present.
• Symptoms include only a sudden VF defect, floaters are present depending on inflammatory involvement. No flashes as vitreoretinal traction absent. Floaters if associated vitritis.
• Presents as a convex retinal appearance similar to RD without a crinkled border & smoother looking, mobile raised area of retina and post-detachment leopard spots may be present. SRF present
• Causes - Posterior scleritis, Choroidal melanomas or neoplasms, Choroidal neovascularisation

Question 6

PVD:

Answer 6

• When the PVD ‘goes wrong’, it can cause:
  
  • Vitreous haemorrhage - red cells in anterior vitreous (shafer’s bigger & more pigmented) - red cells can also be combined with shaffer’s in certain RDs so always make sure you’re looking out for them!
  • Retinal traction and tears – shafers sign (very likely there is a retinal break as a result of the PVD)
  • SRF
  • Weiss ring - look this up in AOC lecture

Question 7

Examination

Questions for Flashes:

Answer 7

Onset? Appearance (lightning strike - pvd, kaleidoscope - migraine, shimmering lights - migraine)? Which eye & where? How many? Colour? How long do they last, constant? Worsening/becoming bigger or more numerous? Other sxs?

Question 8

Examination

Questions for Floaters:

Answer 8

Onset? Appearance (worms, spots, cobwebs)? Which eye & where & how big? How many? Colour? Are they always there? Any change? Any shadows, curtains? Other sxs?

Question 9

Examination

Examination includes:

Answer 9

• Questions for Flashes:
• Questions for Floaters:
• Pupils
• VAs - compared to previous measures
• IOPs
• Slit lamp biomicroscopy of the anterior and posterior segments,
• Schaffer’s
• Dilated Fundus Examination

Question 10

Slit lamp biomicroscopy of the anterior and posterior segments, noting:

Answer 10

a) Pigment cells in anterior vitreous, ‘tobacco dust’ (Shafer’s sign),
particularly in the absence of any recent intraocular surgery
b) Vitreous haemorrhage
c) Cells in anterior chamber (mild anterior uveitic response)

Question 11

Schaffer’s

Answer 11

Pigment may have settled & clumped at bottom of anterior vitreous due to gravity so worth making patient looking up, then straight, then down, then straight to make it move

Question 12

Dilated Fundus Examination

Answer 12

• 8 cardinal gazes
• a) Status of peripheral retina, including presence of retinal tears, holes,
  detachments, operculums or lattice degeneration
  b) Presence of vitreous syneresis or Posterior Vitreous Detachment
  (PVD)
  c) Is the macula on or off (i.e. does the detachment involve the macula or
  not)

Question 13

Management

Symptoms requiring urgent review within 24 hours

Answer 13

• Sudden increase in number of floaters, patient may report as “numerous”,
  “too many to count” or “sudden shower or cloud of floaters” - Suggests blood
  cells, pigment cells, or pigment granules (from the retinal pigment epithelium)
  are present in the vitreous. NB Should be signs of retinal break or detachment
  present
• Cloud, curtain or veil over the vision - Suggests retinal detachment or vitreous
  haemorrhage – signs of retinal break or detachment should be present

Question 14

Management

Signs requiring referral within 24 hours

Answer 14

• Retinal detachment with good vision – Macula on
• Vitreous or pre-retinal haemorrhage
• Pigment ‘tobacco dust’ in anterior vitreous
• Retinal tear/hole with symptoms

Question 15

Management

Signs requiring referral to next available clinic appointment at the HES

Answer 15

• Retinal detachment with poor vision - Macula off - College says refer within 24 hrs
• Retinal hole/tear without symptoms?? - A retinal hole or tear does not always lead to retinal detachment -
• Lattice degeneration with symptoms of recent flashes and/or floaters

Question 16

Uncomplicated PVD or partial PVD

Answer 16

• Vitreous liquefaction and or shrinkage can lead to PVD. Both can happen at same time or one after another
  
  • Liquefaction = Synchesis = normal age related change, earlier in myopia. Collapse of collagen framework causing pocketed spaces in vitreous
  • Shrinkage = Syneresis = normal age related change, earlier in diabetes. Traction more likely of one point of vitreous attaching to retina, likely to cause retinal holes & flashes

Question 17

If age related PVD

Answer 17

• then takes 3 weeks to 3 months to detach, so px will have floater centrally (weiss ring) & if flashes present then normally crescent shaped flashing lights in temporal periphery (almost always) (if elsewhere then maybe RD or ocular migraine) stimulated by eye movements & most noticeable under dark conditions – Moore’s Lightening Streaks
  
  • PVD = sudden increase in F+F. So always dilate! Floaters normally veils or cobwebs. Not shadows or cutains otherwise highly suspicious of RD!
  • Sometimes sneezing or some other trigger can lead to PVD
  • Always consider vitreous haem (normally from underlying cause like diabetes) or RD
    
    • Causes of Vitreous haem: Retinal neovasc in diabetes, Vein occlusion, Trauma, Tractional detachment

Question 18

Must know why tobacco dust/schaffers forms

Answer 18

• Pigment granules in Shafer’s sign likely originate from shearing force on the retinal pigment epithelium (RPE) during a PVD, releasing brown pigment into the vitreous.
• Presence of Shafer’s sign indicates a 52-fold increased risk of retinal tears.
• Brown pigment granules suggest retinal breaks, while red-pigmented cells indicate vitreous hemorrhage, with a 70% correlation with retinal tears following acute PVD—both require further investigation.

Question 19

Treatment:Explain

Answer 19

There are various types of surgery used to reattach the retina and your ophthalmologist may combine different methods depending on your detachment. Most retinal detachment surgery is done under local anaesthetic, meaning that you’ll be awake but feel nothing in your eye.

Question 20

Preventing a full detachment:

Answer 20

• If a tear or a hole in your retina is found that hasn’t yet led to a retinal detachment, then it’s possible to have treatment to stop the detachment from happening.
  This treatment can be done two ways, either using laser, or with cryotherapy (a freezing treatment).
• Laser treatment uses a carefully targeted beam of light to cause very small burns around your retinal hole or tear. These small burns act to weld your retina more firmly to the back of your eye, preventing a detachment.
• Cryotherapy uses very low temperatures to freeze the area of the retina around your retinal tear or hole from the outside of the eye. The retinal tear or hole is surrounded by these treatments and sealed to prevent fluid passing through to cause a detachment.

Question 21

vitrectomy: explain

Answer 21

• During surgery your ophthalmologist reattaches the area of your retina that has become detached, removing some of the vitreous gel in your eye and replacing it with a gas bubble. The gas bubble holds your retina in place against the inside of your eye while it heals. The gas slowly disappears over about six weeks following the operation.
  
  • Depending on how your retina has detached, your ophthalmologist may chose to use clear silicone oil instead of a gas bubble. The silicone oil keeps your retina in the right place while it heals, but unlike the gas bubble you will need further surgery to remove the oil at some point in the future.

Question 22

scleral buckle: Explain

Answer 22

A scleral buckle may be used to treat your detachment. The sclera is the white outer layer of your eye.
A scleral buckle involves attaching a tiny piece of silicone sponge or harder plastic to the outside white of your eye. This presses on the outside of the eye, causing the inside of your eye to slightly move inwards. This pushes the inside of the eye against the detached retina and into a position which helps the retina to reattach. Cryotherapy or laser treatment is then used to seal the area around the detachment. The buckle is usually left in place permanently and can’t be seen once surgery is finished.

Question 23

Gas bubble?

Answer 23

If your retinal detachment is small and uncomplicated, a gas bubble can be injected into the vitreous of the eye, without removing any of the vitreous. This bubble then presses the retina back in place, and cryotherapy or laser is applied round the hole or tear. The gas is reabsorbed over a period of weeks and the retina remains in place. Depending on the size and position of the bubble, your vision may be very blurred in the first few weeks. This type of surgery has been found to be less successful than other types and is not often done in the UK.

Question 24

A pneumatic retinopexy

Answer 24

A pneumatic retinopexy is another procedure done which can be less complicated and easier to do compared to a vitrectomy or scleral buckle. However, it’s only done on superior breaks and less complicated cases. Uses a gas bubble without removing the vitreous and uses cryotherapy to solder the retinal break into place after preventing the retina from detaching with the bubble.