RETINAL DETACHMENT. RETINAL DETACHMENT

a disorder of the eye in which the retina peels away from its underlying

layer of support tissue. Initial detachment may be localized, but without

rapid treatment the entire retina may detach, leading to vision loss and

blindness. It is a medical emergency.

The retina is a thin layer of light sensitive tissue on the back wall of the eye. The optical system of the eye

focuses light on the retina much like light is focused on the film in a camera. The retina translates that

focused image into neural impulses and sends them to the brain via the optic nerve. Occasionally,

posterior vitreous detachment, injury or trauma to the eye or head may cause a small tear in the retina.

The tear allows vitreous fluid to seep through it under the retina, and peel it away like a bubble in

wallpaper.

Eye after retinal detchment

Types of Retinal Detachment

Rhegmatogenous retinal detachment – A rhegmatogenous retinal detachment occurs due to a hole, tear, or break in the retina that allows fluid to pass from the vitreous space into the subretinal space between the sensory retina and the retinal pigment epithelium.

Exudative, serous, or secondary retinal detachment – An exudative retinal detachment occurs due to inflammation, injury or vascular abnormalities that results in fluid accumulating underneath the retina without the presence of a hole, tear, or break.

Tractional retinal detachment – A tractional retinal detachment occurs when fibrovascular tissue, caused by an injury, inflammation or neovascularization, pulls the sensory retina from the retinal pigment epithelium.

A substantial number of retinal detachments result from trauma, including blunt blows to the orbit, penetrating trauma, and concussions to the head. A retrospective Indian study of more than 500 cases of rhegmatogenous detachments found that 11% were due to trauma, and that gradual onset was the norm, with over 50% presenting more than one month after the inciting injury.

Prevalence Rate

A physician using a "three-mirror glass" to diagnose retinal detachment

The risk of retinal detachment in otherwise normal eyes is around 5 in 100,000 per year. Detachment is more frequent in the middle-aged or elderly population with rates of around 20 in 100,000 per year. The lifetime risk in normal eyes is about 1 in 300.

Retinal detachment is more common in those with severe myopia (above 5–6 diopters), as their eyes are longer and the retina is stretched thin. The lifetime risk increases to 1 in 20. Myopia is associated with 67% of retinal detachment cases. Patients suffering from a detachment related to myopia tend to be younger than non-myopic detachment patients.

Retinal detachment can occur more frequently after surgery for cataracts. The estimated of risk of retinal detachment after cataract surgery is 5 to 16 per 1000 cataract operations.The risk may be much higher in those who are highly myopic, with a frequency of 7% reported in one study.Young age at cataract removal further increased risk in this study. Long term risk of retinal detachment after extracapsular and phacoemulsification cataract surgery at 2, 5, and 10 years was estimated in one study to be 0.36%, 0.77%, and 1.29%, respectively.

Causes of Retinal Detachment

Retinal detachment can occur as a result of:

Trauma Advanced diabetes

An inflammatory disorder, such as sarcoidosis or cytomegalovirus retinitis

Sagging or shrinkage of the jelly-like vitreous that fills the inside of your eye

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.

The Risk Factors of Retinal Detachment

The following factors increase your risk of retinal detachment:

Aging — retinal detachment is more common in people older than age 40 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 on the sides (periphery) of your retina

PATHOPHYSIOLOGY

The development of rhegmatogenous RD is a consequence of both posterior vitreous detachment and the development of one or more breaks in the retina. Fluid can then pass from the vitreous cavity through these retinal breaks into a subretinal space, which extends the detachment once the amount of incoming fluid exceeds the removal capacity of the retinal pigment epithelium (RPE). Detachment of the posterior vitreous is considered a major - in fact indispensable - factor in the pathogenesis of rhegmatogenous RD. However, no preoperative diagnostic technique can accurately distinguish between a posterior vitreous detachment and a posterior vitreoschisis. Progression of the detachment depends on many factors, including:

Location of the break: superior faster than inferior Size of the break: larger faster than smaller

Adhesion of the remaining vitreous gel to the retina: stronger faster than weaker

Movement of the patient's head and eyes: this is also important because lack of such movement, as with bilateral patching, can result in the reattachment of the retina spontaneously, albeit temporarily.

In eyes with tractional RD, the membranes on either surface of the retina are 1) attached to the retina, and 2) elastic. As the membranes contract, the retina detaches from the RPE. Accumulation of the subretinal fluid is a secondary event; as part of the normal fluid transport from the vitreous to the choroid, the fluid simply fills the space created by the elevated retina.

In serous and haemorrhagic RD, the fluid that accumulates under the neuroretina separates it from the RPE.

Clinical Manifestations of Retinal Detachment

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 Bright flashes of light, especially in peripheral vision Shadow or blindness in a part of the visual field of one eye

Medical Management

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.

Surgery for retinal detachment:

Pneumatic retinopexy. For a relatively uncomplicated detachment with the tear located in the upper half of the retina, your ophthalmologist may recommend this outpatient procedure, usually done under local anesthesia. The procedure often starts with cryopexy to treat the retinal tear. Repair of the retinal detachment may require softening the eye by withdrawing a small amount of fluid from the space between the clear dome 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. The gas eventually disappears after several weeks.

Scleral buckling. This is one of the most common surgeries 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.

Vitrectomy. Removing portions of the vitreous itself is occasionally necessary when vitreous clouding blocks the surgeon's view of the detached retina or retinal scarring limits the effectiveness of pneumatic retinopexy or scleral buckling.

Nursing Care Plans

1. Risk for injury r/t the presence of veil or curtain in the field of vision Interventions

Maintain a safe environment Assist with ambulation and self care activities as needed

Keep side rails raised and bed in low position

Maintain bed in low position with side rails up Remove environmental barriers to ensure safety

2. Disturbed body image r/t to the slight feeling of heaviness in the eye secondary to the diseaseprocess Interventions

Provide hope within parameters of individual situations; do not give false reassurance

Assist patient to identify extent of actual change in appearance/body functions

Support and encourage patient; provide care with a positive, friendly attitude

Assess central vision with each eye, individually and together Assess factors or aids that improve vision, such as glasses, contact lenses, or

bright and/or natural light.

3. Anxiety r/t the presence of floaters or hair in the temporal part of the central vision

Interventions

Provide accurate, consistent information regarding prognosis of the disease. Avoid arguing about patient’s perceptions of the situation

Provide open environment in which the patient feels safe to discuss feelings or to refrain from talking

Develop a trusting relationship being honest and non judgemental, providing opportunity for questions and answers

Introduce self to patient, and acknowledge visual impairment Communicate type and degree of impairment to all involved in patient’s care

4. Self- esteem disturbance related to the presence of floaters in the field of visions

Interventions

Promote self- concept without moral judgement Provide accurate, consistent information regarding prognosis of the disease.

Avoid arguing about patient’s perception of the situation

Help patient’s formulate goals for self and create a manageable plans to reach those goals one at a time.

Encourage expressions of fears, negative feelings and grief over body changes

Assess factors or aids that improve vision, such as glasses, contact lenses, or bright and/or natural light.

5. Risk for activity intolerance r/t to the changes in field of vision: straight lines that suddenly appear curved secondary to retinal detachment

Interventions

Instruct patient to change position slowly Instruct patient to stop activity if changes in field of vision occur

Provide/ recommend assistance with activities/ambulation as necessary

Determine nature of visual symptoms, onset, and degree of visual loss. Ask patient about specifics such as ability to read, see television, history of fall Assess eye and lid for inflammation, edema, positional defects, and deviation.

Birmingham Ophthalmologists Develop New Retinal Detachment Laser Pevention (July 2008)By: JANE EHRHARDT

Previously anyone at high risk of a retinal detachment could do little but wait and hopefully keep on seeing. But two Birmingham ophthalmologists have now completed a pilot study on a laser procedure that may become the first reliable retinal detachment preventative procedure for high-risk eyes.

With rhegmatogenous retinal detachment (RRD) being so effectively repairable, not much attention has been given to preventing it. “But not everyone gets back all their vision after a retinal reattachment, and it’s sometimes a difficult operation,” said Robert Morris, MD, with Retina Specialists of Alabama and a clinical associate professor at UAB. “If someone has already lost vision due to a retinal detachment in one eye, they don’t want the other shoe to fall. Those second eyes are the ones we’ve performed this procedure on in this first study.”

Morris and his partner C. Doug Witherspoon, MD, also with Retina Specialists and UAB, devised their laser prophylaxis as an extension of the current repair process for retinal tears. Retinal tears are a primary cause of RRD as the opening allows vitreous cavity fluid to pass behind the retina, floating it away from the eye wall. If not treated quickly, this leads to vision loss and even blindness.

To repair retinal tears, a laser surrounds the tear with “burns” to create a chorioretinal scar that effectively welds the surrounding retina to the eye wall (figure 1). This treatment is over 95 percent effective in preventing progression of that particular retinal tear to retinal detachment. “Basically, it creates tight adhesion by means of a well-controlled microscopic scar that effectively bonds those tissues together,” Witherspoon said. “But new tears often occur at other clock hours in the peripheral retina.”

When repairing an existent retinal detachment, many physicians encircle the retina in some fashion with a laser treatment to help prevent any future tears or retinal detachment (figures 2 and 3). It was in this technique that the two ophthalmologists saw even more potential. “We took the encircling laser to a purely preventive level by applying it to the second eye where no tears existed, only high risk of tears or detachment,” Morris said.

They realized that if encircling worked in eyes with existent RRD, it might be similarly effective in eyes at high risk from other causes, such as being severely nearsighted with a family history of retinal detachment. “The new thing we’re doing,” Witherspoon said, “is taking the encircling procedure to a second eye as a preventive measure, especially in eyes that have had cataract removal.”

So they used the encircling technique to create a new “boundary” on the retina in eyes that were

known to be at risk but not actually damaged. “Most tears occur in the outer regions of the retina, so we take that area out of play,” Morris said. 

Using a laser, they burn a ring of minute scars several millimeters wide, just behind the ora serrata, the anterior line of the retina. “We’re creating a second line — a second ora — further back from the ora serrata. We’re calling that the ora secunda,” Morris said.

The ora serrata circumscribes the back two-thirds of the eye orb — in front of the equator of the eye — so the laser “welding” effectively creates a new retinal boundary. “All the lasering is done in front of the equator of the eye where little vision occurs,” Morris said. “The lasering is far out in the peripheral field, but those are the exact same areas that suffer tears that cause detachment.”

The primary candidates for this new procedure are eyes that harbor multiple risk factors, such as cataract surgery, a family history of detachments, eye trauma, and severe myopia. With over 1.35 million cataract surgeries in the U.S. and about 1 percent suffering retinal detachments, that leaves 13,500 eyes at risk of RRD. Morris notes that if a patient has had cataract surgery in both eyes and a retinal detachment in one, there’s a 20 percent chance of a RRD in the second eye.

“All these things can add up, and the key is to determine the actual risk for that particular eye,” Witherspoon said. “Although laser is noninvasive, you don’t want to be lasering eyes that don’t have a high risk of retinal detachment.”

The two ophthamologists researched this innovative surgery in a study of 266 eyes and accumulated five to ten years of follow-up data. They recently released a paper introducing the concept, and plan to present the hard data this year in more formal medical journals. 

The Helen Keller Foundation for Research and Education in Birmingham, of which Morris is president, helped sponsor this discovery.

New Approaches Make Retinal Detachment Highly Treatable

ScienceDaily (Dec. 1, 2008) — Retinal detachment, a condition that afflicts about 10,000 Americans each year, puts an individual at risk for vision loss or blindness. In a new study in the New England Journal of Medicine, a leading ophthalmologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center writes, however, that a high probability of reattachment and visual improvement is possible by using one of three currently available surgical techniques.

"Although no randomized trials have been conducted that show definitively that one procedure is best for every situation, improvements in these surgical techniques have led to effective treatments for most patients," says Dr. Donald J. D'Amico, ophthalmologist-in-chief at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, professor and chairman of ophthalmology at Weill Cornell Medical College, and an international leader in vitreoretinal surgery.Although relatively rare, retinal detachment can occur when holes, tears or breaks appear in the light-sensitive retina as a result of trauma or pulling away of the gelatinous mass, known as the

vitreous, that fills the back of the eye. Retinal tears occur most often in adults over age 60, but may occur much earlier, particularly in those with high myopia. The sudden onset of light flashes and "floaters" could be the warning signs of an impending retinal detachment, although these symptoms do not always mean that a retinal tear has occurred. Surgery is the only treatment for a retinal detachment.Dr. D'Amico offers his recommendations for treating a 57-year-old man who experiences sudden flashes and floaters in one eye, progressive loss of vision and a retinal detachment in the article, "Primary retinal detachment."The three surgical options currently in use to treat such a case are:

1. Scleral Buckling. A common way to treat a retinal detachment, scleral buckling surgery has been performed with success for several decades. In this procedure, a piece of silicone is sutured onto the outside wall of the eyeball and left in place permanently to create an indentation, or buckle, that restores contact with the detached retina. The individual tears are then closed by a localized scar that is induced with a freezing probe or laser. According to Dr. D'Amico, scleral buckling is a relatively involved procedure and requires the use of a hospital operating room. It is usually performed on an outpatient basis with local anesthesia with intravenous sedation, and the overall success rate for reattachment is about 90 percent.

2. Pneumatic Retinopexy. A newer and less invasive procedure than scleral buckling, pneumatic retinopexy is usually done in the retina specialist's office under local anesthesia. The procedure involves injecting a gas bubble into the vitreous cavity of the eye, then positioning the patient's head so that the bubble floats to the break in the detached retina. The bubble spans and closes the retinal break, and this allows the natural forces in the eye to reattach the retina. The break is permanently sealed by the application of a freezing probe or laser to create a scar around the break. The gas bubble then resolves over several days, and in successful cases, the retina is left reattached without a trip to the operating room, and with no permanent buckling material applied to the eye. According to Dr. D'Amico, pneumatic retinopexy is not suitable for every patient and has a somewhat lower success rate with initial treatment than does scleral buckling or vitrectomy. Nevertheless, he says, because of its minimally invasive attributes, and the fact that an attempted pneumatic does not reduce the ultimate chance for success if additional surgery is required for recurrent detachment, patient and surgeons increasingly select pneumatic retinopexy for suitable primary retinal detachments after a careful discussion of the limitations.

3. Vitrectomy. In contrast to scleral buckling, vitrectomy is a surgery within the eye in which the vitreous gel is removed. Because vitreous traction is the typical cause of the retinal tears in a detachment, this approach has the advantage of directly attacking the underlying cause of the detachment. Vitrectomy surgery -- a few decades old -- is a newer surgery than scleral buckling, and it is continually improving due to innovations in instrumentation and technique. Recent studies have shown success rates comparable to those of scleral buckling. Dr. D'Amico notes that there is a very strong shift toward vitrectomy, and away from buckling, for retinal detachment, particularly by younger surgeons and for patients that have detachment after cataract surgery. Vitrectomy for detachment may be associated with a higher risk of postoperative cataract, and this appears to be its main disadvantage compared to buckling, which has lower risk of cataract but higher risk of other complications. In cases where bleeding in the vitreous gel is present with the detachment, a vitrectomy approach is clearly preferred to remove the vitreous hemorrhage in order to gain better visualization to find and repair tears or holes in the retina. Vitrectomy, like scleral buckling, is typically done on an outpatient basis with local anesthesia with intravenous sedation.

For the patient described in the vignette who went to his ophthalmologist with classic symptoms of primary retinal detachment, including flashing lights, floaters and progressive loss of vision, Dr. D'Amico's first recommendation would be to perform a pneumatic retinopexy. "I would select this option for this patient because this specific detachment is well-suited to pneumatic retinopexy by virtue of the retinal breaks being located close together in the superior retina, which is the easiest location to treat with an intraocular gas bubble. Furthermore, the procedure can be done immediately in the doctor's office at lower cost and with fewer risks of complications, compared to buckling or vitrectomy, and it also compares quite favorably with

the other procedures with having a 75 percent chance of restoring vision to 20/50 or better after this minimally invasive procedure," Dr. D'Amico says.As with any surgery, there are risks associated with each of these techniques. For example, vitrectomy can cause cataract or elevated pressure inside the eye, especially in people with glaucoma; scleral buckling can cause a change in the shape of the eye that may require alteration of the eyeglass prescription; and pneumatic retinopexy often requires more than one surgery to reattach the retina."The benefits of surgery, however, far outweigh the risks," says Dr. D'Amico, who performs all of these procedures. "No matter which procedure the surgeon chooses, there is a very good chance today that a patient's retina can be reattached and his or her vision preserved."