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Department of OphthalmologyMoch Hoesin Hospital Palembang 2015Case report Thursday, May 21th 2015 Management for Giant Retinal Tear in Rhegmatogenous Retinal Detachment Case

Andrian Suner*

Consultant dr. H.A.K Ansyori, SpM(K), Mkes, MARSdr. Ramzi Amin, SpM(K)

Introduction BackgroundRetinal detachment : separation of the neuroepithelium from the pigment epithelium occur at potential space.Potential space neuroepithelium-pigment: space between the original layers of the embryonic optic cup

2Introduction Retinal detachments are classified as:1. Rhegmatogenous (most common type)2. Tractional (less common)3. Exudative

Term regma means...3introductionRhegmatogenous retinal detachmentrhegma(Greek) = breakcaused by liquefied vitreous passing into the subretinal space

The term rhegmatogenous is derived from the Greek word rhegma, which means a discontinuity or a break. 4Introduction Epidemiology data:RD in USA : 12,5 cases/10.000 per year 40-50% Myopic eyes30% history of Cataract surgery 10-20% associated to ocular trauma (mostly at 25-40 yo)

Principal Management of RD: Reattachment retina+ close the break + release traction of vitreoretinaSurgery: Scleral Buckling Pars Plana Vitrectomy Pneumatic retinopexy5PURPOSETo report a case of Rhegmatogenous Retinal Detachment with Giant Retinal Tear manage by Scleral Buckle + Pars Plana Vitrectomy + endolaser + Silicone Oil injection6Case ReportIdentification: A boy, 13 yo, rural, came to ophthlamology polyclinic at April 15th, 2015.

Chief of Complaint: Blurred vision at left eye since 2 weeks ago.

Case ReportHistory present illness: 2 weeks ago, the patient complain had sudden blurred vision at left eye with a flash light and floating object sight at left eye. 2 days later blurry vision became worse, blur like covered by curtain (+). Patient went to general practician and referred to private hospital and last referred to RSMH.

History Past Illness: Trauma (-)Spectacle: was used spheric -9 D since 9 years oldCicatrix on the right eye since patient was born.Family HistoryThe same disease in family (-)

Case ReportPhysical ExaminationGeneral Status : NormalOphthalmology Status:

RELEVANLP1/300IOPP=N+05 mmHgEye ballPosititonSymetricEye Ball MovementGood to All GazeGood to All Gaze

PalpebraNormalNormal Case ReportConjunctivaNormalNormalCorneaCicatrix all over cornea surfaceClearAnterior ChamberModerateModerateIrisPosterior synechia (+)NormalPupil Oval, LR (-) NRound, Central,LR(+) , 5 mmLensCant be assessedClear Fundus ReflexNegative PositivePapilCant be assessedRound, blurred margin, Normal Red Colour, C/D: Cant be assessed A/V:2/3MaculaFoveal reflex(-)Retina4 quadrants detachment (+), giant retinal tear (+) temporal region.

Case ReportLEFT EYE FUNDUS PHOTOGRAPH

This is the fundus photograph or left eye which found giant retinal tear at the temporal region.12Case ReportRETINAL DRAWINGRE

13Left eye usg

Vitreus: Echospike (hiperechoic), high reflextivity, low mobility, and membran-like shapeRetina: non-intakInterpretation: Ablasio Retina LE

14RIGHT eye usg

Vitreus: Echospike (hiperechoic), high reflextivity, low mobility, and membran-like shapeRetina: non-intakInterpretation: Ablasio Retina LE

15Case ReportDiagnosis : Rhegmatogenous Retinal Detachment LE + Cornea Leukoma RE + Retinal Detachment LE Management:Informed ConsentHospitalizedLaboratorium Examination + Chest X-RayPro consult Anesthesiology DepartmentPro Scleral Buckle + Pars Plana Vitrectomy + Endolaser + Silicone Oil LE with General Anesthesia

Prognosis :Quo ad Vitam : BonamQuo ad Functionam: Dubia ad bonamCase ReportSurgical Report: (21-4-2015)Patient in supine position with GAAseptic & antiseptic performed, surgical field was narrowed3600 conjunctival peritomy & extraocular muscle isolatedSilicone band inserted under rectus muscle, Sleeve installed at nasal inferior & band sutured to sclera at 4 with mersilene 5.0Sclerotomy site marked at 3 mm from limbal and at 8 oclock filled infusion cannula, 10 oclock-vitrector & 2 oclock-endoilluminatorDetached retina and tear was identified, proceed to performing vitrectomy until optimal clearance

Case report7. Heavy fluid injected to stabilize retina and to do the endodrainage8. fluid-air exchange performed, endolaser applied around tear and 3600 peripheral retina9. Silicone Oil injected to vitreal cavity10. Infusion cannula,endoilluminator & vitrector were removed from cavity & sclera sutured with 8.0 vycril11. Dexamethason-gentamycin injected subconjunctival and eye was closed with sterile patch

Post opertive therapyCefixime 2 x 100 mgParacetamol 3 x 250 mgMetil prednisolon 3x 4 mgTobramycine + dexametason ED 6 x 1 gtt OD

Case report (Follow Up)

Right Eye1st day post op 8th day post opVA4/60 PH(-)6/60 ph (-)IOP13,1 mmHg15,6 mmHgFR(+)(+)Papil Round, Firm margin, Normal Red Colour, C/D:0,3 A/V:2/3Round, Firm margin, Normal Red Colour, C/D:0,3 A/V:2/3Macula Foveal reflex (+)Foveal reflex(+) Retina Tigroid appearance, Lattice degeneration (+) , scar laser (+), subretinal hemorrhagic (+)

Tigroid appearance, Lattice degeneration (+), scar laser (+), subretinal hemorrhagic (+)

Case report1st day post op9th day post opDiagnosisPost Buckle Sklera + pars plana vitrectomy+ Endolaser + Silicon oil LE+ corneal leucoma RE + Retinal detachment REPost Buckle Sklera + pars plana vitrectomy+ Endolaser + Silicon oil LE+ corneal leucoma RE + Retinal detachment RETherapyCefixime 2 x 100 mgParacetamol 3 x 250 mgMetil prednisolon 3x 4 mgTobramycine + dexametason ED 6 x 1 gtt ODTobramycine + dexametason ED 6 x 1 gtt ODLiterature reviewIt extends almost as far anteriorly as the ciliary bodyEnding point The ora serrataThe outer surface of the sensory retina is apposed to the retinal pigment epithelium and thus related to Bruch's membrane, the choroid, and the sclera.RETINAThe retina is a thin, transparent structure that develops from the inner and outer layersof the optic cup.23Thickness 0.1 mm at the ora serrata and 0.56 mm at the posterior poleThe macula lutea is defined anatomically as the 3 mm diameter area containing the yellow luteal pigment xanthophyll

RETINA24FOVEAThe retinal avascular zone of fluorescein angiography. 1.5 mm

25A depression that creates a particular reflection when viewed ophthalmoscopically. In the center of the macula 4 mm lateral to the optic disk 0.25 mm

FOVEOLA26In the middle ofThe thinnest part of area of the retina 0.25 mmOnly cone photoreceptors. Providing optimal visual acuity.

FOVEOLA27`

28Literature reviewRetinal detachment: separation of the sensory retina from the pigment epithelium which occur at potential space.

Literature reviewNormally, sensoryneural attach to RPE maintained by balance hydrostatic. RPE preserve the potential space free from fluid by osmotic gradient and active-pump mechanism.

3 major factor of RD:full-thickness retinal defect (break) Traction of retinaSubretinal fluid

Literature reviewPotential space in RD filled with subretinal fluid. Fluid came from syneretic vitreous through retinal break and separate the sensory retina from RPE

Literature reviewRisk factor:Myopic eye Trauma Lattice degenerationHistory of surgeryFamily history

Lattice degeneration is a predisposing factor of RRD. 8 % of population have lattice and 40% case of RD associated with lattice

SYMPTOMSMetamorphopsiaPhotopsiaShadow or curtain over a portion of visual field Blur in vision

The symptoms of retinal detachment include:33Literature reviewManagement of RRD: find and close the breakReattachment retina

Post operative outcome depend on: Macular involvement duration of separation until surgical management apply

The principal of RRD management are:34Literature reviewSurgical Technique1. Scleral Buckling

Performed : single break & peripheral good visualization only in 1 quadrant 90% good result

DrainageThe Purpose of scleral buckling is for scleral indentation to bring the sensory of retina near the RPE by encircling the silicone band or tire around the globe.The second purpose of SB is to make chorioretinal adhesion by cryotherapy or laser.The retinopexy can act as internal tamponade which can assist the adhision of RPE.SB is performed if....35Literature reviewSCLERAL BUCKLING COMPLICATIONSB complication can classified to intraoperativ and post operativ complication36Literature review2. VitrectomyRationally, vitrectomy is a procedure to overcome traction and avoid complication of scleral buckling.

VITRECTOMY clean up hyaloid cortex of vitreous avoid vitreoretinal traction_RRD associated vitreous mobility (liquefaction & PVD)Scleral BuckleRelaxation vitreal tractionRRD could manage with ....Vitrectomy use to ....... So it can ......If combine with SB would make a relaxation...37Literature reviewVITRECTOMY PROCEDUREThe vitrectomy procedure are1. Removal of vitreus gel38INDICATIONDisease: Diabetic RetinopathyPVRMacular involvementTrauma Malignancy caseCondition: Giant tearsVitreous hemorrhageMultiple breakEquatorial tear

Literature reviewVitrectomy ComplicationGiant retinal tears circumferential retinal breaks of 90 degrees or more

Giant retinal tears are defined as circumferential retinal breaks of 90 degreesor more.

41The general principles of management: Unfold the posterior flap of the tearFlatten it against the eye wallSeal the tear with a fi rm adhesion.The general principles of management of giant retinal tears are to unfold the posterior flap of the tear, flattenit against the eye wall, and seal the tear with a fi rm adhesion.42discussionAnamnesisSudden blur visionNo reddish eyePhotopsiaFloaters Curtain-like vision

Seeing flash light (photopsia) and Flying matter( floaters) are 50% of RRD early symptoms.Retinal detachment could be establish throug anamnesis from patient which he complain ...From the literature....

43DISCUSSIONFundus Examination: Retinal detachment (undulation bulae)Foveal involvement Giant retinal tearLattice degeneration

DISCUSSIONHistory of wearing spectacles (+) -9D high miopia lattice degeneration

Lattice degeneration: Abnormal condition of retina caused by thinning of inner limitting membrane with athropic process of neurosensory, which is lead retinal break formation migration of vitreous fluid subretinal the sensory retinaRPE separation

History of wearing spectacles with power lens -9D indicate high myopia condition which can cause lattice degeneration

45Management for this patient is Sclera buckle + Pars Plana Vitrectomy + Endolaser + Injection Silicone Oil Intravitreal Giant retinal tear

46Reason :Retinal detachment shallowGood identification of retinal tear

Post operative outcome:Complication not foundRetinal flat (+)Visual acuity improvement at follow upPrognosis :Quo ad vitam: bonamQuo ad fungsional : dubia ad bonam Follow Up : better visual acquity, attached retina, no complication

The functional prognosis of patient was dubia ad bonam cause from follow up there was better visual acquity, attached retina, and no complication found.48Its have been reported a case of Rhegmatogen retinal detachment with giant retinal tear managed by Sclera buckle + Pars Plana Vitrectomy + Endolaser + Injection silicone oil intravitreal.RRD caused by lattice degeneration history of high miopia.Prognosis dubia ad bonam for this patient better visual acquity, attached retina, no complication CONCLUSIONRRD caused by lattice degeneration history of high miopia.Prognosis dubia ad bonam for this patient from better visual acquity, attached retina, no complication were found at follow up.

THANK YOUralatPrognosis : dubia ad bonamSetelah tindakan operasi didapatkan retina yang attach dan perbaikan tajam penglihatan pada follow up, serta tidak didapatkan komplikasi tindakan bedah.

Certified standard52

Laser Tissue EffectPhotocoagulation effects. Thermal effects, those most commonly encountered with retinal photocoagulationvisible or infrared light is absorbed by tissue pigment absorption of laser energy results in a 10 to 20 C temperature rise --- protein denaturation is seen clinically as tissue whiteningLaser Tissue EffectThermal effects.

SYMPTOMSfloaters - bits of debris in field of vision that look like spots, hairs or strings

58

Literature reviewVitrectomy + Scleral BuckleDegenerasi lattice merupakan kelainan dari permukaan vitreoretinal, dapat ditemukan 6-10% dari populasi umum dan bilateral pada 1/3 sampai jumlahkasusdegenerasi lattice. Degenerasi lattice sering muncul pada pasien dengan miopia, tapi tidak hanya terbatas pada pasien dengan miopia, 70Vitrectomy cutter baush and lomb

Retinal breaksa - Large U-tear with subclinical RD - treatb - Large symptomatic U-tear - treatc - Operculated tear bridged by blood vessel - treatd - Asymptomatic operculated tear - do not treat72Retinal breaks not requiring treatmente - Asymptomatic dialysis surrounded by pigmentf - Breaks in both layers of retinoschisisg - Small asymptomatic holes near ora serratah - Small inner layer holes in retinoschisis

73

Typical lattice degeneration Present in about 8% of general population Present in about 40% of eyes with RD Spindle-shaped islands of retinal thinning Network of white lines within islands Variable associated RPE changes Small round holes within lesions are common Overlying vitreous liquefaction Exaggerated attachments around margin of lesionRetinaVitreous74Complications of lattice degenerationIndications for prophylaxis No complications - in most cases RD associated with atropic holes, particularly in young myopes RD associated with tractional tears in eyes with acute PVD RD in fellow eye Extensive lattice in high myopia

75Classification Of PVRThe term "proliferative vitreoretinopathy" was coined in 1983 by the Retina Society Terminology Committee. In 1989, the classification was amended by the Silicone Study Group before being most recently modified in 1991 to its current classification. Currently, PVR is divided into grades A, B, and C. Grade A is limited to the presence of vitreous cells or haze. Grade B is defined by the presence of rolled or irregular edges of a tear or inner retinal surface wrinkling, denoting subclinical contraction. Grade C is recognized by the presence of preretinal or subretinal membranes. Grade C is further delineated as being anterior to the equator (grade Ca) or posterior to the equator (grade Cp) and by the number of clock hours involved (1 to 12).Proliferative vitreoretinopathy Vitreous haze and tobacco dustGrade A (minimal) Rigid retinal folds Vitreous condensations and strandsGrade C (severe) Retinal wrinkling and stiffness Rolled edges of tearsGrade B (moderate)

78PRINCIPLES OF RETINAL DETACHMENT SURGERY1. Scleral buckling2. Pneumatic retinopexy Configuration of buckles Preliminary steps Localization of breaks Insertion of local explant Encircling procedure Drainage of subretinal fluid 3. Vitrectomy Giant tears Proliferative vitreoretinopathy (PVR) Diabetic tractional RD79Vitrectomy for Retinal DetachmentRelease of circumferential tractionRelease of antero-posterior tractionEndophotocoagulation

Vitrectomy for PVR

Dissection of star folds and peeling of membranes Injection of expanding gas or silicone oilIntraocular gasesSulfur hexafluoride (SF6) perfluoropropane (C3F8) are the gases most frequently used.Success also has been reported with sterile room air.

Preliminary stepsPeritomyInsertion of squint hook under rectus muscleInsertion of bridle sutureInspection of sclera for thinning or anomalous vortex veins

84Encircling procedureStrap fed under four rectiEnds secured with Watzke sleeveStrap slid posteriorly and secured in each quadrantStrap tightened to produce requiredamount of internal indentation