20. Vitreo/retinal Detachment
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What is a degenerative retinoschsis and what causes it?
- split of retina at the OPL found in the peripheral retina due to coalescing of cystoid spaces
- creating outer and inner holes
- will produce VF defects
- found mostly in periphery
- 1st appears in infero-temporal quadrant
- slowly progressive with age
What are the types of degenerative retinoschisis and where is it found?
bulbous visible vs non visible flat
bullous Degen retino cf RD?
How does liquefaction of the vitreous occur and how can it lead to a PVD?
- pockets of liquid appear within central vit and coalesce
- weakensing of VR adhesion
- liquid vit dissects gel away from ILM of the retina-> PVD
How is a retinal horseshoe tear formed?
- incomplete PVD- traction of the retina
- vitreous pulls away from sensory retina but remains attached to one end of the tear while the base is at the retina
What are sx of RB?
- blurry va
What are signs of RB?
- atrophic holes
- operculated tears
- linear tears
- retinal dialysis
how is RD associated with PVD?
- RRD-> acute PVD
- TRD-> incomplete PVD
- serous/exudative NOT REALTED TO PVD
risk of RD with retinoschisis?
low as hard for liquefying vitreous to get through the lesion
What are some acute PVD sx?
- blurry vision
Signs of acute PVD?
- weiss ring
- disc haem
- vit haem
DDX for photopsia VR traction?
PVD, optic neuritis, migraine, hypotension, TIA
DDX for floaters?
PVD, PDR, uveitis
DDX for VF loss- peripheral detachment?
OPtic neuropathy CVA BRVO BRAO
Sx of RD?
- VF loss- black curtain
- decreased VA
- IOP changes
- retinal appearance: grey/opaque, balloning tears
Risk factors for RD?
aging, cataract surgury, focal retinal atrophy, myopia, trauma
What is the most common type of RD?
- most common form of RD
How does an RRD occur?
- fluid from vitreous cavity passes through retina defect into subretinal space and separates neural retina from RPE
- retinal break + vitreous liquefication + traction
What can predispose a retinal break?
- lattice degeneration
- snail track degen
- peripheral cystoid degeneration
- retinal tuft
How urgent is a RD?
- if macula on detachment: urgent
- if not on: few days
Most common site of tear?
What is a tractional retinal detachment caused by?
- fibrotic/fibrovascular membranes in vit (assoc with inflam exudates + vit haem) creating a retinal traction
- PVR, ROP, trauma, cataract, post uveitis
What are some features of TRD?
- concave and no breaks
- retinal mobility is reduced
- photopsia+floaters absent
- VF defect slow prog
What is dynamic traction?
What is a static traction?
- indep of eye movement
- TDR and PVR
What is Proliferative Vitreoretinopathy?
- wound healing process
- prolif of avascular retinal membranes assoc with RRD
- contraction of membranes-> macula pucker-> new RB/RD and ocular hypotony
What is a combined RTRD?
- combination of retinal break+traction
- 2ndy to traction
Therapeutic retinal detachment
- OAG miotics cause intense miosis leading to retinal stretching in high myopic eyes -> RT
What is a serous/exudative/2ndy RD?
elevation of neural retina due to accumulation of subretinal fluid in ABSENCE of a retinal break or sig preretinal traction
What are some key features of a serous/exudative RD?
- subretinal fluid shifts with head position
- lack of RRD/TRD
- 2ndy to local ocular/systemic etiology
How can subretinal fluid accummulate?
- increase in fluid flow in subret space: leaky vessels in tumour
- impaired outflows: choroidal inflam
- outer BRB breakdown + impairment of RPE pump: CSCR
Signs of serous RD?
- convex smooth elevation
- mobile deep and shifting fluid
- leopard spots: subret pigment
- fluid escapes from vessels into body tissue/space
- transudative fluid from choriocap
- thickening of choroid/choroid detachment
- uveal effusion (-)inflammation, surgery, hypot
- abnormal scleral collagen
- vortex vein compression
RD prophylactic tx?
- laser photocoagulation
- laser/scleral indentation
- scleral buckling
- pneumatic retinopexy: gas bubble, seal break/reattach retina
- cryotherapy: scar-fusion of RPE and retina
Pars plana vitrectomy?
- remove vitreal opacities/vitreous: decrease of other RB
- release VR traction
above midline progress to RD faster than below
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