Retinal Tear and Retinal Detachment

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Retinal Tear and Retinal Detachment

The retina is essentially a thin sheet of light-sensitive nerve tissue lining the eye’s back wall, much like wallpaper. However, due to a common condition called posterior vitreous detachment (PVD), normal aging can endanger your retina. PVD targets the vitreous (or vitreous gel or humor), a clear, jelly-like gel that maintains the eye’s shape and provides light with a clear pathway to the retina. Over time, the vitreous shrinks and sticks to the retina, pulling it away from the eyewall and leading to the development of retinal tears.

A tear can create an opening, allowing vitreal fluid to leak behind the retina. As more fluid seeps in, the retina’s pushed and separates from the eye wall. Eventually, it completely detaches and moves out of its proper place; this is known as a retinal detachment. Contrary to popular belief, retinal tears and detachments don’t only occur in those who’ve experienced trauma. These conditions are very common, and generally, they occur through no fault of the patient.

Demographics

Retinal tears and detachment can affect any age group, male or female. Typically, within two months of retinal tear symptoms’ onset, 10 percent of affected eyes develop subsequent retinal tears. If you have a new retinal tear, your risk for a detachment is about 70 percent.

There’s no way to predict who might develop a retinal tear or when it may occur. And while PVD is the most common cause, other risk factors include: eye injury or trauma; previously having a retinal tear or detachment in your other eye; family history of retinal tears or detachment; having weak retinal areas, as seen during an eye exam; and having undergone eye surgery for cataracts or glaucoma.

Myopia is also a risk factor for retinal tears and detachment. Myopic eyes are shaped longer, which stretches and thins the retina, increasing tearing risks. The worse your myopia, the greater your chances of retinal detachment development. Another risk factor is lattice degeneration, in which patches of the peripheral (side) retina thins, and the vitreous develops abnormal adhesion, making tearing more likely. Individuals with lattice degeneration are about 10 times more likely to develop a detachment.

Additionally, certain inflammatory conditions and infections, particularly viral, are associated with higher retinal detachment risks. In some cases, no definite cause for detachment can be identified.

Retinal Detachment

Across the population, retinal detachment occurs in approximately 1 out of every 7,000 people. There are three specific types of retinal detachment:

• Rhegmatogenous retinal detachment, the most common form, results from a small retinal tear or break. It may occur due to PVD, myopia, eye injuries and eye surgery.
• Tractional retinal detachment develops when scar tissue forms on your retina, pulling it away from the eyewall. It is usually due to diabetic retinopathy, which damages retinal blood vessels, leading to scarring.
• Exudative retinal detachment involves fluid building up behind your retina, but without tears or breaks. If enough fluid gets trapped, your retina pushes away from the eyewall. Among the risk factors are eye tumors, injuries or trauma, diseases causing eye inflammation, and age-related macular degeneration (AMD).

Clinical Appearances & Symptoms

Generally, retinal tears and detachments are painless. Retinal tears may be asymptomatic and only discovered during a routine eye exam. But they typically present with such visual symptoms as:

• Sudden onset of floaters, tiny, solidified particles that slowly drift in front of the retina. They may look like small moving specks, cobwebs, squiggly lines or really anything.
• Sudden flashes of light (photopsia), which may occur first thing in the morning and fade throughout the day, or appear in the dark. They may look like streaks of light or bursts of lightning.
• If the torn retina is associated with some bleeding, your vision may become hazy.
• If the tear has led to a retinal detachment, there may be a fixed shadow or dark spot in your visual field.

If you experience any of these symptoms, seek immediate help from an ophthalmologist, or you may risk permanent vision loss in the affected eye.

When the vitreous gel pulls on the retina, the most common result is a gradual release of the gel and resolution of symptoms. The flashes often disappear completely, while floaters tend to linger. Occasionally, the traction occurs near a blood vessel, resulting in sheering of the blood vessels and bleeding into the vitreous cavity. Or, you may experience a different type of floaters, caused by blood cells floating in the liquefied vitreous gel, which may be severe enough to cause temporary blindness.

Left alone, fluid will generally continue to accumulate under the retina and peel it off the eyewall. Early on, you may notice a shadow in your peripheral vision. As time progresses, the shadow gets closer to the macula, the center of vision, and if left untreated, the macula detaches.

Retinal detachment is critical because it is a potentially blinding disease. The retina depends on two blood supplies to function properly and enable vision: one within the retina, and one on the back eye wall. A detached retina is separated from this second blood supply and its nerve tissue is starved of oxygen and nutrition. The longer it’s detached, the more nerve cells ultimately die. Therefore, it’s very important to try to repair a retinal detachment before any macular involvement, which often results in permanent visual loss or symptoms.

Once the macula detaches, it’s still important to reattach it to restore as much vision as possible. After a detachment is repaired and the blood supply is restored, cells often recover. However, dead cells cannot be replaced, and this is responsible for potential permanent visual loss.

Diagnosis

Should you suspect any retinal tear or detachment signs, you should quickly schedule an eye exam. While symptoms may be due to another cause, the sooner you’re properly diagnosed, the sooner your retinal specialist can provide the optimal treatment.

Your ophthalmologist will conduct a detailed, dilated examination to identify the extent of the retinal detachment, find any tears, and plan surgical repair. And, they’ll look for any complicating conditions, such as lattice degeneration. Your ophthalmologist may perform scleral depression, where gentle pressure is applied to the eye, with the use of a 3-mirror lens. If the retinal view’s obstructed, such as from a hemorrhage (excess bleeding), an ophthalmic ultrasound may be needed.

Treatment

As retinal tears may be asymptomatic, they can be monitored, and may even heal on their own. But if treatment is needed, most often, you’ll have an in-office procedure, usually laser surgery or cryotherapy, a freezing technique. Both effectively seal tears and properly secure the retina, helping to prevent full detachments. There’s little discomfort, but as additional tears may develop, continuous monitoring is required.

Treatment may reduce the risk of tears progressing to a retinal detachment to about one percent. The technique depends upon three factors: finding, sealing, and supporting the retinal tear(s). Your specific treatment may depend on such factors as:

• Your age and health
• The tears’ number and locations
• The detachment size
• Your degree of nearsightedness
• The presence of lattice degeneration, vitreal hemorrhage, a natural lens or cataract surgery.

Common Retinal Detachment Procedures

Basically, there are three surgical procedures for retinal detachment:

Pneumatic Retinopexy

With this, the simplest technique, the retinal specialist localizes any tears or detachment, seals the tears with cryotherapy or lasers, as the fluid under the retina disappears. A small gas bubble is injected into the vitreous, through the sclera, the eye’s white part, which disappears on its own in about two weeks.

You’ll be positioned for several days to allow the retina to heal properly. If you have such problems as back or neck problems, advanced age, or young children, this procedure is not recommended. But you can expect a quick healing period, with a general success rate of around 85 percent. It’s most successful if you have one tear located in the retina’s top half, or you have natural lenses, as opposed to having undergone cataract surgery.

Scleral Buckle

With this procedure, the retinal specialist localizes any retinal tears and detachment, sealing tears with cryotherapy or laser treatment. A small piece of silicone sponge or semi-hard plastic is placed on the sclera, holding the eye against the retina, and putting it back into contact with the eye wall. The material may be wrapped around the eye to provide 360-degree retinal support, resulting in improved outcomes, with single surgery success rates close to 90 percent.

Afterward, your eye may be left bruised, red and swollen, and it may take up to six weeks to heal completely. But once healed, your eye will look completely normal. While the buckle is generally left on the eye permanently, it may occasionally be removed due to an associated infection, or if it works its way through the surface tissues (known as extrusion). You may experience increased myopia, and there may be a discrepancy in the size of objects. Occasionally, there may be an eyelid droop or lack of full eye movement. Bleeding, while rare, is generally the worst complication.

Vitrectomy

A vitrectomy involves the complete removal of the vitreous through tiny openings made in the eyewall. The fluid is drained from under the retina, and any tears are treated with lasers. The entire vitreous cavity is filled with a gas bubble, which usually lasts 1-8 weeks, to press on the tears and allow the laser to seal, as the retina heals.

Single-surgery success rates approach 95 percent, and this procedure is particularly valuable in patients who have previously had cataract surgery. For those who haven’t had cataract surgery, cataract progression is quicker following a vitrectomy. While rare, complications may include bleeding and infection. For some patients, particularly high-risk cases, vitrectomy is often combined with scleral buckling to improve success rates.

Redetachment

One of the most common retinal detachment surgery complications is redetachment of the retina. Generally, this occurs due to:

1. New retinal tears can develop after surgery, causing fluid to enter and start the detachment process all over again. Additional surgery is necessary in these cases.

2. Scar tissue can grow on the retinal surface following detachment repair. This causes the scar tissue to pull on the retina, opening up old or new tears, and eventually, redetachment. This requires advanced surgical techniques, and the visual results are sometimes disappointing. Typically, a vitrectomy is performed to access the retinal surface and peel off the scar tissue, as the retina lays flat against the eye wall. An oil bubble, rather than gas, is often injected into the eye to achieve long-term support. Once the retina’s stabilized, you may need a second surgery if the bubble has to be removed.

With modern techniques, over 98 percent of retinal detachments are successfully reattached. But while early intervention leads to better outcomes, any detachment can lead to blindness. Patients with extensive scar tissue or detachments left untreated for a long time tend to have the worst outcomes.