What is a Retinal Detachment?
A retinal detachment (torn retina) is an emergency condition in which the thin layer of tissue which contain the rods and cones (the retina) pulls away from its normal position, causing loss of vision. It often requires retinal detachment surgery. It usually arises from a retinal hole or retinal tear which allows fluid to access the potential space behind the retina.A retinal detachment can occur at any age, but is more common in people over the age of 40. Risk factors for developing a retinal detachment include:
- Myopia (near sightedness)
- Previous retinal detachment in the fellow eye
- Family history of retinal detachment
- Eye trauma
- Predisposing genetic conditions
- Uncommonly, following cataract surgery
- Other predisposing eyes diseases or disorders
What is the treatment for a retinal detachment?
Retinal detachment surgery is performed in an operating room. It can be performed while you are awake (under sedation) or while you are asleep (under general anaesthetic).
There are several types of surgery to repair a detached retina:
Below is a video of an eye operation to repair a detached retina.
Pars plana vitrectomy
This is the most common form of retinal reattachment surgery. Three small incisions are made through the sclera (the white of the eye). A microscope and a special viewing system are used to operate directly in the eye. A special instrument, called a vitrector, is used to remove the vitreous gel. This instrument aspirates the gel while simultaneously cutting it. The fluid under the retina is then drained and the retina is reattached by infusing air into the vitreous cavity. Laser is applied around the retinal tear or retinal hole to permanently seal it off. A tamponade agent is inserted to keep the retinal attached while the laser takes effect. This can either be an absorbable gas or silicone oil. The surface tension of the gas acts to seal off the retinal breaks while the laser spots are maturing. Several types of gas bubbles can be used during retinal detachment surgery, and the decision whether to use a gas bubble or silicone oil is made during the operation, depending on several characteristics of the retinal detachment. You may be asked to position your head in a specific way after surgery to position the gas bubble on the retinal breaks. The gas bubble will slowly be absorbed by your eye at different rates depending on the type of gas used. If silicone oil is placed within the vitreous cavity instead of gas, a second surgery will be required to remove the oil. Sometimes a combination of both scleral buckle and vitrectomy surgeries will be performed.
This procedure is used to treat a retinal detachment with very specific characteristics. A temporary gas bubble is injected into the vitreous cavity of the eye. The surface tension of the gas bubble acts to seal off the retinal tear or hole. Your eye can then pump out the fluid that has accumulated under the retina. The success of this procedure requires strict positioning of your head after the gas injection to ensure the bubble seals of the retinal break. The retinal tears are treated directly with cryopexy or retinal laser to prevent the detachment from the returning once the bubble is absorbed by your eye.
In this procedure, a silicone band is placed around the outside of the eye behind the insertion of the four major muscles that move the eye. The band is inert and remains in place life-long. This band indents the eye wall to move it closer to the retina. This acts to release the pulling effect of the vitreous gel on the retina to allow for closure of the retinal breaks. Cryotherapy is placed over the retinal hole or retinal tear to create a reaction which causes it to stick to the underlying tissues. Fluid is then removed from the front of the eye to decrease pressure inside the eye. Finally, a temporary gas bubble is injected into the eye, which is absorbed by the eye over time. The surface tension of the gas bubble acts to seal off the retinal tear or hole.
What is intraocular gas and silicone oil?
A gas bubble placed in the eye will gradually reabsorb over a 2 to 8 week period following retinal detachment surgery, depending of the type and concentration of gas used. As the gas bubble is reabsorbed, the vitreous cavity refills with the fluid that is naturally produced by the eye. Vision will be markedly reduced immediately after surgery since you cannot see well through a gas bubble. As the bubble is reabsorbed you will gradually see more and more. You should not expect to experience significant improvement in vision until at least six weeks after retinal detachment surgery. Final visual outcome may not be obtained for up to 2 years following the retinal detachment repair. You may not fly in an aeroplane after retinal detachment surgery (any type of air travel) or travel to high elevations until the bubble is completely gone (2 to 8 weeks, depending on the type of gas used). Some types of general anaesthetic agents must be avoided (nitrous oxide) while there is a gas bubble in the eye.
Silicone oil does not reabsorb on its own and must be removed with an additional surgical procedure. It is reserved for cases where the retinal detachment requires a long-term tamponade to heal. There are no travel restrictions with silicone oil.
How long does recovery take post retinal detachment surgery?
This depends on several factors, including the configuration of the retinal detachment and the amount of scar tissue the eye has produced. You can expect to be off work for 2 weeks. You may be expected to position your head for 5 to 7 days to allow the gas bubble or silicone oil to press against a certain part of the retina while it heals. Some floaters can be expected after the retinal detachment surgery, but these are usually transient and subside over a few weeks.
The single operation success for retinal detachment repair in an acute (no signs of chronicity) retinal detachment is approximately 85%. The reason for this is due to the scar tissue the eye produces when it heals following a retinal detachment. The visual recovery time (sight) following a retinal detachment repair is not always predictable and the final visual result will only be known several months following surgery.
It is recommended to refrain from all exercise for 2 weeks following a retinal detachment repair. During this time, head positioning and rest are very important for a favourable outcome. Between week 2 and week 4 following retinal detachment surgery, you can gradually start resuming normal activities, and 1 month after surgery all activity restrictions are usually lifted.
You will be given eye drops to take home. These include steroid eye drops to control inflammation and antibiotic eye drops to prevent infection.
Driving after a retinal detachment repair and its requirements will differ depending on the type and configuration of the detachment, and whether gas or silicone oil is used to treat the detachment. This will be discussed with you in detail before the operation.
Is laser used to treat a retinal detachment?
Yes, laser is used during the retinal detachment surgery to create an adhesion between the retina and underlying tissues around the retinal tear or retinal break. The retinal laser is used in conjunction with surgery and is not performed in isolation during a retinal detachment repair. In some cases (like in a scleral buckle procedures) cryotherapy is used instead of laser. The laser takes approximately one week to create an adhesion with the underlying tissue, and this is the reason a tamponade agent (gas bubble or silicone oil) is placed in the eye, allowing the retinal laser to take full effect so the retina may heal.
Read Dr Lapere’s published study A rare case of perfluoro-n-octane in the orbit following vitreoretinal surgery on the Canadian Journal of Ophthalmology website.
Download Dr Lapere’s abstract study Vitrectomy and injection of subretinal tissue plasminogen activator for subfoveal hemorrhage: Prognostic factors and clinical outcomes.