Retinal Detachment

Other Names: Detached retina, and retinal tear.

Definition of Retinal Detachment

Retinal Detachment is a separation of the retina (the inner nervous
tunic of the eye) from the choroid (the middle, vascular tunic of the
eye) in the back of the eye, usually resulting from a hole in the retina
that allows the vitreous humor (fluid) to leak between the choroid and
the retina.
Description of Retinal Detachment
The retina is a thin, transparent tissue of light-sensitive nerve fibers
and cells. It covers the inside wall of the eye the same as wallpaper
covers the walls of a room.
Most retinal detachments are caused by the presence of one or more
small tears or holes in the retina. Normal aging can sometimes cause
the retina to thin and deteriorate, but more often shrinkage of the
vitreous body, the clear gel-like substance which fills the center of the
eye, is responsible for deterioration and retinal tears.
The vitreous is firmly attached to the retina in several places around
the back wall of the eye. As the vitreous shrinks, it may pull a piece of
the retina away with it, leaving a tear or hole in the retina.
Though some shrinkage of the vitreous body occurs naturally with
aging and usually causes no damage to the retina, abnormal growth of
the eye (sometimes a result of nearsightedness), inflammation or
injury, may also cause the vitreous to shrink. In most cases, a
significant change in the structure of the vitreous body occurs before
the development of a retinal detachment.
Once a retinal tear is present, watery fluid from the vitreous space may
pass through the hole and flow between the retina and the back wall of
the eye. This separates the retina from the back of the eye and causes
it to "detach." The part of the retina that is detached will not work
properly and there will be a blindspot in vision.

Causes and Risk Factors of Retinal Detachment

Retinal detachment will affect about one out of 10,000 people each
year in the U.S. It is a serious eye problem that may occur at any age,
though usually it occurs in middle-aged or older individuals.
It is more likely to develop in people who are nearsighted, or whose
relatives had retinal detachments. A hard, solid blow to the eye may
also cause the retina to detach. Severe trauma to the eye, such as a
contusion or a penetrating wound, may be the cause, but in the great
majority of cases, retinal detachment is the result of internal changes
in the vitreous chamber associated with aging, or less frequently, with
inflammation of the interior of the eye.
It should be noted that there are some retinal detachments that are
caused by other diseases, such as tumors, severe inflammations or
complications of diabetes. These so-called secondary detachments do
not have holes or tears in the retina, and treatment of the disease
which caused the retinal detachment is the only treatment which may
allow the retina to return to its normal position.
Symptoms of Retinal Detachment
In most cases, retinal detachment develops slowly. The first symptom
is often the sudden appearance of a large number of spots floating
loosely in the eye. The person may not seek help, because the number
of spots tends to decrease during the days and weeks before
detachment. The person may also notice a curious sensation of
flashing lights as the eye is moved.
Because the retina does not contain sensory nerves that relay
sensations of pain, the condition is painless.
Detachment usually begins at the thin peripheral edge of the retina
and extends gradually beneath the thicker, more central areas. The
person perceives a shadow that begins laterally and grows in size,
slowly encroaching on central vision. As long as the center of the retina
is unaffected, the vision when the person is looking straight ahead, is
normal; but when the center becomes affected, the eyesight is
distorted, wavy and indistinct. If the process of detachment is not
halted, total blindness of the eye ultimately results. The condition does
not spontaneously resolve itself.
Treatment of Retinal Detachment
All cases of retinal detachment should be referred to an
ophthalmologist as soon as possible.
If the retina is torn and retinal detachment has not yet occurred, a
detachment may be prevented by prompt treatment. Treatment is
aimed at closing retinal tears (so as to facilitate reattachment of the
retina). Once the retina becomes detached, it must be repaired
surgically.
Certain types of uncomplicated retinal detachment are now being
treated by the technique of pneumatic retinopexy. The retina is
reattached by injection of expansile gas into the vitreous cavity (a
procedure that can be performed under localanesthesia as an office
procedure) followed by careful positioning of the head. Once the retina
is reattached, the retinal tear can be sealed by laser photocoagulation
or cryotherapy. Occasionally, removal of vitreous and internal
tamponade of the retina with air, expansile gases or even silicone oil,
is necessary.
About 80 percent of all uncomplicated cases can be cured with one
operation; an additional 15 percent will need repeated operations and
the remainder will never reattach. The prognosis is worse if the macula
is detached or if the detachment is of long duration.
Without treatment, retinal detachment often becomes total within six
(6) months. Unfortunately, due to continual shrinkage of the vitreous
and the development of fibrous growths on the retina, not all retinas
can be reattached. If the retina cannot be reattached, then the eye will
continue to lose sight and ultimately become blind.

What is retinal detachment?

The retina is the light-sensitive layer of tissue that lines the inside of the eye and sends visual messages
through the optic nerve to the brain. When the retina detaches, it is lifted or pulled from its normal position. If
not promptly treated, retinal detachment can cause permanent vision loss.

In some cases there may be small areas of the retina that are torn. These areas, called retinal tears or
retinal breaks, commonly occur when there is traction on the retina by the vitreous gel inside the eye. In a
child’s eye, the vitreous has an egg-white consistency and is firmly attached to certain areas of the retina.
Over time, the vitreous gradually becomes thinner, more liquid and separates from the retina. This is known
as a posterior vitreous detachment (PVD).

PVDs are typically harmless and cause floaters in the eye; but in some cases, the traction on the retina may
create a tear. Retinal tears frequently lead to detachments as fluid seeps underneath the retina, causing it
to separate and detach.

What are the symptoms of retinal detachment?

Symptoms include a sudden or gradual increase in either the number of floaters, which are little "cobwebs"
or specks that float about in your field of vision, and/or light flashes in the eye. Another symptom is the
appearance of a curtain over the field of vision. A retinal detachment is a medical emergency. Anyone
experiencing the symptoms of a retinal detachment should see an eye care professional immediately.

What are the different types of retinal detachment?

There are three different types of retinal detachment:

1. Rhegmatogenous [reg-ma-TAH-jenous] -- A tear or break in the retina allows fluid to get under the
retina and separate it from the retinal pigment epithelium (RPE), the pigmented cell layer that
nourishes the retina. These types of retinal detachments are the most common.
2. Tractional -- In this type of detachment, scar tissue on the retina's surface contracts and causes the
retina to separate from the RPE. This type of detachment is less common.
3. Exudative -- Frequently caused by retinal diseases, including inflammatory disorders and
injury/trauma to the eye. In this type, fluid leaks into the area underneath the retina, but there are
no tears or breaks in the retina.
Who is at risk for retinal detachment?
A retinal detachment can occur at any age, but it is more common in people over age 40. A retinal
detachment is also more likely to occur in people who:

1. Are extremely nearsighted

2. Have had a retinal detachment in the other eye
3. Have a family history of retinal detachment
4. Have had cataract surgery
5. Have other eye diseases or disorders, such as retinoschisis, uveitis, degenerative myopia, or lattice
degeneration
6. Have had an eye injury

Detection and Diagnosis

Retinal detachments are usually found because the patient calls the doctor’s office with a symptom
mentioned above. It is critical that these problems are reported early, because early treatment can greatly
improve the chance of restoring vision.

The doctor makes the diagnosis of a retinal detachment after thoroughly examining the retina
with ophthalmoscopy. The retinal surgeon’s first concern is to determine whether the macula (the center of
the retina) is attached. This is critical because the macula is responsible for the central vision. Whether or
not the macula is attached determines the type of corrective surgery required and the patient’s chances of
having functional vision after the operation.

Ultrasound imaging of the eye is also very useful for the doctor to see additional detail of the condition of the
retina from several angles.

How is retinal detachment treated?

Small holes and tears are treated with laser surgery or a freeze treatment called cryopexy. These
procedures are usually performed in the doctor's office. During laser surgery tiny burns are made around the
hole to "weld" the retina back into place. Cryopexy freezes the area around the hole and helps reattach the
retina.

Retinal detachments are treated with surgery that may require the patient to stay in the hospital. Pneumatic
retinopexy is one type of procedure to reattach the retina. After numbing the eye with a local anesthesia, the
surgeon injects a small gas bubble into the vitreous cavity. The bubble presses against the retina, flattening
it against the back wall of the eye. Since the gas rises, this treatment is most effective for detachments
located in the upper portion of the eye. In order to manipulate the bubble into the ideal location, the surgeon
may ask the patient to keep his or her head in a specific position. The gas bubble slowly absorbs over the
next 2-6 weeks.

In some cases a scleral buckle, a tiny synthetic band, is attached to the outside of the eyeball to gently push
the wall of the eye against the detached retina. The scleral buckle is not visible and remains permanently
attached to the eye. This technique of reattaching the retina may elongate the eye, causing
nearsightedness.
If necessary, a vitrectomy may also be performed. During a vitrectomy, the doctor makes a tiny incision in
the sclera (white of the eye). Next, a small instrument is placed into the eye to remove the vitreous, a gel-like
substance that fills the center of the eye and helps the eye maintain a round shape. Gas is often injected to
into the eye to replace the vitreous and reattach the retina; the gas pushes the retina back against the wall
of the eye. During the healing process, the eye makes fluid that gradually replaces the gas and fills the eye.
With all of these procedures, either laser or cryopexy is used to "weld" the retina back in place.

With modern therapy, over 90 percent of those with a retinal detachment can be successfully treated,
although sometimes a second treatment is needed. However, the visual outcome is not always predictable.
The final visual result may not be known for up to several months following surgery. Even under the best of
circumstances, and even after multiple attempts at repair, treatment sometimes fails and vision may
eventually be lost. Visual results are best if the retinal detachment is repaired before the macula (the center
region of the retina responsible for fine, detailed vision) detaches. That is why it is important to contact an
eye care professional immediately if you see a sudden or gradual increase in the number of floaters and/or
light flashes, or a dark curtain over the field of vision.