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Retinal detachment
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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.

  • 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.

  • 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.

  • 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.

  • Scleral buckling. This is the most common surgery for repairing retinal detachment. It's usually done in an operating room under local or general anesthesia. If you have an uncomplicated retinal detachment, this surgery may be done on an outpatient basis. 

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).

  • 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 > 1 > 2 > 3 > 4

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Last Modified : 03/15/08 02:04 AM