Retinal Detachment
Retinal detachment is a serious condition where the thin, light-sensitive layer of tissue at the back of the eye, known as the retina, becomes separated from its underlying supportive tissue. This separation can lead to significant vision loss and is a notable cause of blindness globally. Retinal detachment can occur at any age, but it is most prevalent among individuals over 40, particularly those with specific risk factors such as previous retinal detachment, eye injuries, or certain eye diseases. There are three primary types of retinal detachment: rhegmatogenous, which is caused by tears allowing fluid to seep underneath the retina; tractional, resulting from scar tissue pulling on the retina; and exudative, where fluid accumulates without tears, often due to underlying diseases.
Treatment for retinal detachment has evolved significantly, with modern surgical techniques showing success rates of approximately 90%. Early detection and timely intervention are crucial for preserving vision, as the longer the retina remains detached, the less likely complete visual recovery is. Current surgical options include laser therapies, gas bubble injections, scleral buckling, and vitreous surgery, each tailored to the specific nature and severity of the detachment. As understanding and technology improve, the outlook for those affected by retinal detachment has become much more favorable compared to historical standards.
On this Page
Retinal Detachment
Inside the eye chamber, a thin light-sensitive membrane called the retina is attached to the wall. Any tear or detachment of that delicate layer can cause loss of vision. It is a major source of blindness throughout the world. Retinal detachment occurs at any age, though most commonly in those over forty years of age and those with risk factors.
There are three different types of retinal detachment: Rhegmatogenous, the most common form of detachment, occurs when the break permits fluid to get between the retina and the retinal pigment epithelium, a layer of cells that provides nutrients to the retina. The less common tractional detachment is caused by scar tissue contraction on the retinal surface that initiates separation from the retinal pigment epithelium. In exudative detachment there are no tears or breaks, but fluid seeps under the retina, separating it from the retinal pigment epithelium. It is most often caused by disease or inflammatory disorders or injury to the eye.
Brief History
The first ophthalmoscope was invented by German physician Hermann von Helmholz in 1850, with a subsequent diagnosis of a retinal tear made in 1853 by fellow German Ernst Adolf Coccius, who described the progression of the separation. Various treatment ideas emerged throughout the nineteenth century, primarily based on rest, binding the eyes and other techniques to prevent ocular movement (molds, weights, and atropine to name a few). Surgical intervention was largely based on reducing vitreous and or subretinal fluid and immobilization of the patient for long periods.
Prior to the beginning of the twentieth century, successful treatment of retinal detachment was mainly a matter of luck, with a dismal 5 percent healing rate. For the most part, victims were condemned to a loss of vision or total blindness. Part of the problem was that ophthalmologists believed the tear or detachment was the result of the condition and not the cause. Swiss ophthalmologist Jules Gonin pioneered a technique much resisted by his peers: he reattached the damaged membrane by means of direct cauterization. The cautery bonded the tear to the underlying choroid and retinal pigment epithelium. It was several years later that his technique and principle were accepted lauded by the international community.
Over time, the ophthalmologic community has come to recognize risk factors. Retinal damage is more likely in those who have already had a retinal detachment in the other eye. Those who have undergone cataract surgery are at greater risk, as are those who are more than slightly nearsighted or who have a close relative diagnosed with a retinal detachment. Eye injury as well as an eye disorder or disease (including degenerative myopia, lattice degeneration, retinoschisis, and uveitis) also increase the occurrence rate of retinal displacement or tear.
Treatment options have changed dramatically, even from the beginning of this century. There are two primary modes that now exist for small holes and tears: laser and cryopexy (freezing), which are performed in the physician’s office. Other procedures may require hospitalization. However, gone are the days where patients were required to lie supine for extended periods of time.
Overview
Surgery is considered the most reliable and cost-effective treatment for retinal detachment, with other treatments remaining significantly more costly and showing insufficient evidence-based success. Unlike the early days of treatment with a 5 percent cure rate, current surgical techniques have 90 percent successful outcomes. Early detection and prompt treatment are high priorities, and timely management can preserve vision by securing the retina before it separates totally. The more prolonged the duration of detachment, the less likely it is that full visual acuity can be restored.This urgent nature of repairs is independent of whether it is a small tear or the beginning of a major detachment. A tear is just a stepping stone into the realm of retinal separation.
Current surgical techniques fall under one of several categories, the choice of which is dependent on the nature of the damage and comfort level of the surgeon. Retinopexy is the attachment of the retina by use of a laser, and pneumatic retinopexy, which is the injection of a gas bubble into the vitreous, then positioning the patient so that the bubble is over the tear, exerting pressure. The gas closes the break and forces reabsorption of the underlying subretinal fluid. A second step utilizes laser and/or cryopexy to form a chorioretinal seal at the break.
Scleral buckling is the application of external pressure on the globe of the eye by means of a device (sponge, silicone, semihard plastic, or rubber) sewn to the sclera, which flattens out the eye and shortens the distance between the separated retina and the underlying layers. This is commonly done in conjunction with laser or cryopexy to bond the retina to the wall, since buckling alone will not prevent the tear from recurring.
Vitreous surgery removes the vitreous fluid and replaces it with saline or other fluid after the retina is repaired. Some situations are in conjunction with pneumatic retinopexy. This technique can reduce scar tissue as well as blood that does not clear. Intraocular tamponade is the insertion of a fluid other than saline to replace the vitreous. The location of the detachment is the determining factor in molecular weight, viscosity, specific gravity, and surface tension of the fluid. Intraocular tamponade is most often done in tandem with other procedures, such as laser and or cryopexy repair.
Bibliography
Besharse, Joseph C., and Dean Bok. The Retina and Its Disorders. Oxford: Academic Press, 2011. Print.
Clark, Antony, et al. "Risk for Retinal Detachment After Phacoemulsification." Archives of Ophthalmology 130.7 (2012): 882–88. Print.
Fineman, Mitchell S., and Allen C. Ho. Retina. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2012. Print.
Kreissig, Ingrid, ed. Primary Retinal Detachment: Options for Repair. Heidelberg: Springer, 2005. Print.
Pournaras, Constantin, et al. "Surgical and Visual Outcome for Recurrent Retinal Detachment Surgery." Journal of Ophthalmology 2014 (2014): 1–6. Web. 8 Jan. 2016.
Rogers, Adam H., and Jay S. Duker. Retina. Philadelphia: Mosby Elsevier, 2008. Print.
Soubrane, Gisèle, and Gabriel Coscas. "Pathogenesis of Serous Detachment of the Retina and Pigment Epithelium." Retina (2013): 618–23. Print.
Yorston, D., and S. Jalali. "Retinal Detachment in Developing Countries." Eye 16.4 (2002): 353–58. Print.