Retinal Detachment

The retina is a thin layer of light-detecting cells located at the back of the eye. It sits flush against the inside back wall of the eye. The eye focuses incoming light on the retina, the retina detects the light, and then the retina sends the image to the brain via the optic nerve. If the retina becomes detached however, it no longer lies flush against the back of the eye. This results in blurred and distorted vision. If the retina becomes damaged, permanent vision loss can result. Therefore, retinal detachment can pose a serious threat to the vision.

By far the most common situation leading to a detachment occurs when the vitreous gel (the substance which fills the inside of the back of the eye) contracts and in doing so tugs or pulls on the retina. This contraction is called a posterior vitreous separation or posterior vitreous detachment (PVD) and usually occurs naturally with time but can also occur suddenly with trauma.

Several other conditions are also associated with retinal detachment, including diabetes, sickle cell disease, scar tissue (for example, from previous retinal detachment), trauma, inflammatory and autoimmune disorders, certain cancers, retinal degenerations (for example, lattice), and high myopia.

There are three types of retinal detachment:

Rhegmatogenous: A tear or break can develop in the retina, often in the far periphery. This is usually a result of vitreo-retinal traction, where pulling (tractional) forces in the vitreous gel of the eye on the retina causes the tear or break in the retina. Liquid from within the eye can then seep in through the tear and begin to detach the retina. As a result, the retina no longer sits flush against the back of the eye and is instead partially loose and displaced forward. This is the most common type of retinal detachment. The tear or break most often develops following a posterior vitreous separation (mentioned above). Though the vast majority of vitreous separations occur without any retinal damage, a few will result in tears. Eyes which are highly nearsighted (myopic) or have a condition called lattice degeneration are particularly vulnerable to retinal tears.

Tractional: Scar tissue or abnormal membranes can develop on or within the retina. If these abnormal tissues contract they may place traction on the retina, pulling it away from its normal position. Such scars and membranes are associated with various conditions, including diabetes, sickle cell disease, trauma, and previous retinal detachment.

Serous: Fluid that builds up under the retina can push the retina away from its usual position. Fluid under the retina can accumulate in a variety of conditions such as diabetes, macular degeneration, inflammatory and autoimmune disorders, and certain cancers.

Blurred vision, dim vision, and distorted vision are the most common symptoms. People often describe seeing a cloud or a curtain-like obstruction in their vision. If a detachment is confined to the periphery however, there may be no symptoms at all.

Floaters and flashing lights are commonly perceived, sometimes for days or weeks preceding the detachment.

The retinal detachment per se is typically painless, however if it is associated with inflammation or elevated eye pressure, there may be significant pain.

There are usually no signs of a retinal detachment visible from the outside. In cases with associated inflammation or elevated eye pressure, the eye may be red, but typically the eye looks normal.

Within the eye, there are signs visible to the doctor examining the eye with the aid of ophthalmoscopy equipment. There may be pigment or blood cells floating within the liquid in the front of the eye (aqueous) as seen through a slit lamp. With a dilated pupil and ophthalmoscopy (and other diagnostic methods), tears and detachments of the retina can often be visualized directly by the doctor.

One should seek care from an eye doctor as soon as possible if experiencing any of the symptoms mentioned above. Once the detachment is found, a treatment plan can be put in place. Generally, one has a better chance of a good outcome when treated early.

The eye doctor will ask for a history of prior eye disease and medical conditions that might predispose you to having a retinal detachment.

A complete eye exam, including dilation of the pupils, is performed to look for the presence and extent of a detachment. In some cases, there may be significant vitreous floaters, inflammatory cells, or blood in front of the retina, obscuring the doctor's view. In such cases, ultrasound may be used to determine if the retina detached.

Other technology, such as OCT imaging, can be helpful in studying scar tissue or membranes in tractional detachments. Fluorescein angiogram may be performed to locate the source of fluid in a serous detachment.

The goal of treatment is to reposition the retina and address any underlying causes. The choice of treatment will depend on the type, location, and size of the detachment.

Underlying conditions (inflammatory eye disease, autoimmune disorders, cancerous growths, and others) that lead to serous retinal detachments need to be treated appropriately in order to control fluid buildup.

In rhegmatogenous and tractional detachments, a surgical procedure will usually be necessary.

In the case of rhegmatogenous detachment, in addition to repositioning the retina, any tears or breaks need to be sealed. This can be achieved in various ways.

Sometimes an air bubble or gas bubble can be injected into the eye in the office (pneumatic retinopexy). The bubble gently pushes the retina back in place, and the tear(s) are sealed with either laser or with a freezing technique using a small probe (cryopexy). Following placement of the bubble, one may need to adopt a certain posture (for example, upright, or face-down) to direct the bubble in the desired direction. Avoid traveling to high altitudes or flying until your doctor gives clearance, as the bubble could expand and cause dangerously elevated eye pressure.

Because pneumatic retinopexy does not relieve vitreo-retinal traction, more extensive surgery with scleral buckling or vitrectomy or both is often necessary:

Scleral buckling, which involves placement of a silicone band around the eye, is often used for repair of retinal detachments. The band is placed around the eye (far enough back that it is not usually visible from the outside) and tightened like a belt, producing an indentation that helps relieve the pulling force coming from the vitreous. Retinal tears or breaks are surrounded by heat or freezing during surgery.

Some retinal detachments require a vitrectomy (surgical removal of the vitreous gel). Vitreo-retinal traction is thereby eliminated or reduced. Retinal tears or breaks are surrounded by laser during surgery. In addition, membranes or scar tissue can also be partially or completely removed during vitrectomy. An absorbable gas is often injected into the eye.

In complicated cases, non-absorbable silicone oil may be inserted into the eye to help push the retina into place (much like the air or gas bubble mentioned above). In this case, a second later surgery is necessary to remove the oil.

In cases of trauma, there may be need for additional surgery to repair other damaged areas of the eye.

Recovery time will depend on several factors. It often takes several weeks for the retina to be securely reattached, and sometimes months to recover vision. Close follow-up will be necessary to watch for any redetachments or other abnormalities. It is very important to review and comply with the follow-up plan and report any change in vision or other symptoms to your doctor right away.

In lattice degeneration, the eye doctor might recommend preventive fortifying vulnerable areas of the retina with laser or cryotherapy.

Tight blood sugar control in diabetes can reduce the chances of developing tractional detachments from fibrovascular membranes that develop in proliferative diabetic retinopathy.

Highly myopic individuals and those with lattice degeneration should undergo routine annual dilated examinations to look for any small asymptomatic retinal breaks or tears. They can be sealed with laser early on, before they lead to a detachment.

Inflammatory eye disease, autoimmune disorders, cancerous growths, and other conditions that predispose to serous retinal detachments need careful management to prevent recurrences.

If the detached portion of the retina lies outside of the central part of the retina (the macula), and the retina is successfully reattached, the prognosis is excellent.

However, if the central portion of the retina is detached, the prognosis for good vision is guarded. Vision may be noticeably compromised if the central retina was detached for a long period of time prior to treatment because the retina's health depends on nutrients from underlying layers of tissue (retinal pigment epithelium, choroid). This is why time is of the essence in diagnosing a detachment and creating a treatment plan.

If scar tissue forms in, under, or over the retina (for example, in proliferative vitreoretinopathy), there is an increased risk of redetachment in the future. These eyes warrant very close follow-up.

Diabetes, inflammatory diseases, and other underlying medical conditions should be optimally controlled or treated to minimize chances of a recurrent detachment.