Retinal detachment

It is a severe ophthalmological disorder because undetected and untreated quickly, it leads to loss of vision. Retinal detachment occurs when the two membranes of which the retina is composed detach from each other (the light capturing retinal membrane detaches from the nourishing vascular membrane). It usually affects only one eye, but can also be bilateral, in which case it affects both eyes.

Retinal detachment can be primitive and occurs due to retinal ageing in people over 50-60 years of age. People with a family history of this disorder are also at increased risk. It can also occur as a complication in the following conditions:

• eye trauma, big pressure variations, intense physical effort
• high myopia – strong
• diabetic retinopathy
• intraocular tumors
• retinal dystrophy, retinopathy of prematurity (in preterm and especially low birth weight babies)

Retinal detachment can occur because the vitreous fluid of the eye (a gel-like fluid) withdraws from the back of the eye, pulling on the retina and tearing it. This fluid can then pull away from the back of the eye and detach the retina. Some causes and risk factors for retinal detachment include glaucoma, severe injuries, myopia, previous cataract surgery, previous retinal detachment in the other eye, or a family history of retinal detachment.

Retinal detachment is a medical emergency. There is a risk of permanent vision loss if retinal detachment is left untreated or if treatment is delayed. The success of treatment depends directly on getting to the doctor quickly, within a maximum of 24-72 hours, but also depends on where the break occurred. Treatment is strictly surgical and aims to stabilize the rupture and restore the retina. However, if the rupture has affected the central part of the retina (macula), vision will be compromised even if the surgery has been successful.

Risk factors for retinal detachment include:

• posterior vitreous detachment, which is common in older adults
• extreme myopia, which causes more pressure on the eye
• family cases of retinal detachment
• eye injury
• people over 50 are more prone to the condition
• family history of retinal detachment
• complications of cataract surgery
• diabetes mellitus

There is no pain associated with retinal detachment, but there are usually symptoms before the retina detaches. Primary symptoms include:

• blurred vision
• partial loss of vision, looking as if a curtain has been drawn across the visual field, with a shadowing effect on one side
• sudden flashes of light that appear when you look sideways
• the appearance in your visual field of small floating particles/objects that appear as black spots or strings floating in front of your eyes
• the appearance of a dark shadow (“curtain”) before the eyes. It is important to be clear from which side the “curtain” has appeared, as over time it can expand and take up the whole visual field
• the perception of bright spots like sparks or lightning
• distortion of the image of the letters viewed, of the objects, indicating that the detachment has reached the center of the retina
• sudden and irreversible loss of vision, often described by the patient as a “black curtain” often covering half of the vision
• Sometimes the patient notices that in the horizontal position of the body the vision improves because the retina is repositioned, and in the vertical position the vision defects reappear because it detaches again from the vascular membrane.

To diagnose retinal detachment, we perform a thorough examination. The following will be checked:

• vision
• eye pressure
• physical appearance of the eye
• the ability to see colors

In some cases, the retina’s ability to send impulses to your brain will be also checked by checking blood flow along the eye and specifically in the retina. We may also recommend an ultrasound of the eye.

There are several types of surgery to repair a detached retina. It can be treated by freezing, called cryotherapy, or by a laser procedure. Different types of retinal detachment require different types of surgery and different levels of anesthesia. The type of procedure your doctor prepares will depend on the severity of the retinal detachment.

A vitrectomy is a procedure performed for severe retinal detachments whereby the modified vitreous body is removed and in its place a substance (liquid silicone or special gas) is introduced that reattaches the retina to the vascular membrane from the inside. Laser coagulation is applied to delineate the broken regions and thinned segments of the retina.

The procedure can take between one and two hours, after which the patient goes home. The next day the patient is called in for a check-up, where local treatment with eye drops is recommended for 45 days, after which the patient is called in again for check-up.

There are three types of retinal detachment:

• rhegmatogenous
• tractional
• exudative

Rhegmatogenous retinal detachment

If you have a rhegmatogenous retinal detachment, you have a tear or hole in your retina. This allows fluid from the eye to leak through the opening and get behind the retina. The fluid separates the retina from the retinal pigment epithelium, which is the membrane that provides your retina with food and oxygen, causing the retinal detachment. This is the most common type of retinal detachment.

Tractional retinal detachment

Tractional retinal detachment occurs when scar tissue on the retinal surface contracts and causes the retina to pull away from the back of the eye. This is a less common type of detachment, usually affecting people with diabetes mellitus. Poorly controlled diabetes mellitus can lead to problems with the retinal vascular system, and this vascular damage can subsequently lead to the build-up of scar tissue in the eye, which could cause retinal detachment.

Exudative detachment

Exudative detachment is caused by diseases of the retina, and does not involve its actual detachment:

• Inflammatory disorder that causes fluid to accumulate behind the retina
• cancer behind the retina
• Coats disease, which causes abnormal development of blood vessels so that they leak proteins that accumulate behind the retina

Usually, the retina can be attached in one surgery, but sometimes several procedures are needed. Over 90% of retinal detachments can be repaired if diagnosed early. In retinal detachments that cannot be repaired, the patient will have either poor vision or no vision in that eye.

The success of retinal surgery depends on the severity of the detachment and how much scar tissue has formed in the retina. If the macula or central part of the retina has not been damaged, vision will be good. If the macula has been detached for a long time, some of the vision will return, but often it will be less than 20/200, which is close to blindness. It may take several months of healing after surgery to determine how much vision will return.

You may experience pain in your eyes and your vision may be blurred for a few days after the surgery. Your eye may be swollen, red or tender for several weeks. If your doctor used a gas bubble to flatten your retina during surgery, you may need to hold your head in a special position for a few days or longer. You will need 2 to 4 weeks to recover before returning to your normal activities.

There are several risks associated with retinal detachment surgery that you need to be fully aware of before starting the surgery. The most common are as follows:

• risk of infection (endophthalmitis). Whenever surgery is performed on the eye, this is a possible complication.
• risk of bleeding. Whenever surgery is performed, bleeding in the eye is a possible complication. This can occur in or around the eye. We will review any medications you are taking before surgery to make sure you are not taking blood thinners, which can increase your risk of bleeding.
• cataract progression. If you have not yet had cataract surgery, vitrectomy surgery will accelerate the progression of cataract in that eye. Although this is not always the case, you can expect to need cataract surgery within a year of vitrectomy surgery on the operated eye.

• the patient goes home immediately after the surgery, remains with a dressing on the eye until the following day, after which it will come to the clinic to have the dressing removed and to be told how to disinfect the operated eye and how to administer the treatment
• treatment will be prescribed, which the patient will follow at home for 45 days
• the operated eye will be washed with boiled and cooled water or saline and cotton pads
• touching the operated eye with a handkerchief or a dirty hand must be avoided
• bathing is allowed, but with caution not to get water in the operated eye
• physical effort should be avoided and especially pressing or rubbing the operated eye
• at any change in symptoms the patient should see a doctor immediately
• wear sunglasses during the day
• you may need to wear an eye patch or eye shield for a few days

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