Retinal Tears and Detachments

Introduction
The eye is roughly the size of an egg or a small ping pong ball. Light enters the eye through a small opening in the front (the pupil). The light passes through various clear structures in the eye. The bulk of the inside of the eye is filled with a clear jelly-like substance called vitreous. This "vitreous" is similar to the egg white inside of the egg. The retina lines the inside of the eye just as you have the membrane lining the inside of the egg.

Normal Retina (fluorescein angiogram) Click to Enlarge

Normal Retina (fundus photo - same patient) Click to Enlarge

The Retina
The retina is the light sensitive membrane that lines the inside of the eye and converts light energy into nerve impulse energy. This nerve energy is then transmitted to the brain via the optic nerve. The retina is composed of two basic areas. The central portion of the retina directly in the back provides us with fine (reading) vision and is called the macula. The remaining portion of the retina provides us with vision off to the sides, up and down. Over 95% of the retina accounts for this peripheral vision.

Retinal Detachment
A retinal detachment exists when this light sensitive membrane which lines the inside of the eye separates or peels from the underlying inner wall of the eye. The area of the retina that has peeled from the wall of the eye is thereby detached and does not work properly. The detatched retina becomes separated from its underlying nourishing blood supply and the retina may suffer irrevocable damage as a result. If the central vision area of the retina (macula) is detached, then central vision will be lost.

Retinal Detachment (fundus photo) Click to Enlarge

Retinal Detachment (fundus photo) Click to Enlarge

Retinal Detachment (fundus photo) Click to Enlarge

Rhegmatogenous Retinal Detachment
A rhegmatogenous retinal detachment occurs when a hole or tear develops in the retina. This opening in the retina allows the clear jelly-like material (vitreous) filling the eye to percolate through the tear and separate the retina from the wall of the eye. This is the most common form of retinal detachment. Rhegmatogenous retinal detachments can be seen in people who are near sighted, who have hard cataract surgery, or in people who have suffered eye trauma.

Horseshoe Tear (fundus photo) Click to Enlarge

Treated Tear (fundus photo) Click to Enlarge

Tractional Retinal Detachment
A tractional retinal detachment is said to exist when bands of scar tissue or membranes actually pull the retina from the wall of the eye, tenting the retina up. This type of detachment is commonly seen in patients with advanced diabetic changes in the eye.

Exudative Retinal Detachment
Leakage from underneath the retina causes fluid to accumulate beneath the retina and causes an exudative retinal detachment. This disorder is most commonly seen when there are tumors or inflammatory conditions in the eye.

Symptoms of Retinal Detachment
In any individual patient the symptoms of retinal detachment may vary and can include some or all of the following: Flashes of light, "Floaters" or specks that may drift in your vision, a curtain or veil of gray or black that may obscure a portion of your field of vision, and blurred vision are common symptoms of retinal detachment.

Treatment of Rhegmatogenous Retinal Detachment
The goal of treatment in rhegmatogenous retinal detachments is to seal up the hole or holes that caused the problem and get the fluid out from under the retina. This allows the retina to reposition itself (reattach) against the wall of the eye and thereby regain its nourishing blood supply and restore vision. Fortunately, over 80 to 90 percent of retinal detachments can be repaired with only one procedure. The following are the most commonly used methods to repair a retinal detachment.

Scleral Buckle
Scleral buckling entails sewing a piece of solid silicone or silicone sponge to the outside wall of the eye. This material may be sewn to a section of the outside eye wall, or it may go around the eye for 360 degrees forming a "belt" around the eye. This silicone material indents the wall of the eye (buckles) and pushes the wall of the eye closer to the retinal tear. The tear is treated with freezing therapy which causes local tissue damage. This damage heals by scarring, and the scarring seals the tear and prevents further fluid from getting under the retina. The fluid that has already gotten under the retina is either absorbed or drained from under the retina and the retina is thereby reattached. This type of surgery can be done under local anesthesia with the patient sedated but awake, or it can be done under general anesthesia when the patient is asleep.

Vitrectomy
Pars plana vitrectomy is a method which entails placing tiny instruments inside of the eye ball and removing the jelly like substance (vitreous) inside and replacing it with a salt solution. This procedure allows us to operate on the retina directly, from the inside of the eye. One may or may not do a vitrectomy in conjunction with scleral buckling. Sometimes it is necessary to place a gas bubble inside of the eye. The patient may have to maintain a certain head position for several days or weeks after surgery in order to achieve the appropriate reattachment. This procedure can be done under local or general anesthesia.

Pneumatic Retinopexy
In certain retinal detachments, when the offending tear or tears are located in the upper half of the retina, it is sometimes possible to reattach the retina with this technique. This procedure is frequently done in the office and eliminates the need for the patient to go to the operating room. A local injection of anesthetic is placed in the eye socket. A small gas bubble is placed in the eye itself. The tear is treated with either freezing or laser therapy. The patient then positions their head so that the injected gas bubble goes to the area of the tear, closing the tear and pushing the tear against the wall of the eye. The previous freezing or laser treatment causes local tissue damage. This tissue damage heals by scarring and when the tear is touching the wall of the eye, the tear seals as a result of this scarring. The patient is required to maintain the proper head position for approximately one week after the surgery.

Laser Surgery
In certain selected cases it may be advisable to "wall off" the detachment to prevent the retinal detatchment from spreading within the eye. In cases such as these, a barrier of scar tissue forms as a result of laser (or freezing treatment) and the detachment remains fixed in its position. This technique is most often used when the area of detachment is way off on the side and may not even be noticed by the patient. This technique may also be used when the patient is not capable to undergo any of the above noted procedures.

Surgical and Visual Results
Results of retinal reattachment surgery are divided into two categories: anatomic results and visual results. Most forms of retinal detachment have an anatomic success rate of approximately 90%. This means that we can put the retina back into place about 90% of the time. Sometimes more than one procedure is required to achieve the appropriate anatomic success. The visual result is dependent upon the patient's pre-operative vision. If the macula (center vision area) is attached prior to the surgery, then there is an approximately 90% chance that the patient will have the same vision post operatively. However, if the macula is detached prior to the surgery and thereby away from its underlying nourishing blood supply, then there may be irrevocable permanent visual loss even in the face of successful reattachment surgery.

Treatment of Exudative Retinal Detachments
These types of detachments are caused by tumors or inflammatory conditions in the eye. The treatment is directed at determining the nature of the underlying problem and then treating the specific underlying problem. This treatment may require medical and/or surgical therapy, as well as extensive medical evaluations. The anatomic and visual outcomes are dependent upon the underlying cause of the problem.

Treatment of Tractional Retinal Detachments
The treatment of these types of detachments is directed at the offending scar tissue which is pulling the retina away from the wall of the eye. Most frequently a vitrectomy is required to cut away the scar tissue and allow the tented retina to settle back against the wall of the eye. Occasionally, it may be necessary to perform scleral buckling surgery in addition to the vitrectomy to enhance the reattachment process. The anatomic as well as the visual results are dependent upon the pre-operative status of the retina as well as the underlying problem causing the retinal detachment.

Retinal Disorders

Diabetic Retinopathy
Age-Related Macular Degeneration
Retinal Vein and Artery Occlusions
Macular Hole
Macular Pucker
Retinal Tears and Detachments
What is Fluorescein Angiography?
What is Photodynamic Therapy?
What is ICG Angiography?
What is optical coherence tomography?

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