Retinal Tears and Retinal Detachment

Retinal detachment describes an emergency situation in which a thin layer of tissue (the retina) at the back of the eye pulls away from its normal position.

Retinal detachment separates the retinal cells from the layer of blood vessels that provides oxygen and nourishment. The longer retinal detachment goes untreated, the greater your risk of permanent vision loss in the affected eye.

Warning signs of retinal detachment may include one or all of the following: the sudden appearance of floaters and flashes and reduced vision. Contacting an eye specialist (ophthalmologist) right away can help save your vision.

Symptoms

Retinal detachment itself is painless. But warning signs almost always appear before it occurs or has advanced, such as:

• The sudden appearance of many floaters — tiny specks that seem to drift through your field of vision
• Flashes of light in one or both eyes (photopsia)
• Blurred vision
• Gradually reduced side (peripheral) vision
• A curtain-like shadow over your visual field

When to see a doctor

Seek immediate medical attention if you are experiencing the signs or symptoms of retinal detachment. Retinal detachment is a medical emergency in which you can permanently lose your vision.

Causes

Vitreous gel, the clear material that fills the eyeball, is attached to the retina in the back of the eye. As we get older, the vitreous may change shape, pulling away from the retina. If the vitreous pulls a piece of the retina with it, it causes a retinal tear. Once a retinal tear occurs, vitreous fluid may seep through and lift the retina off the back wall of the eye, causing the retina to detach or pull away.

Vitreous fluid normally shrinks as we age, and this usually doesn’t cause damage to the retina. However, inflammation (swelling) or near-sightedness (myopia) may cause the vitreous to pull away and result in retinal detachment.

There are three different types of retinal detachment:

• Rhegmatogenous: These types of retinal detachments are the most common. Rhegmatogenous detachments are caused by a hole or tear in the retina that allows fluid to pass through and collect underneath the retina, pulling the retina away from underlying tissues. The areas where the retina detaches lose their blood supply and stop working, causing you to lose vision.

The most common cause of rhegmatogenous detachment is aging. As you age, the gel-like material that fills the inside of your eye, known as the vitreous, may change in consistency and shrink or become more liquid. Normally, the vitreous separates from the surface of the retina without any complications — a common condition called posterior vitreous detachment (PVD). One complication of this separation is a tear.

As the vitreous separates or peels off the retina, it may tug on the retina with enough force to create a retinal tear. Left untreated, the liquid vitreous can pass through the tear into the space behind the retina, causing the retina to become detached.

• Tractional. This type of detachment can occur when scar tissue grows on the retina’s surface, causing the retina to pull away from the back of the eye. Tractional detachment is typically seen in people who have poorly controlled diabetes or other conditions.
• Exudative. In this type of detachment, fluid accumulates beneath the retina, but there are no holes or tears in the retina. Exudative detachment can be caused by age-related macular degeneration, injury to the eye, tumours or inflammatory disorders.

Risk factors

The following factors increase your risk of retinal detachment:

• Aging — retinal detachment is more common in people over age 50
• Previous retinal detachment in one eye
• Family history of retinal detachment
• Extreme near-sightedness (myopia)
• Previous eye surgery, such as cataract removal
• Previous severe eye injury
• Previous other eye disease or disorder, including retinoschisis, uveitis or thinning of the peripheral retina (lattice degeneration)

Diagnosis

Your doctor may use the following tests, instruments and procedures to diagnose retinal detachment:

• Retinal examination. The doctor may use an instrument with a bright light and special lenses to examine the back of your eye, including the retina. This type of device provides a highly detailed view of your whole eye, allowing the doctor to see any retinal holes, tears or detachments.
• Ultrasound imaging. Your doctor may use this test if bleeding has occurred in the eye, making it difficult to see your retina.

Your doctor will likely examine both eyes even if you have symptoms in just one. If a tear is not identified at this visit, your doctor may ask you to return within a few weeks to confirm that your eye has not developed a delayed tear as a result of the same vitreous separation. Also, if you experience new symptoms, it’s important to return to your doctor right away.

Treatment

Surgery is almost always used to repair a retinal tear, hole or detachment. Various techniques are available. Ask your ophthalmologist about the risks and benefits of your treatment options. Together you can determine what procedure or combination of procedures is best for you.

Retinal tears

When a retinal tear or hole hasn’t yet progressed to detachment, your eye surgeon may suggest one of the following procedures to prevent retinal detachment and preserve vision.

• Laser surgery (photocoagulation). The surgeon directs a laser beam into the eye through the pupil. The laser makes burns around the retinal tear, creating scarring that usually “welds” the retina to underlying tissue.
• Freezing (cryopexy). After giving you a local anaesthetic to numb your eye, the surgeon applies a freezing probe to the outer surface of the eye directly over the tear. The freezing causes a scar that helps secure the retina to the eye wall.

Both of these procedures are done on an outpatient basis. After your procedure, you’ll likely be advised to avoid activities that might jar the eyes — such as running — for a couple of weeks or so.

Retinal detachment

If your retina has detached, you’ll need surgery to repair it, preferably within days of a diagnosis. The type of surgery your surgeon recommends will depend on several factors, including how severe the detachment is.

• Injecting air or gas into your eye. In this procedure, called pneumatic retinopexy, the surgeon injects a bubble of air or gas into the centre part of the eye (the vitreous cavity). If positioned properly, the bubble pushes the area of the retina containing the hole or holes against the wall of the eye, stopping the flow of fluid into the space behind the retina. Your doctor also uses cryopexy during the procedure to repair the retinal break.

Fluid that had collected under the retina is absorbed by itself, and the retina can then adhere to the wall of your eye. You may need to hold your head in a certain position for up to several days to keep the bubble in the proper position. The bubble eventually will reabsorb on its own.

• Indenting the surface of your eye. This procedure, called scleral buckling, involves the surgeon sewing (suturing) a piece of silicone material to the white of your eye (sclera) over the affected area. This procedure indents the wall of the eye and relieves some of the force caused by the vitreous tugging on the retina.

If you have several tears or holes or an extensive detachment, your surgeon may create a scleral buckle that encircles your entire eye like a belt. The buckle is placed in a way that doesn’t block your vision, and it usually remains in place permanently.

• Draining and replacing the fluid in the eye. In this procedure, called vitrectomy, the surgeon removes the vitreous along with any tissue that is tugging on the retina. Air, gas or silicone oil is then injected into the vitreous space to help flatten the retina.

Eventually the air, gas or liquid will be absorbed, and the vitreous space will refill with body fluid. If silicone oil was used, it may be surgically removed months later.

Vitrectomy may be combined with a scleral buckling procedure.

After surgery your vision may take several months to improve. You may need a second surgery for successful treatment. Some people never recover all of their lost vision.

Coping and support

Retinal detachment may cause you to lose vision. Depending on your degree of vision loss, your lifestyle might change significantly.

You may find the following ideas useful as you learn to live with impaired vision:

• Get glasses. Optimize the vision you have with glasses that are specifically tailored for your eyes. Request safety lenses to protect your better-seeing eye.
• Brighten your home. Have proper light in your home for reading and other activities.
• Make your home safer. Eliminate throw rugs and place coloured tape on the edges of steps. Consider installing motion-activated lights.
• Enlist the help of others. Tell friends and family members about your vision problems so they can help you.
• Get help from technology. Digital talking books and computer screen readers can help with reading, and other new technology continues to advance.
• Check into transportation. Investigate vans and shuttles, volunteer driving networks, or ride shares available in your area for people with impaired vision.
• Talk to others with impaired vision. Take advantage of online networks, support groups and resources for people with impaired vision.