5/11/21

TYPES OF RETINAL DETACHMENT

Pathogenesis and ž Rhegmatogenous RD Management of ž Traction RD Retinal Detachment ž Surendar S. Purohit, MD Exudative RD

1 2

Gonin’s Principle Pathogenesis of Retinal Detachment

ž PVD results in retinal tear ž Jules Gonin (1870-1935) ž Opposing forces — Professor of Ophthalmology — Vitreous traction on tear vs. RPE pump Lausanne, Switzerland

ž Recognised that the retinal break was the cause of the detachment ž Closure of the retinal break cured the detachment

3 4

Retinal Tears Retinal holes / tears

ž PVD — Vitreous hemorrhage — Pigment cells ž Symptomatic tears with persistent vitreoretinal traction 33-55% risk of RD

5 6

1 5/11/21

Pathogenesis of Retinal Detachment Retinal Detachment

ž If vitreous traction ž Macula status overwhelms RPE ž Acute vs Chronic pump ž Liquid vitreous ž Status of posterior hyaloid migrates through ž Location of tear tear into subretinal ž Type of tear space ž PVR

7 8

Proliferative Vitreoretinopathy (PVR) Total RD with Massive PVR

ž Retinal traction / detachment due to proliferative cells that contract on retinal surface and vitreous ž Folds ž Stiff retina ž Retinal shortening

9 10

Pneumatic Retinopexy

Repair of Retinal Detachment Indications

ž Pneumatic Retinopexy Least invasive

ž Scleral buckle

Most ž Vitrectomy ± scleral invasive buckle

11 12

2 5/11/21

RD with Superior Retinal Break Pneumatic Retinopexy

žMechanism of RD Repair

— Surface tension of gas bubble closes tear — RPE pumps out subretinal fluid

13 14

Pneumatic Retinopexy

ž Advantages — Least invasive procedure — Performed in outpatient setting — Good success rate with proper patient selection ○ Phakic: 70% ○ Pseudophakic 60%

15 16

Pneumatic Retinopexy RD with Superior and Inferior Breaks

ž Disadvantages

— Requires proper patient positioning — Gas bubble may result in shifting of subretinal fluid and formation of new retinal breaks

17 18

3 5/11/21

Scleral Buckle

Indications Scleral Buckle

ž Mechanism of RD Repair

— Tear(s) is supported by indentation produced by explant — Explant results in indirect release of vitreous traction on tear(s)

19 20

21 22

Scleral Buckle Advantages Retinal Dialysis

ž External procedure ž Disease of young males — No vitreous invasion ž Disinsertion of retina at the — No PVR stimulus ora serrata ž No intravitreal gas complications ž Most commonly located in — Cataract progression inferotemporal quadrant — Concerns regarding air travel ž Vast majority secondary to ○ Gas expansion and elevated IOP blunt trauma (fist or ball) ž Faster visual rehabilitation ž Primary reattachment rate: 90-95%

23 24

4 5/11/21

Retinal dialysis RD Pars Plana Vitrectomy

25 26

Vitrectomy Advantages Vitrectomy Disadvantages

ž Remove traction from inside the eye — More invasive ž Transconjunctival sutureless small procedure gauge surgery — cataract ž No refractive changes progression ž Can address surface pathology — Longer visual rehabilitation with ž Remove media opacities use of intraocular ž Less time / faster recovery gases (SF6, C3F8)

27 28

Vitrectomy ± Scleral Buckle

ž Mechanism of RD Repair — Vitrectomy results in DIRECT release of vitreous traction on tear(s)

— Indentation of scleral explant results in INDIRECT release of vitreous traction on tear(s)

29 30

5 5/11/21

31 32

Giant Retinal Tear Giant Retinal Tear

ž Defined as peripheral break extending through ≥90 degrees of retinal circumference — Vitreous is attached to the anterior flap thereby allowing independent mobility of the posterior edge of tear

33 34

35

6 5/11/21

Financial disclosure

Dr. RaShawn Venerable Specialty Eye Institute § No financial conflicts to disclose. The Ins and outs of the Nasal Lacramal Duct

1 2

ANATOMY AND PHYSIOLOGY OF THE ANATOMY AND PHYSIOLOGY OF THE LACRIMAL SYSTEM SECRETORY LACRIMAL SYSTEM SECRETORY APPARATUS: APPARATUS:

§ LACRIMAL GLAND § LACRIMAL GLAND – Levator aponeurosis (lateral horn of the levator) divides the gland into an – Afferent pathway: TRIGEMINAL (V) NERVE. Efferent pathway: orbital and palpebral lobe. Lacrimal ducts (8-12) empty into superior cul-de- FACIAL (VII) NERVE. The nerve travels through the orbital lacrimal sac 5mm above lateral tarsal border. Ducts from the orbital portion run gland and once this is removed the palpebral lobe cannot be through palpebral lobe— cannot remove palpebral lobe without damaging activated. all the ducts! Therefore, biopsies should be performed on orbital portion.

3 4

LACRIMAL EXCRETORY APPARATUS § ACCESSORY LACRIMAL GLANDS OF • PUNCTA should be inverted against the globe. KRAUSE AND WOLFRING: Located in the • CANALICULI: Ampullae 2mm - superior cul-de-sac. vertical. Horizontal course - 8-10 mm. 90%: upper and lower join – Basic secretors: no efferent nerve supply. forming common canaliculus. • Rosenmuller's valve at lacrimal sac – TEAR FILM entrance prevents reflux from the sac into the canaliculi. § Inner layer: mucin from the conjunctival goblet cells. • LACRIMAL SAC: 10mm in length. § Middle aqueous layer: main and accessory lacrimal Lies between anterior and glands. posterior crus of medial canthal tendon within the lacrimal sac § Outer oily layer: Meibomian glands. fossa

5 6

1 5/11/21

LACRIMAL EXCRETORY LACRIMAL PUMP APPARATUS • NASOLACRIMAL DUCT: § PRETARSAL AND 12mm long. Drains into the PRESEPTAL ORBICULARIS inferior meatus. Ostium covered by mucosal fold: ARE KEY PLAYERS. – EYELIDS CLOSE Superficial and deep • VALVE OF HASNER. Child: 20mm heads of pretarsal orbicularis contract: from external nares. Adult: 30mm Compress the ampulla. Shorten the from external nares. horizontal canaliculus. Punctum moves medially. Superficial and deep heads of preseptal orbicularis contract: Pull lacrimal fascia laterally. Lacrimal sac expands: creating negative pressure. Fluid drawn from canaliculi into the sac. – EYELIDS OPEN Muscles relax. Sac collapses: tears are forced into the nose. Punctum moves laterally and tears enter canaliculi.

7 8

9 10

LACRIMAL EVALUATION EXCRETORY TESTS

§ Cause of tearing § DYE DISAPPEARANCE TEST – Hyper secretion of tears – Excellent test for children! Fluorescein instilled in both cul-de-sacs. Tear film observed with or without cobalt – Impaired drainage blue light. Asymmetry over a five-minute period: relative – HISTORY Constant vs. intermittent Unilateral vs. obstruction on the side retaining the dye. Etiology not bilateral Any ocular discomfort determined, could be due to lid malposition, a poor tear – Previous lacrimal, sinus, or facial surgery or trauma pump, punctal stenosis, canalicular obstruction, or – Are tears clear or contains blood or discharge nasolacrimal duct obstruction. – Any topical medications – EXAM includes -ocular surface -tear film -eyelid position -punctal opening and position -lacrimal sac

11 12

2 5/11/21

EXCRETORY TESTS EXCRETORY TESTS

§ PRIMARY DYE TEST § SECONDARY DYE TEST - JONES 2 – JONES 1-(33% false negatives) Fluorescein is instilled – After JONES 1 test wash out dye from the fornices. Irrigate lacrimal in conjunctival cul-de-sac. Recover from inferior meatus sac with saline: § 1. Positive Dye recovered from nose indicates incomplete or functional with cotton-tipped probe. Have patient blow nose. If no block in nasolacrimal duct. (Positive Jones 2) dye recovered, there is an anatomic or functional block. § 2. No Dye recovered from nose, but unstained fluid recovered indicates § No dye=Negative test defect in canaliculi or pump. (Jones 2 Negative) § If dye recovered in a patient with epiphora look for ocular reason for hyper secretion.

13 14

EXCRETORY TESTS SECRETORY TESTS

§ LACRIMAL § TEAR FILM EXAMINATION IRRIGATION – Tear meniscus: the size of the lake, presence of precipitated proteins and stringy mucus may indicate – most commonly abnormal tear film. used test to evaluate system irrigation thru system doesn’t r/o functional block

15 16

SECRETORY TESTS SECRETORY TESTS

§ TEAR FILM EXAMINATION § TEAR FILM EXAMINATION – Tear break up time: After a fluorescein strip is – Corneal evaluation with rose bengal, fluorescein or moistened by tears the patient is asked not to blink. Lissamine green staining. Tear break-up of less than 10 seconds indicates poor function of the mucin layer.

17 18

3 5/11/21

SECRETORY TESTS SECRETORY TESTS

§ SCHIRMER TESTS § SCHIRMER TESTS – BASIC SECRETION – SCHIRMER 2 Use when Schirmer 1 and basic secretion are low to § SCHIRMER TEST Reflex secretion is eliminated by anesthetizing the confirm activity of the reflex secretors. Anesthetize conjunctiva and conjunctiva and blotting the inferior cul de sac dry. 10 mm or more is considered irritate middle turbinate. normal. Good test for ptosis and blepharoplasty patients.

– SCHIRMER 1 Measures both basic and reflex secretion. No topical anesthesia is used. Normal: 10-30mm.

19 20

EXCRETORY TESTS EXCRETORY TESTS

§ SCINTIGRAPHY Use gamma ray emitting radionuclides § CT SCAN-with or without contrast in lacrimal such as technetium-99 to evaluate the physiological flow of tears. system Indicated in craniofacial injuries, § DACRYOCYSTOGRAPHY Radiopaque dye is irrigated congenital deformities or when lacrimal sac into both lacrimal drainage systems. Plain x-ray technique neoplasia is suspected. can be augmented with subtraction studies. Helpful to delineate site of obstruction, confirm suspicion of tumor or stones. § NASAL ENDOSCOPY direct visualization of lacrimal outflow area

21 22

CONGENITAL AND DEVELOPMENTAL CONGENITAL AND DEVELOPMENTAL ANOMALIES OF THE LACRIMAL SYSTEM ANOMALIES OF THE LACRIMAL SYSTEM

§ EMBRYOLOGY Embryonic analog of the lacrimal § NASOLACRIMAL DUCT drainage system begins as a cord in the medial OBSTRUCTION canthus and grows laterally and down. Cavitation – Membranous block at the of the canaliculi and ducts occurs to form the valve of Hasner is present in lumen. The NASOLACRIMAL DUCT is the last to 50% of newborns but is canalize. Canalization is not always complete at clinically evident in only 2-6% of infants at 3-4 weeks of age, birth and obstruction at the distal end (Valve of with 1/3 being bilateral. Hasner) is present. – Symptoms are tearing with mucopurulent discharge.

23 24

4 5/11/21

CONGENITAL AND DEVELOPMENTAL CONGENITAL AND DEVELOPMENTAL ANOMALIES OF THE LACRIMAL SYSTEM ANOMALIES OF THE LACRIMAL SYSTEM

§ NASOLACRIMAL DUCT § CONSERVATIVE MANAGEMENT: OBSTRUCTION – Topical antibiotics Massage Nasal – Most obstructions resolve decongestants, antibiotic ointments spontaneously within 4 to 6 weeks. – PROBING: 6-12 – 90% of obstructions have – Technique: Probe superior canaliculus, may resolved by 1 year also infracture the inferior turbinate and irrigate with fluorescein. § > 12 months- probe and irrigate and Ballon Dacryoplasty. § >= 24 months- Consider DCR.

25 26

CONGENITAL AND DEVELOPMENTAL ANOMALIES OF THE LACRIMAL SYSTEM

§ BALLOON DACRYOPLASTY

27 28

CONGENITAL AND DEVELOPMENTAL CONGENITAL AND DEVELOPMENTAL ANOMALIES OF THE LACRIMAL SYSTEM ANOMALIES OF THE LACRIMAL SYSTEM

§ DACRYOCYSTOCELE § ANOMALIES OF PUNCTA AND – Combination of CANALICULI nasolacrimal duct – Punctal agenesis and dysgenesis Look for obstruction and amniotic lacrimal papillae-system intact under membrane fluid or mucus trapped in If no system present will need CDCR when the sac. older – Sterile at first: treat with antibiotics and massage. If infection develops or doesn’t resolve, probing is needed. May extend into the nose and if bilateral can cause airway obstruction

29 30

5 5/11/21

CONGENITAL AND DEVELOPMENTAL ACQUIRED LACRIMAL DRAINAGE ANOMALIES OF THE LACRIMAL SYSTEM DISORDERS

§ ANOMALIES OF PUNCTA AND § PUNCTAL CONDITIONS CANALICULI – Punctal Stenosis Dilation. Ampullotomy - snip – Congenital lacrimal-cutaneous fistula Usually procedure. Silicone intubation / stent placement. asymptomatic but 1/3 may be associated with – Punctal malposition nasolacrimal duct obstruction

31 32

ACQUIRED LACRIMAL DRAINAGE ACQUIRED LACRIMAL DRAINAGE DISORDERS DISORDERS

§ CANALICULAR DISORDERS § CANALICULAR DISORDERS – CANALICULAR OBSTRUCTION – CANALICULAR OBSTRUCTION § Etiology: Trauma, punctal plug, systemic § Treatment medications(5 FU, Docetaxel. Idoxuridine), topical – Partial Silicone intubation. DCR with intubation may be medications (IDU, phospholine iodide, eserine), viral necessary. infections (vaccinia, herpes simplex) and immune – Complete-try DCR with tubes disorders (pemphigoid, Stevens-Johnson). Conjunctivodacryocystorhinostomy(CDCR): done in cases of extensive canalicular obstruction. CDCR: Jones’ pyrex glass tubes

33 34

35 36

6 5/11/21

ACQUIRED LACRIMAL DRAINAGE ACQUIRED LACRIMAL DRAINAGE DISORDERS DISORDERS

§ CANALICULAR DISORDERS § CANALICULAR DISORDERS – CANALICULAR OBSTRUCTION – CANALICULAR OBSTRUCTION § CANALICULITIS – Can be caused by various bacterial, viral, chlamydial or mycotic organisms; however, most common cause is ACTINOMYCES ISRAELII (Streptothrix). Filamentous Gram-positive rod. Follicular conjunctivitis. Erythematous, dilated, pouting punctum. May be result of retained intracanalicular plug!!! (smart plugs; herrick plugs)

37 38

39 40

ACQUIRED LACRIMAL DRAINAGE ACQUIRED LACRIMAL DRAINAGE DISORDERS DISORDERS

§ CANALICULAR DISORDERS § CANALICULAR DISORDERS – CANALICULAR OBSTRUCTION – CANALICULAR OBSTRUCTION § CANALICULITIS § TRAUMATIC INJURY-lateral traction on the lid - – TREATMENT: Canaliculitis Gentle probing and irrigation. medial canthal area the weakest area Milk out concretions and curette: gram stain. Irrigate with – TREATMENT-repair laceration with silicone intubation penicillin. Oral antibiotics - tetracycline, PCN, Sulfonamide. Apply 1% iodine solution to involved area. Canaliculotomy with curettage

41 42

7 5/11/21

ACQUIRED LACRIMAL DRAINAGE ACQUIRED LACRIMAL DRAINAGE DISORDERS DISORDERS

§ CANALICULAR DISORDERS § CANALICULAR DISORDERS – DACRYOCYSTITIS Acutely presents with – TREATMENT- Acute Dacryocystitis Avoid swelling and erythema with distension of the irrigation and probing. Warm compresses. lacrimal sac below the medial canthal tendon, Topical antibiotics are of limited value Oral Can spread into the orbit and cause orbital antibiotics: bactrim, keflex, augmentin cellulitis. Parenteral antibiotics for severe infection. Incise and drain if pyocele-mucocele is localized and pointing. DCR when quiet. May resolve with system open

43 44

ACQUIRED LACRIMAL DRAINAGE ACQUIRED OBSTRUCTION OF DISORDERS NASOLACRIMAL DUCT

§ CANALICULAR DISORDERS – INVOLUTIONAL STENOSIS – DACRYOLITHS Caused by infection with § Most common in women. Actinomyces or Candida or long term – Naso-orbital trauma. – Dacryocystitis. epinephrine use. Remove dacryolith at time of – Radioacitve Iodine for thyroid cancer Chronic sinus disease. DCR. – Lacrimal plugs – Neoplasm

45 46

ACQUIRED OBSTRUCTION OF ACQUIRED OBSTRUCTION OF NASOLACRIMAL DUCT NASOLACRIMAL DUCT

– TREATMENT – LACRIMAL SAC TUMORS § SILICONE INTUBATION: Works in some cases of § Lacrimal sac tumors are rare and most commonly partial obstruction present in the fifth decade. § DACRYOCYSTORHINOSTOMY: creates an – CLINICAL COURSE: Epiphora, chronic dacryocystitis, anastomosis between lacrimal sac and nasal cavity lacrimal sac mass (above medial canthal tendon), epistaxis, bleeding from the puncta, ulceration. Malignant lesions through a bony ostium. spread to regional lymph nodes and metastasize. – SURGICAL TECHNIQUE – DACRYOCYSTOGRAM: filling defect with delayed draining § External, Internal(endoscopic), or Transnasal laser of contrast. CT SCAN: mass in lacrimal sac area. approaches TRANSNASAL LASER DCR-less long- term success § BALLOON DACRYOPLASTY-good for partial obstruction -Mitomycin C may have usefulness in preventing fibrosis

47 48

8 5/11/21

ACQUIRED OBSTRUCTION OF ACQUIRED OBSTRUCTION OF NASOLACRIMAL DUCT NASOLACRIMAL DUCT

– LACRIMAL SAC TUMORS – LACRIMAL SAC TUMORS § TREATMENT: SURGICAL EXCISION Wide excision § Benign epithelial tumors: of sac, canaliculi and nasolacrimal duct. If malignant, – SQUAMOUS CELL PAPILLOMAS excision includes a lateral rhinotomy. Radiation: – TRANSITIONAL CELL lymphoid lesions and extensive epithelial Malignant epithelial tumors: malignancies.. – SQUAMOUS CELL CARCINOMA – TRANSITIONAL CELL CARCINOMA – ADENOCARCINOMA Non-epithelial tumors: – FIBROUS HISTIOCYTOMA – LYMPHOMA MELANOMA

49 50

Key Statistics The Key

§ 46% Lacrimal Obstruction § Dry eyes is the most common cause of § 22% multifactorial tearing. § 22% reflex tearing § 10% eyelid malposition § Do not Assume that the etiology is a single factor. § About 50/50 – male/female – Unilaterial/Bilaterial § Keep your thoughts open to many other – Over the age of 60 things

51 52

Reference

1. Product insert and Websites

Thank you

53 54

9