PhytoScience - Article

Retinal detachment

 

The retina is the light-sensitive tissue that lies smoothly against the inside back wall of your eye and sends messages to your brain through your optic nerve. Underneath the retina is the choroid; a thin layer of blood vessels that supplies oxygen and nutrients to the retina. Retinal detachment occurs when the retina separates from the choroid.

Retinal detachment is a medical emergency, and time is critical. Unless the detached retina is promptly surgically reattached, this condition can cause permanent loss of vision in the affected eye.

The good news is that warning signs often appear before retinal detachment occurs, and early diagnosis and treatment by a specialist trained in eye diseases and conditions (ophthalmologist) can save your vision.

Signs and symptoms

Retinal detachment is painless, but visual symptoms almost always appear before it occurs. Warning signs of retinal detachment include:

  • The sudden appearance of many floaters; small bits of debris in your field of vision that look like spots, hairs or strings and seem to float before your eyes
  • Sudden flashes of light in one or both eyes
  • A shadow or curtain over a portion of your visual field
  • A sudden blur in your vision

If you experience any of these signs or symptoms, seek urgent evaluation by an ophthalmologist. In most cases, these signs and symptoms don't indicate a serious problem. However, if you do have a retinal tear or retinal detachment, prompt treatment is necessary to preserve your vision.

Causes

Retinal detachment may be caused by trauma, advanced diabetes or an inflammatory disorder. But it often occurs spontaneously, as a result of changes in the jelly-like vitreous that fills the vitreous cavity of your eye.

As you age, your vitreous may change in consistency and partially liquefy or shrink. Eventually, the vitreous may sag and separate from the surface of the retina; a common condition called posterior vitreous detachment (PVD), or vitreous collapse. This occurs to some extent in most people's eyes as they age.

PVD usually doesn't cause serious problems, but it can cause visual symptoms. If the vitreous pulls on the retina as it shifts and sags, you may see flashes of sparkling lights (photopsia) when your eyes are closed or when you're in a darkened room. The shifting or sagging vitreous may also cause the appearance of new or different floaters in your field of vision. These spots, specks, hairs and strings are actually small clumps of gel, fibers and cells floating in the vitreous. And what you're seeing are the shadows that this material casts on the retina.

Common floaters appear gradually over time and, although they're annoying, they are rarely a problem and hardly ever require treatment. However, the sudden onset of floaters can signal the development of a retinal tear, particularly when accompanied by flashes of light. This occurs when the pulling of the sagging vitreous becomes strong enough to tear the retina, leaving what looks like a small, jagged flap.

Retinal detachment occurs when vitreous liquid (vitreous humor) leaks through the tear and accumulates underneath the retina. Leakage can also occur through tiny holes where the retina has thinned due to aging or other retinal disorders. Less commonly, fluid can leak directly underneath the retina, without a tear or break.

As liquid collects, areas of the retina can peel away from the underlying choroid. Over time these detached areas may expand, like wallpaper that, once torn, slowly peels off a wall. The areas where the retina is detached lose their ability to see.

Most retinal tears caused by PVD lead to retinal detachment if left untreated. Detachments that go undetected and untreated can progress and eventually involve the entire retina, causing complete loss of vision.

Risk factors

Your risk of developing a detached retina generally increases with age simply because the vitreous changes as you grow older. The condition tends to affect more whites than blacks. The following factors also increase your risk of retinal detachment:

  • Previous retinal detachment in one eye
  • A family history of retinal detachment
  • Extreme nearsightedness (myopia)
  • Previous eye surgery, such as cataract removal
  • Previous severe eye injury or trauma
  • Weak areas in the periphery of your retina

When to seek medical advice

If you experience any of the warning signs of retinal detachment, see your ophthalmologist right away. Prompt medical attention is necessary to save your vision.

Unfortunately, many people don't appreciate the urgency of the warning signs of retinal detachment, and they tend to put off seeing a doctor in the hope that symptoms will disappear. In some cases, symptoms temporarily diminish only to be followed by a loss of vision over the next few days or weeks, caused by advanced retinal detachment. This condition can't always be successfully repaired with surgery, and vision loss may be permanent. So it's best to see your doctor at the earliest signs of retinal detachment.

Screening and diagnosis

An ophthalmologist can look carefully at your eye with special instruments to determine what's causing your visual symptoms. It's possible to tell if you have a retinal hole, tear or detachment by looking at your retina with an ophthalmoscope; an instrument with a bright light and powerful lens that allows your doctor to view the inside of your eyes in great detail and in three dimensions.

If blood in your vitreous cavity prevents a clear view of the retina, your ophthalmologist might also use sound waves (ultrasonography) to assess your retina. Ultrasonography is a painless test that sends sound waves through your eye to bounce off the retina. The returning sound waves create an image on a monitor that allows your doctor to determine the condition of the retina and other structures inside your eye. This test usually provides the information your doctor needs to determine whether your retina is detached.

Treatment

Surgery is the only effective therapy for a retinal tear, hole or detachment. Your ophthalmologist can tell you about the various risks and benefits of your treatment options. Together you can determine what treatment is best for you.

If a tear or a hole is treated before detachment develops or if a retinal detachment is treated before the central part of the retina (macula) detaches, you'll probably retain much of your vision.

Surgery for retinal tears
When a retinal tear or hole hasn't yet progressed to detachment, your eye surgeon may suggest an outpatient procedure, which can usually prevent retinal detachment and preserve almost all vision. Healing typically takes about two weeks. Your vision may be blurred briefly following either of these procedures:

  • Laser surgery (photocoagulation). During photocoagulation your surgeon directs a laser beam through a special contact lens or through a special ophthalmoscope to make burns around the retinal tear. The burns cause scarring, which usually "welds" the retina to the underlying tissue. This procedure requires no surgical incision, and it causes less irritation to your eye than does cryopexy.

  • Freezing (cryopexy). With cryopexy your surgeon uses intense cold to freeze the retina around the retinal tear. After a local anesthetic numbs your eye, a freezing probe is applied to the outer surface of the eye directly over the retinal defect. This freezes the area around the hole, and the resulting delicate scar helps secure the retina to the eye wall. Cryopexy is used in instances where the tears are more difficult to reach with a laser, generally along the retinal periphery. Your eye may be red and swollen for some time after cryopexy.

Surgery for retinal detachment
Doctors commonly use one of three surgical procedures to repair a retinal detachment. Some of these procedures are done in conjunction with photocoagulation or cryopexy. The purpose of these treatments is to close any retinal holes or tears and to reduce the tug on the retina from a shrinking vitreous. The type, size and location of any retinal detachment will determine which procedure your eye surgeon recommends. In general, these surgeries can successfully treat more than 90 percent of cases of retinal detachment, although a second treatment is sometimes necessary.

  • Pneumatic retinopexy. This surgical technique is generally used for a relatively uncomplicated detachment when the tear is located in the upper half of the retina. It's usually done on an outpatient basis under local anesthesia. Often your surgeon initially will treat the retinal tear with cryopexy. Then, to soften the eye, he or she may withdraw a small amount of fluid from the space between the domed clear area at the front of your eye (cornea) and the colored part of your eye (iris). Next, your surgeon injects a bubble of expandable gas into the vitreous cavity. Over the next several days, the gas bubble expands, sealing the retinal tear by pushing against it and the detached area that surrounds the tear. With no new fluid passing through the retinal tear, fluid that had previously collected under the retina is absorbed, and the retina is able to reattach itself to the back wall of your eye.

    You may have to hold your head in a cocked position for a few days after surgery, to make sure the gas bubble seals the retinal tear. And it may take several weeks for the bubble to disappear completely. Until the gas is gone from your eye, avoid lying or sleeping on your back. This keeps the bubble away from your lens and reduces the risk of cataract formation or a sudden pressure increase in your eye.

    During this time, you can't travel by airplane or be at a high altitude because a sudden drop in atmospheric or cabin pressure would cause the gas bubble to expand rapidly, resulting in a dangerously high pressure in your eye. The gases used in general anesthesia can cause similar problems. Talk to your anesthesiologist if you have to undergo general anesthesia for some unrelated problem. Check with your eye surgeon to find out when these dangers have passed.

    The success rate of pneumatic retinopexy isn't as good as that of another procedure; scleral buckling. However, it can avoid both a trip to the operating room and the need for more invasive surgery (incisional surgery).

    Complications of pneumatic retinopexy may include recurring retinal detachment, scar tissue formation in the vitreous and retina, cataracts, increased pressure inside your eyeball (glaucoma), gas under the retina, and infection. These complications are rare, but if they do occur and go untreated, they can cause severe loss of vision. A retinal detachment that has recurred can usually be repaired with another surgical procedure.

  • Scleral buckling. This is the most common surgery for repairing retinal detachment. It's usually done in an operating room under local or general anesthesia. If you have an uncomplicated retinal detachment, this surgery may be done on an outpatient basis.

    First your surgeon treats the retinal tears or holes with cryopexy. Then he or she attaches a tiny silicone band (buckle) to the white of your eye (sclera) over the affected area. The silicone material is in the form of either a soft sponge or a solid piece. The buckle closes the tear and helps reduce the traction on the retina, which prevents further vitreous pulling and separation. When you have several tears or holes or an extensive detachment, your surgeon may create an encircling scleral buckle around the entire circumference of your eye.

    The scleral buckling material is stitched to the outer surface of the sclera. Before tying the sutures that hold the buckle in place, the surgeon may make a small cut in the sclera and drain any fluid that has collected under the detached retina. The buckle usually remains in place for the rest of your life. Some surgeons may choose a temporary buckle for simple retinal detachments, using a small rubber balloon that's inflated and later removed.

    A reattached retina doesn't guarantee normal vision. How well you see after surgery depends in part on whether the central part of the retina (macula) was affected by the detachment before surgery, and if it was, for how long a period. Your sight isn't likely to return to normal if the macula was detached.

    Although scleral buckling is generally successful, sometimes the retina fails to reattach. Most commonly this is because of scar tissue that forms on the retinal surface. Scar tissue present even before the operation can pull on the retina and prevent it from reattaching. The pull of scar tissue that forms after the operation can cause the retina to separate again after having been attached during surgery. This usually happens in the first couple of months after surgery.

    This condition is treated by removing the scar tissue with a procedure called vitrectomy. It may also be treated with another scleral buckling operation. In some complicated cases, the surgeon injects air, other gases or silicone oil into the vitreous cavity to push the retina back against the wall of the eye. Eventually the eye absorbs the air or gas and replaces it with fluid that the eye normally produces. Silicone oil, however, isn't absorbed and needs to be removed once the retina is reattached and healed completely.

    Complications occur infrequently in scleral buckling but can result in the need for more surgery, the loss of some or all vision in the involved eye, or in rare instances, the loss of that eye. Complications include bleeding under the retina or into the vitreous cavity, glaucoma, and sometimes scarring on the surface of the eye that can lead to problems with the muscles that control eye movements. This can cause double vision (diplopia) and may require corrective surgery.

  • Vitrectomy. Occasionally, bleeding or inflammation clouds the vitreous and blocks the surgeon's view of the detached retina. In other instances, scar tissue makes it impossible to repair a retinal detachment with pneumatic retinopexy or scleral buckling alone. In these situations, your doctor may recommend removing the clouded vitreous or scar tissue with vitrectomy; a procedure that involves making a tiny incision in the sclera of your eye.

    Your surgeon accomplishes this with a variety of delicate instruments passed into the eyeball through small openings in the sclera. These instruments include a light probe that illuminates the inside of your eye, a cutter to remove vitreous or scar tissue, and an infusion tube that replaces the volume of removed tissue with a balanced salt solution to maintain the normal pressure and shape of the eye.

    After completing the vitrectomy, your surgeon may perform a scleral buckling procedure and may fill the inside of your eye with air, gas or silicone oil to help seal the retina against the wall of your eye.

    Vitrectomy surgery typically lasts more than an hour but may take several hours in more complex cases. The complex cases are often done under general anesthesia, but shorter procedures are usually performed under local anesthesia.

    After surgery, you may experience some discomfort and a scratchy sensation in your eye. Severe pain is unlikely. If it occurs, let your surgeon know right away. You can expect your eye to be red, swollen, watery and slightly sore for up to a month following any surgery for retinal detachment. Wearing an eye patch may provide some relief. Your doctor may also prescribe antibacterial or dilating eyedrops to help the healing process. You'll have to avoid strenuous activities during this time. It takes about 10 weeks for your eye to heal fully. Then your doctor will examine your eyes to assess your vision and, if you wear eyeglasses, determine whether you need a new prescription.

    Your vision may take many months to improve after surgery to repair a complicated retinal detachment. Some people don't recover any lost vision.

    The complications of vitrectomy are similar to those for other types of retinal detachment surgery. They include a retinal tear, recurring detachment of the retina, a cataract or an infection. Any of these complications can lead to partial or complete loss of vision in the affected eye or, rarely, loss of the eye itself. How much vision you retain depends on the severity of the detachment.

Coping skills

Unless you undergo prompt surgery, retinal detachment will cause you to lose vision in the portion of your field of vision that corresponds to the detached part of the retina. Losing part of your vision can greatly change your lifestyle; affecting your ability to drive, read and do many other things you're accustomed to doing. Yet there are ways to cope with impaired vision:

  • Check into transportation. Investigate vans and shuttles, volunteer driving networks, or rideshares available in your area for people with impaired vision.

  • Get special glasses. Optimize the vision you have with glasses that are specifically prescribed for the effects of retinal detachment and keep an extra pair in the car.

  • Brighten your home. Have proper light in your home for reading and other activities.

  • Make your home safer. Eliminate throw rugs and other tripping hazards within your home.

  • Enlist the help of others. Tell friends and family members about your vision problems so that they can help you perform certain tasks and help you recognize people.

  • Talk to others with impaired vision. Take advantage of online networks, support groups and resources for people with impaired vision.

Complementary and alternative medicine

A range of dietary supplements and herbal medicines claim to offer new ways to prevent or treat diseases in general. Some supplements show promise and are slowly gaining acceptance in mainstream medicine. But the benefits and risks of many products and practices remain unproved in human clinical trials.

Unfortunately, the production of these products isn't well regulated, and the amount of active ingredient may vary from company to company, bottle to bottle or even pill to pill. Take the necessary time to research a company that provides nutritional supplements. The goal is to find reputable products produced by trustworthy companies.

Mangosteen. Mangosteen has been demonstrated to exhibit potent anti-inflammatory properties. Natural remedies that lower inflammation can be very beneficial in the prevention or treatment of disease. Mangosteen can be used as an effective adjunct with standard therapies to reduce many of the side effects and helps to speed up recovery. When indicated; mangosteen may be preferred over some medications that have adverse effects with prolonged usage.

Mangosteen juice from the whole fruit puree, consumed daily, has successfully been used to treat inflammatory conditions and has demonstrated numerous additional benefits over other natural products. More mangosteen research is needed, but current scientific studies have demonstrated promising results. Mangosteen Science