Diseases
Overview
Age-Related Macular Degeneration
Diabetic Retinopathy
Retinal Vein and Artery Occlusions
Flashes of Light and Floaters
Retinal Tears and Retinal Detachments
Macular Pucker (Epiretinal Membrane)
Macular Hole
Vitreomacular Traction
Uveitis (Inflammation in the Eye)

Retinal Tear and Rhegmatogenous Retinal Detachment

What is a Retinal Tear or Detachment?
Inside the eye, the retina lines the interior wall and the vitreous gel fills the main body. When the eye forms, the gel is adherent to the surface of the retina but, as a normal process of aging, the vitreous begins to degrade and consolidate causing it to shrink and liquefy. Eventually this process causes the vitreous gel to separate from the retina and form a posterior vitreous detachment (PVD). Tears in the retina occur when the vitreous gel pulls too strongly on an area of weak retina or in an area that is abnormally adherent. If a tear occurs, it is typically far in the peripheral retina and will not affect the vision. However, fluid can migrate through the opening and cause the retina to separate and detach from the wall of the eye. Retinal detachments cause vision loss and require surgery to treat. If the retinal tear is identified early, it can be treated to prevent a retinal detachment. 
 
What are the symptoms of a Retinal Tear or Detachment?
As the vitreous gel separates from the retina it can pull on the retina, causing stimulation that is experienced as a flash of light, like a spark or lightning strike. When the vitreous gel consolidates and separates from the retina it can cause a shadow that is seen as a floater. New onset of flashes and floaters can indicate an active vitreous detachment and warrants a full, dilated examination to ensure the retina has not been damaged. If the retina is torn there may be no other symptoms, but if fluid migrates through a retinal tear it will cause the retina to separate from the wall of the eye and detach and will start with a decrease in peripheral vision with the appearance of a veil or shadow. As the detachment progresses, the shadow can progress from peripheral to central and can eventually take up the entire visual field.
 
Who is at risk of developing a Retinal Tear or Detachment?
The vitreous separating from the retina is an age related process that almost everyone will experience making most people at some risk of developing a retinal tear or detachment. The majority of people do not have any symptoms and the process goes unnoticed. With flashes and floaters there is a 10-12% chance of having an associated retinal tear.  If the eye is highly nearsighted or myopic, has had prior surgery, undergone trauma, or has a family history of retinal tear or detachment the risk is higher. Since the risk is related to the way the eye was made and aging, not much can be done to reduce the risk of developing a retinal tear or detachment. Having a thorough, dilated exam can identify areas of retina that may be at higher risk and may benefit from prophylactic treatment.
 
How can a Retinal Tear be treated?
To treat a retinal tear, laser photocoagulation is performed to burn the retina around the opening of the tear; the burn will scar and seal the retina preventing fluid from migrating through and detaching the retina. Immediately after the laser procedure, the retina does not have additional strength; only after the laser burn starts to scar does the seal form. In the retina, the laser scar has full strength at 10-14 days. During this time the retina is still at risk of detaching, though every day the risk decreases as the scar develops increasing strength. It is advised to avoid strenuous and vigorous activity during this time to minimize the risk of developing a retinal detachment.

How is a Retinal Detachment repaired?
Surgery is required to repair a retinal detachment and there are several procedures commonly used, these are: scleral buckle, pars plana vitrectomy, and pneumatic retinopexy.
 
Scleral buckle surgery has been widely used since the 1950’s. In this procedure, a silicone band is placed around the outside of the eye to indent the wall of the eye toward the retina. This provides the retina a solid foundation to reattach to and relieves any potential traction on the retina. Scleral buckle surgery can be performed by itself or in combination with a pars plana vitrectomy. When performed alone, cryotherapy is applied to the wall of the eye beneath the retinal tear to freeze the tissue. This freezing causes a scar to form to permanently adhere the retina to the wall of the eye and seal the retinal tear.  
 
Pars plana vitrectomy involves small incisions made in the wall of the eye and, using a microscope for viewing, small instruments are used to remove the gel in the eye. Careful attention is paid to remove all vitreous traction from the retinal tear. Once the gel is removed the retina is flattened and then laser photocoagulation is applied around the retinal tear. This laser burns the retina and will form a scar that permanently seals the retina.  To hold the retina in place while the scar is forming, a gas bubble is placed inside the eye. To properly position the gas bubble and hold the retina in place it is important to hold the head in the face down position and positioning may be required up to 2 weeks after surgery depending on the damage to the retina. The gas bubble will be resorbed over time and replaced with the eye’s natural fluid but can take up to 2 months to completely resolve. During this time it is very important to avoid air travel, high altitudes, and nitrous oxide anesthesia as these can cause an increase in the size of the gas bubble that will result in elevated eye pressure and potentially vision loss. If the retina requires more support that the gas bubble can offer or if there is a need for air travel, a silicone oil bubble can be used. The oil has the same function as the gas, to hold the retina in place during healing. After the retina has healed and stabilized the oil is removed with another surgery.  Depending on the damage the silicone oil may be left in indefinitely to support the retina. 
 
Pneumatic retinopexy is an office based procedure during which a gas bubble is injected into the eye to seal the retinal tear. After sterilizing the surface of the eye, a small bubble of gas is injected into the eye and head is positioned in a way that the bubble will float to cover the retinal tear. Once the tear is covered, the fluid can absorb and flatten the retina back to the wall of the eye. When the retina has flattened, cryotherapy or laser photocoagulation can be applied to seal the retinal tear. The head must maintain position until the scar tissue forms completely, proper positioning is essential for the success of the procedure. 

Each procedure has specific advantages and disadvantages and can be used alone or in combination to repair retinal detachments.
Laser Retinopexy burns the retina around the tear to form a scar that seals the retina in place


What will the vision be like after Retinal Detachment?
After successful reattachment surgery, the visual recovery is variable. The most important factor is if the central retina, the macula, is detached. When the retina detaches, some cells will have permanent damage that cannot be repaired while others will improve after reattachment. The majority of the recovery happens during the first month but the vision can improve for up to 1 year after surgery.
 
Dr Kruti Dajee Dr Jawad Qureshi Dr Johnathan Warminski