RETINAL DETACHMENT

by Wilma Cleo Yvonne B. Dapog

Retinal detachment refers to the separation of the retinal pigment epithelium (RPE) from the sensory layer. 4 Types: 1. Rhegmatogenous - most common form; age-related collapse of the collagen framework of the vitreous gel wherein a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the RPE. Risk factors: People with high myopia or aphakia after cataract surgery Cause: Trauma, proliferative retinopathy (associated with diabetic neovascularization) 2. Traction Risk factors: diabetic retinopathy, vitreous hemorrhage, or the retinopathy prematurity. Cause: tension or pulling force on the retina from hemorrhage and fibrous scar tissue formation. 3. Combination of rhegmatogenous and traction 4. Exudative Cause: Production of a serous fluid under the retina from the choroid Risk Factors: conditions such as uveitis and macular degeneration. Clinical Manifestations: *Sensation of shade or curtain coming across the vision of one eye cobwebs bright flashing lights sudden onset of a great number of floaters. No pain

Assessment and Diagnostic Findings: 1. Visual Acuity 2. Indirect opthalmoscopy: Dilated Fundus examination (fundus is projected into a screen) 3. Slit-lamp biomicroscopy 4. Stereo fundus photography 5. Fluorescein angiography *For complete retinal assessment: (if view is obscured by a dense cataract or vitreal hemorrhage) 1. Optical coherence tomography

2. Ultrasound Identify all retinal breaks, all fibrous bands that may be causing traction to the retina Identify all degenerative changes. Medical Management: I. Surgical Management Rhegmatogenous detachment - an attempt is made to surgically reattach the sensory retina to the RPE. Traction detachment - the source of traction must be removed and the sensory retina reattached. 1. Scleral Buckle *Procedure: the retinal surgeon compresses the sclera (using a sclera buckle or silicone band) to indent the sclera wall from the outside of the eye and bring the two retinal layers in contact with each other. Advantages: High success rates in the hands of experienced retinal surgeons Causes less damage to the lens of the eye in phakic patients, and less risk of endophthalmitis. Disadvantages: Increased incidence of diplopia Other complications can occurs such as: induced myopia and increased post-op pain 2. Pars Plana Vitrectomy: for Traction retinal detachment *Procedure: An intraocular procedure in which 1- to 4-mm incisions are made at the pars plana. One incision allows the introduction of a light source, and another incision serves as the portal for the vitrectomy instrument. The surgeon dissects preretinal membranes under direct visualization while the retina is stabilized by an intraoperative vitreous substitute. Facts: This surgical technique was originally introduced as a treatment for eyes with conditions that were previously inoperable (such as vitreous hemorrhage, proliferative diabetic retinopathy). Technologic improvements (including operating microscopes, microinstrumentation) have advanced vitreoretinal surgery. May be combined with scleral buckling to repair retinal breaks

3. Pneumatic Retinopexy: for Rhegmatogenous retinal detachment *Procedure: A gas bubble, silicone oil, or perfluorocarbon and liquid may be injected into the vitreous cavity to help push the sensory retinal up against the RPE. Advantages: Least invasive of the 3. Nursing Consideration: Post-operative position of the patient is critical. Rationale: Injected bubble must float into a position overlying the area of detachment, providing consistent pressure to reattach the sensory retina. Nursing Management: 1. Promote comfort. If gas tamponade is used to flatten the retina, the patient may have to be specially positioned to make the bubble float into the best position. Some patients must lie face down or on their side for days. Educate the patient and family members beforehand about providing comfort to patient. 2. Teach about complications. Procedure is performed on outpatient basis. Post-op complications includes: increased IOP, endophthalmitis, development of other retinal detachments, development of cataracts, and loss of turgor of the eye. Teach about signs and symptoms of complications, particularly increasing IOP and postop infection.