Treating Retinal Detachment
If the retina has become detached and
the detachment is too large for laser
treatment or cryotherapy alone, surgery
is necessary to "re-attach" the retina.
Without some type of retinal
re-attachment surgery, vision will
almost always be lost.
Scleral Buckling
The traditional surgery for retinal
detachment is scleral buckling and is
performed in the operation room under
local or general anesthesia. In this
process, after cryotherapy is done to
seal the retinal tears, a piece of
silicone plastic is sewn onto the
outside wall of the eye (sclera) over
the site of the tear. This pushes
(buckles) the sclera in toward the
retinal tear and holds the retina
against the sclera until scarring from
the cryotherapy seals the tear.
This procedure is usually combined with
placement of an encircling silicone band
around the circumference of the eye to
lessen the pulling of the vitreous on
the retina. The surgeon may also drain
fluid from underneath the retina and
place a gas or air bubble into the
vitreous cavity. These buckles and bands
are left permanently and are not visible
from outside. Success rates for
re-attaching the retina with scleral
buckling are approximately 90-95%.
Pneumo-retinopexy
This is another type of surgery for
re-attaching the retina. Instead of
placing a buckle after cryotherapy, the
surgeon injects a gas bubble inside the
vitreous cavity of the eye. The patient
is instructed to keep his or her head in
a specific position so that the gas
bubble seals the retina tear by its
surface tension effect.
Circulation
of fluid through the tear stops and the
retina is re-attached. The gas bubble in
the eye expands for several days and
takes 2 to 4 weeks to disappear. During
this time air travel and travel to high
altitudes must be avoided, because the
gas may expand, thereby increasing the
eye pressure, and cause damage to the
optic nerve.
Vitrectomy
Occasionally, retinal detachment is so
complicated and severe that it cannot be
treated with either standard scleral
buckling surgery or pneumatic
retinopexy. Moreover scleral-buckling
surgery fails approximately 5% to 10% of
the time because excessive scar tissue
grows on the surface of the retina. This
scar tissue is very bad for the eye. It
pulls on the retina, causing it to
re-detach. Retinal re-detachment usually
occurs four to eight weeks after the
initial surgery. The vitreous pulls on
the retina, detaching it from the back
wall of the eye. The scar tissue also
puckers the retina into stiff folds,
like wrinkled aluminum foil. This
condition is called proliferative vitreo-retinopathy
(PVR). The only way to unfold and
re-attach the retina is to cut away the
vitreous and remove the scar tissue with
vitrectomy surgery and then re-attach
the retina.
The
surgeon uses a fibre-optic light to
illuminate the inside of the eye and a
variety of instruments (scissors,
forceps and laser probes). The vitreous
gel is removed as well as abnormal scar
tissue, and replaced with fluid or air.
Sometimes the natural lens or a
previously existing intraocular lens (IOL)
may have to be removed if the case is
complicated. The holes and tears are
sealed with laser, and fluid under the
retina is drained. At times, vitrectomy
is combined with placement of a scleral
buckle. Often air, gas or silicone oil
is placed in the vitreous cavity to hold
the retina in place. If silicone oil has
been used, it has to be removed at a
later date as a separate surgical
procedure.
Removing the vitreous and especially the
scar tissue from the surface of the
retina is a delicate process that
requires the surgeon to lift and peel
strands of scar tissue away from the
retina. The surgery may take many hours
in severe cases.
SutureLess Vitrectomy is also
available these days.
If the retina is successfully
re-attached, the eye will recover some
sight, and blindness will have been
prevented. However, the degree of vision
that finally returns up to six months
after successful surgery depends upon a
number of factors. Unfortunately,
success in re-attaching the retina
(anatomic success) does not always
translate into marked visual improvement
(functional success). This is because of
permanent damage to fine vision cells of
the macula. In general, there is less
visual return when the retina has been
detached for a long duration, or there
is a fibrous growth on the surface of
the retina. It should be clearly
understood that often the purpose of
surgery for PVR is to give the patient
an eye that would have some supporting
vision and could serve as a "spare tyre",
if the other eye ever loses vision
entirely.
Vitreous surgery for Primary Retinal
Detachment
Vitreous surgery is now often undertaken
for primary detachments when the tears
are very large or placed very far back (posteriorly)
on the retina, when there is a macular
hole causing detachment, or if there is
blood in the vitreous blocking a clear
view of the retina. Success rates for
these cases are much better with
vitrectomy than with scleral buckling
alone.
What are the complications of surgery?
Even though the surgery for retinal
detachment is generally successful,
certain complications can occur. They
include drooping of the upper lid and
double vision, which are temporary.
Serious complications include infection,
bleeding severe enough to interfere with
vision, glaucoma and cataract formation.
However, these complications are very
infrequent. Retinal re-detachment is the
most commonly occurring problem. If this
occurs, your surgeon will discuss the
chance that a re-operation will
successfully re-attach the retina. It is
important for the patient to know that
surgery may fail due to complications,
or simply due to the progressive nature
of the retinal disease.
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