The retina is the light-sensitive layer of tissue that lines the inside of the eye and sends visual messages through the optic nerve to the brain. When the retina detaches, it is lifted or pulled away from its normal position. If not promptly treated, retinal detachment can cause permanent vision loss. A retinal tear, hole (or break) can lead to a retinal detachment.
Symptoms include a sudden or gradual increase in the number of floaters and/or light flashes in the eye or the appearance of a curtain over the field of vision (that is loss of vision in the peripheral field of vision). A retinal detachment is a medical emergency. Anyone experiencing the symptoms of a retinal detachment should see an eye care professional immediately.
There are different types of retinal detachments. For the purpose of this guide, I will limit my discussion to the rhegmatogenous type of detachment (ie caused by a tear or break in the retina). This is the most common type of retinal detachment. I will refer to rhegmatogenous retinal detachments as RD in the rest of the text.
Who is at risk of retinal detachment?
Although anyone can experience a retinal detachment (1:10,000 people per year), people with certain eye conditions are at increased risk of retinal detachment. Risk factors for retinal detachment include:
Other eye conditions such as diabetic retinopathy can result in fibrous scar tissue forming inside the vitreous and on the surface of the retina. This scar tissue can then pull on the retina causing a tractional retinal detachment.
A less common cause of retinal detachment happens because of another condition such as inflammation or tumour in the eye. This is called an exudative or serous retinal detachment.
How is retinal detachment treated?
Small holes and tears (without RD) are treated with laser surgery or cryopexy (a freeze treatment). These procedures are usually performed in an outpatient setting (in clinic). If the holes or tears are associated with a RD, surgery is required. In general, the sooner treatment is carried out, the better the likely results, but in some cases the timing of surgery does not influence outcome (you therefore need to discuss timing of surgery with your Consultant). If retinal detachment is not treated then you will lose all the vision in the affected eye. Treatment options include:
Retinal detachments are treated with surgery that may require the patient to stay in hospital.
A pneumatic retinopexy is a relatively simple procedure performed under local anaesthesia and involves the injection of a gas bubble in the eye, and cryopexy to close the break. Depending on the size and position of the bubble, your vision may be blurred for the first few weeks. This is almost always performed as a day case procedure.
In some cases a scleral buckle, a tiny synthetic band, is attached to the outside of the eyeball to gently push the wall of the eye against the detached retina. Cryopexy or laser treatment are also necessary to seal the retinal break (or breaks). The buckle is usually not removed and is not visible once surgery is finished. The eye is red after surgery for approximately 2-4 weeks.
In most cases, retinal detachment treatment is performed through an internal approach called “vitrectomy” which involves the removal of the vitreous jelly that fills the vitreous cavity, the closure of the retinal break with laser laser or cryopexy (freezing) and the placement of a gas bubble in the vitreous cavity. Vitrectomy is almost always necessary in case of an extensive or complicated RD. Vitrectomy is performed through 3 small key holes in the sclera (white of the eye). In some cases, the vitreous cavity is subsequently filled with silicone oil (for complex RDs). The patient is usually asked to posture on his/her side or sitting up for 10 days post operatively.
Early treatment can usually improve the visual acuity of most patients with RD. Some patients, however, will need more than one procedure to repair the RD. Most procedures are performed under local anaesthesia, although an external procedure is more often performed under general anaesthesia.
Post operative care
After the surgery, your eye will feel uncomfortable. There may be some bruising and your eyelids may be sticky. You will be given eye drops to help prevent infection and to control any swelling. The discomfort will usually settle gradually over 2 weeks, and he eye usually looks white again at 4-6 weeks after surgery.
If you have had a gas bubble put into your eye, your vision will be very blurred for a while. This is only temporary. As the gas is absorbed you may see a wavy line across your vision, which is the divide between the gas and liquid content of the eye. This will slowly move and then disappear over a period of 2-3 weeks. Even without a gas bubble your vision may be blurry for a number of days possibly weeks following the surgery. Watching TV or reading using the other eye will not cause any problems.
Posturing is lying or sitting with your head in a certain position. You may be asked to do this before surgery to prevent the spread of the RD, or for approximately 10 days after surgery to improve the success of the surgery.
If you need to posture, your Consultant will explain exactly how to lie. This is usually necessary for 45 minutes every hour. If possible it would be most helpful to have someone at home to help while you are posturing.
If a gas bubble has been used, it is not safe to travel by air until the gas bubble has completely reabsorbed. If you are having any other operations/surgery, the anaesthetist must be informed that you have a gas bubble in the eye. Once any period of posturing is finished you can resume normal activities.
If you have a healthy retina then there is no treatment that can reduce the risk of a detachment. Regular eye tests are recommended to make sure your eyes are healthy.
One important cause of retinal detachment is trauma to the eye. I would therefore recommend wearing eye protection for DIY, gardening or any sport which could pose a risk of sustaining an eye injury (squash, racquetball etc…). Your Optometrist should be able to order for you the appropriate type of protective eye wear.
If you experience symptoms of flashes and floaters and the eye clinic detects a hole or tear in your retina, then this may be treated to reduce the risk of a retinal detachment developing, but not all tears or holes need treating.
Success rates of surgery
Surgery is usually successful at reattaching the retina in approximately 85% of patients. The degree to which your detailed and peripheral vision will be affected is likely to depend on how much of the retina was detached before surgery.
Most people will lose all useful vision if no operation is carried out, or if the treatment is unsuccessful. However, if the first operation does not succeed, it is usually possible to have one or more operations to re-attach the retina. At each stage, I would discuss with you the likelihood of success and the possible need to have more treatment.
If the central retina (the macula), remained attached before surgery, I would then expect the visual result to be reasonably good and for your central vision not be affected. If the macula was detached, then the visual outcome will not be as good and although the central vision may return (depending on how long was the macula detached) but it may be distorted and you may notice waviness. Most patients tend to adjust reasonably well to the central distortion.
In general the longer the detachment is left untreated and the more extensive it is, the worse the vision is likely to be after the operation. Unfortunately for some people, the operation may be successful at reattaching the retina but it may not bring back detailed central vision or areas of peripheral vision.
Most people will lose all useful vision if no operation is carried out, or if the treatment is unsuccessful. However, if the first operation does not succeed, it is usually possible to have one or more operations to re-attachthe retina. At each stage, your Consultant will discuss with you the likelihood of success and the possible need to have more treatment.
Where to seek help?
Being diagnosed with a retinal detachment can be very upsetting. You may find that you are worried about the future and how you will manage with a change in your vision. All these feelings are natural. Some people may want to talk over some of these feelings with someone outside their circle of friends or family. I would recommend that you discuss this with your Consultant or your GP. I have also included at the end of this guide contact details for the Royal College of Ophthalmologists and the RNIB. This is particularly relevant for anyone who has sustained significant loss of vision with little improvement despite surgery.
Royal College of Ophthalmologists
17 Cornwall Terrace, London NW1 4QW
Tel: 020 7935 0702
Prepared by Mr. H.J. Zambarakji FRCOphth, D.M
Consultant Ophthalmic surgeon