Retinal Lesions Kim Son Lett Consultant Ophthalmologist VitreoRetinal
- Slides: 39
Retinal Lesions Kim Son Lett Consultant Ophthalmologist & Vitreo-Retinal Surgeon Birmingham & Midland Eye Centre Director, Acute Eye & VR Services
Topics �Floaters & Flashes �Posterior Vitreous Detachment �Vitreous Haemorrhage �Retinal Degenerations, Holes & Tears �Retinal Detachment �Retinoschisis �Epiretinal Membrane �Macular Hole
Floaters & Flashes (Field Defect) �V common presentation to Eye Cas �Duration, ? Recent exacerbation �Myopia, -5 & -10 D thresholds �Intra-ocular surgery �Trauma �Medical Hx, eg connective tissue Dx �Family Hx retinal detachment
Floaters & Flashes (2) �Only 20 -30% PVD symptomatic �Floaters alone, 2 -5% breaks �Photopsia alone, 8 -14% breaks �Floaters & photopsia, 11 -18% breaks
Floaters & Flashes (3) Schaeffer’s Sign – tobacco dust Pigmented cells in vitreous Pathognomonic of retinal tear – NO! White cells, RBCs – use red free filter Posterior collapse S shaped post hyaloid face Versions will highlight Indicates PVD
Floaters & Flashes (4) Indentation – not expected of optoms 3 mirror lens In a well dilated eye (use pheny & trop) with a good view may not be much advantage
Floaters and Flashes - Mx �Floater +/ Flashes, no tobacco/# �RD warning, SOS �Symptoms, tobacco, no # �Eye Cas �Asymptomatic, tobacco, no # �Recheck history �Symptoms, tobacco, # �Eye Cas
Posterior Vitreous Detachment �Typically occurs 45 -65 �Virtually 100% prevalence over 85 �Only 20 -30% symptomatic �<10% attenders have #s �Weiss ring �Tobacco dust �Vitreous haemorrhage �Retinal tears / detachment
PVD (2) PVD only RD warning, SOS PVD & VH Eye Cas PVD & #/RD Eye Cas
Birmingham and Midland Eye Centre Date: Vitreo-Retinal Referral Form Referring Hospital: Patient NBM from: Patient name: Addressograph label: Date of birth: Address: Contact number: Presenting symptoms & duration: Floaters Field defect Photopsia Asymptomatic Other history & details Prior intra-ocular surgery Myopia Trauma Family history Examination: OD RAPD OS BC VA IOP Lens status PVD Tobacco dust Vit haem Referring Doctor Contact number Referring Consultant informed? Please complete this form and fax to: 0121 507 4068
Vitreous Haemorrhage VH in 1. 2% of floaters alone VH in 0. 2% of photopsia alone VH in 6% of floaters & photopsia #s in 70% of pts presenting with VH All need to be seen in Eye Cas ? flat periphery (indirect ophthalmoscopy) Ultrasound Systemic Dx? Early Vitrectomy vs Observation
Retinal degenerations �Lattice �White without pressure �Paving/cobble stone
Lattice Degeneration 8 -10% of population Commoner in myopes Overlying pocket of synchitic vitreous May be assoc with holes +/- SRF Progression to RD rare Round hole RD before PVD – slow progression Tear related RD after PVD – rapid progression
WWP & Pavingstone WWP Rarely assoc with GRT Normally no prophylaxis Pavingstone Chorio-retinal atrophy Seen in up to 25% eyes No prophylaxis
Types of Break Horseshoe tears, U-tears Arrowhead tears Operculae Atrophic holes Giant retinal tears Dialysis
What Requires Treatment? Tear vs. hole Size Symptomatic Pigmentation Fellow eye RD H/O cataract extraction 0. 5% routine, 2% PCR RRD Myopia FH Systemic Dx Marfan’s, Stickler’s, Ehlers-Danlos Vitreous traction
Definitions �Separation of neurosensory retina from RPE �Rhegmatogenous 95% �Tractional 4% �Exudative 1%
Why is RD a Problem? �Impaired nutrition to photoreceptors �Retinal vessels vs Choriocapillaris �Altered architecture �Photoreceptor death �Poor vision
Causes of RRD �PVD �Peripheral degenerations �Myopia �Intraocular Sx �Trauma �Inflammation �Retinoschisis �Connective tissue disorders
Symptoms & Signs �Floaters �Photopsia �Field defect �Sudden Lo. V – VH �Anterior uveitis �Tobacco dust �Bullous retina �Retinal corrugation & motion �Breaks
Lincoff’s Laws �Harvey Lincoff �Emeritus Professor, Cornell, NY �Pioneering work on �Cryotherapy �Silicone sponge buckling �Scleral balloon �Perfluorocarbon internal tamponade
ST or SN RRD In 98%, primary break within 1. 5 clock hours of highest border Fluid tracks to opposite side
Total / superior RRD crossing 12 o’clock meridian In 93% primary break is at 12 o’clock or within triangle where apex is at ora serrata and sides extend 1. 5 c. h. either side of 12 o’clock. Break on side of lower detachment
Total RRD Break at 12 o’clock
Inferior RRD In 95% break on side of higher detachment Look along bisecting line
Inferior Bullous RRD Inferior bullae originate from superior break Likely to require indentation which may abolish SRF gutter
Other Considerations �Age �PVD �Phakic or Pseudophakic �Number of breaks �Size of break �Anterior vs. posterior break �Macula on or off �LA or GA
Timing of Surgery �Macula on �Before macula comes off! �Ideally within 24 hrs �Macula off �Normally within 10/7
Principles of Surgery �Close the break �Relieve vitreous traction �Fluid drainage optional
External Approach �Cryobuckle �Encirclage �D-ACE �Indirect ophthalmoscopy skills �Accurate indentation �Buckle selection �Suturing into thin sclera �Trans-scleral fluid drainage
Internal Approach �Pars plana vitrectomy �PVD induction? �Break identification and marking �Retinopexy, scarring time �Fluid-air exchange, heavy liquids �Tamponades �Post-op posturing
Success rates �Primary surgery 80 -90% success �Secondary surgery 70 – 80% success �Rates fall off with each successive procedure
Traction RD Commonest in proliferative diabetic retinopathy Also sickle cell retinopathy V poor prognosis PPV, Delamination, Laser, Tamponade
Exudative RD Rare CNVM commonest Inflammatory disease eg scleritis Neoplasia Vascular anomalies Shifting SRF VR surgery rarely indicated
Degenerative Retinoschisis Present in 5% of population > 20 yrs Often bilateral, hypermetropes Split in outer plexiform layer Transparent Immobile No demarcation line Look for breaks in inner & outer leaves If only inner leaf break, no RD If only outer leaf break, RD v. rare as fluid is very viscous ? Tests to differentiate from RRD
Epiretinal Membrane Scar tissue Semi-opaque Contractile fibrocellular membrane Symptoms & signs Routine referral Surgery only if pt troubled PPV, ERM +/- ILM Peel 2 -3 Snellen line gain
Macular Hole Symptoms & signs Gass classification now defunct Routine referral Surgery elective PPV, ILM Peel, Gas 90 -95% success rate 2 -3 Snellen line gain
Summary �No tobacco dust – don’t panic �Not all retinal defects / degenerations require retinopexy – symptomatic traction is key �Vit haem is high risk �Only mac-on RD is ophthalmic emergency �ERM and MH are routine OPD referrals
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