Retinal detachment
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Retinal detachment is a serious eye condition
that almost always leads to blindness if not treated
promptly.
The retina is the light-sensitive tissue that
lies smoothly against the inside back wall of your
eye. Underneath the retina is the choroid, a thin
layer of blood vessels that supplies oxygen and
nutrients to the retina. Retinal detachment occurs
when the retina separates from this underlying layer
of blood vessels. Unless the detached retina is
surgically reattached, you may permanently lose your
vision in the affected eye.
Treatment
Surgery
is the only effective therapy for a retinal tear, hole or detachment. If
a tear or a hole is treated before detachment develops or if a retinal
detachment is treated before the central part of the retina (macula)
detaches, you'll probably retain much of your vision.
Surgery for retinal tears
When a retinal tear or hole hasn't yet progressed to detachment, your
eye surgeon may suggest one of two outpatient procedures:
photocoagulation or cryopexy. Both methods can usually prevent the
development of a retinal detachment. Healing typically takes 10 to 14
days. Your vision may be blurred briefly following either procedure.
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Photocoagulation.
During photocoagulation your surgeon directs a laser beam through a
special contact lens to make burns around the retinal tear. The
burns cause scarring, which usually holds the retina to the
underlying tissue. This procedure requires no surgical incision, and
it causes less irritation to your eye than does cryopexy.
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Cryopexy.
With cryopexy your surgeon uses intense cold to freeze the retina
around the retinal tear. After a local anesthetic numbs your eye, a
freezing probe is applied to the outer surface of the eye directly
over the retinal defect. This freezing produces an inflammation that
leads to the formation of a scar — similar to that resulting from
photocoagulation — which seals the hole and holds the retina to the
underlying tissue. Cryopexy is used in instances where the tears are
more difficult to reach with a laser, generally along the retinal
periphery. Your eye may be red and swollen for some time after
cryopexy.
Surgery for retinal detachment
Three surgical procedures are commonly used to repair a retinal
detachment: pneumatic retinopexy, scleral buckling and vitrectomy. Some
of these procedures are done in conjunction with cryopexy. The purpose
of these treatments is to close any retinal holes or tears and to reduce
the tug on the retina from a shrinking vitreous. Your particular
condition will determine which procedure your eye surgeon recommends.
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Pneumatic
retinopexy.
This surgical technique is used for an uncomplicated detachment when
the tear is located in the upper half of the retina. It's done on an
outpatient basis using local anesthesia. First, your surgeon
performs cryopexy around the retinal tear. Then, to soften the eye,
he or she withdraws a small amount of fluid from the space between
the domed clear area at the front of your eye (cornea) and the
colored part of your eye (iris). Next, your surgeon injects a bubble
of expandable gas into the vitreous cavity. Over the next several
days, the gas bubble expands, sealing the retinal tear by pushing
against it and the detached area that surrounds the tear. With no
new fluid passing through the retinal tear, fluid that had
previously collected under the retina is absorbed, and the retina is
able to reattach itself to the back wall of your eye.
Following surgery, you may have to hold your head in a cocked position
for a few days, to make sure the gas bubble seals the retinal tear. It
takes 2 to 6 weeks for the bubble to disappear. Until the gas is gone
from your eye, you have to avoid lying or sleeping on your back. This
keeps the bubble away from your lens and reduces the risk of cataract
formation or a sudden pressure increase in your eye.
During
this time you can't travel by airplane or be at a high altitude because
a sudden drop in pressure would cause the gas bubble to expand rapidly,
resulting in dangerously high pressure in your eye. Check with your
surgeon to find out when this danger has passed.
The
success rate of pneumatic retinopexy isn't as good as that of scleral
buckling. However, it can avoid both a trip to the operating room and
the need for incisional (cutting) surgery.
The
complications of pneumatic retinopexy may include recurring retinal
detachment, excessive scar tissue formation in the vitreous and retina,
cataracts, increased pressure inside your eyeball (glaucoma), gas under
the retina, and infection. These complications are rare, but if they do
occur and go untreated, they can cause severe loss of vision. A retinal
detachment that has recurred can usually be repaired with scleral
buckling or vitrectomy.
First
your surgeon treats the retinal tears or holes with cryopexy. Then he or
she indents (buckles) the sclera over the affected area by pressing in
with a piece of silicone. The silicone material is either in the form of
a soft sponge or a solid piece. The buckle closes the tear and helps
reduce the circumference of the eyeball, thereby preventing further
vitreous pulling and separation. When you have several tears or holes or
an extensive detachment, your surgeon may create an encircling scleral
buckle around the entire circumference of your eye.
The
scleral buckle is stitched to the outer surface of the sclera. Before
tying the sutures that hold the buckle in place, the surgeon may make a
small cut in the sclera and drain any fluid that has collected under the
detached retina. The buckle remains in place for the rest of your life.
Some surgeons may choose a temporary buckle for simple retinal
detachments, using a small rubber balloon that's inflated and later
removed.
Repairing retinal detachment with scleral buckling works more than 80
percent of the time. But a reattached retina doesn't guarantee normal
vision. How well you see following surgery depends in part on whether
the macula was affected by the detachment before surgery, and if it was,
for how long a period. Your sight isn't likely to return to normal if
the macula was detached. Even if the macula wasn't affected and scleral
buckling successfully repairs your retina, you have a 10 percent chance
of losing some vision due to wrinkling or puckering of the macula.
If the
first operation fails, your doctor can usually try to reattach the
retina with one or more additional operations. Additional surgery
increases the rate of successful reattachment to more than 90 percent.
Although scleral buckling is generally successful, sometimes — in
approximately 5 percent to 10 percent of the procedures — the retina
fails to reattach to the choroid. This is often due to the formation of
scar tissue on the retinal surface. Scar tissue present even before the
operation can pull on the retina and prevent it from reattaching. The
pull of scar tissue that forms after the operation can cause the retina
to separate again after having been attached during surgery. This
usually happens 1 to 2 months following surgery.
This
condition is treated by removing the scar tissue with a procedure called
a vitrectomy and redoing the scleral buckling. In some complicated
cases, the surgeon injects air, other gases or silicone oil into the
vitreous cavity to push the retina back against the wall of the eye.
Eventually your eye absorbs the air or gas and replaces it with fluid
that the eye normally produces. Silicone, however, doesn't get absorbed
and has to be removed once the retina is reattached and healed
completely.
Complications occur infrequently in scleral buckling and can result in
the need for more surgery, the loss of some or all vision in the
involved eye, or in rare instances, the loss of that eye. Complications
include: bleeding under the retina or into the vitreous cavity,
glaucoma, and double vision (diplopia).
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Vitrectomy.
Occasionally, bleeding or inflammation clouds the vitreous and
blocks the surgeon's view of the detached retina. In other instances
scar tissue makes it impossible to repair a retinal detachment with
pneumatic retinopexy or scleral buckling alone. In these situations
a procedure called vitrectomy can remove the clouded vitreous or
scar tissue.
Your
surgeon accomplishes this with a variety of delicate instruments passed
into the eyeball through small openings in the sclera. These instruments
include a light probe that illuminates the inside of your eye, a cutter
to remove vitreous or scar tissue, and an infusion tube that replaces
the volume of removed tissue with a balanced salt solution to maintain
the normal pressure and shape of the eye.
After
completing the vitrectomy, your surgeon performs the scleral buckling
procedure and may fill the inside of your eye with air, gas or silicone
oil to help seal the retina against the wall of your eye.
Vitrectomy surgery typically lasts 1 to 2 hours but may take much longer
in more complex cases. The complex cases are often done under general
anesthesia, and shorter procedures are usually performed under local
anesthesia.
Following surgery, you may experience some discomfort and a scratchy
sensation in your eye. Severe pain is unlikely. If it occurs, let your
surgeon know immediately. You can expect your eye to be red, swollen,
watery and slightly sore for up to a month following any surgery for
retinal detachment. Wearing an eye patch may provide some relief. Your
doctor may also prescribe antibacterial or dilating eyedrops to help the
healing process. You'll have to avoid strenuous activities during this
time. It'll take about 8 to 10 weeks for your eye to heal fully. Then
your doctor will examine your eyes to assess your postoperative vision
and, if you wear eyeglasses, determine whether you need a new
prescription.
Your
vision may take many months to improve following surgery to repair a
complicated retinal detachment. Some people don't recover any lost
vision.
The
complications of vitrectomy are similar to those for other types of
retinal detachment surgery. They include a retinal tear, re-detachment
of the retina, a cataract or an infection. Any of these complications
can lead to partial or complete loss of vision in the affected eye or,
rarely, loss of the eye itself. How much vision you retain depends on
the severity of the detachment.
Retinal detachment
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