What is it?
Detachment of the retina is one of the most serious emergency eye conditions. The retina is the lining at the back of the eye. It is here that the light/image is converted into nerve waves/signals which 'travel' through the nerves to the brain and finally help you to realise or see the light/image. The retina has two layers which are attached (stuck) to each other. A retinal detachment occurs when the two layers become separated (detached) in one or more areas. This is an emergency condition which can result in loss of sight from the affected eye.
The incidence of retinal detachment in the general population is about 0.3%. The incidence increases with age and reaches a maximum for people who are 50 to 60 years old. Patients with severe myopia (short sight) have a 5% chance of developing a retinal detachment while patients who have a cataract operation (an operation done to replace the lens in front of the eye when it gets cloudy and affects the vision with a new synthetic lens) have a 1% chance of developing the condition. Overall, severe myopia is the cause of 40 to 50% of retinal detachments. A cataract operation is the cause in 30-35% of cases. Trauma of the eye is the cause of the detachment in 15 to 20% of cases. Patients who have had retinal detachment in one eye have about a 15% chance of developing one in the other eye.
There are three causes of retinal detachment.
1. Development of holes in the inner layer of the retina which can happen either spontaneously due to degeneration (aging) of the tissue or due to trauma (called rhegmatogenous retinal detachment).
2. Traction on the inner layer of the retina due to contraction of fibrous bands of tissue that have developed between the inner layer of the retina and the vitreous which is the 'jelly ball' that occupies the centre of the eyeball. This happens more frequently in diabetic patients.
3. Development of a fluid collection between the two layers of the retina. This can occur because of trauma, infectious/inflammatory (swelling) processes in the affected area or increased pressure close to the retina due to the development of a tumour which forces fluid between the two retinal layers.
One of the most common symptoms you experience when you have retinal detachment is a sudden increase in the number of floaters (small dots or strings) you see in your field of vision. Although you can experience something like this as you get older without having any significant underlying problem, the sudden appearance of a 'shower of floaters' is usually an indication of a retinal detachment. Another very common symptom is the sudden appearance of light flashes in your field of vision. Some patients often describe the presence of a 'curtain' which is pulled over their field of vision and it means that the detachment has started (as it usually does) from the periphery of the retina. If the detachment involves the centre of the retina (the macula which produces detailed vision), then the vision problems are much more serious and the problem much more urgent. Pain is not necessarily present in retinal detachment but when it is, it is usually when trauma is the cause of the detachment.
The operation
Most patients have the eye numbed with a local anaesthetic. Very rarely, a patient might need to be put to sleep with a general anaesthetic to allow him/her to have this operation comfortably. If you have a local anaesthetic, you will be awake during the operation, but will feel no pain and will not see anything, because the injection stops the eye working. In most cases you will stay in hospital for no more than 24 hours after the operation.
Most operations for retinal detachment last between one and two hours depending on the extent of the retinal damage.
There are three types of surgery for retinal detachment.
1. The scleral buckling operation. Initially the surgeon will identify the areas of the retinal breaks. The next step is to drain any fluid that has accumulated between the two retinal layers. The retinal breaks are then closed by scarring the retina either with extreme cold with a cryoprobe or with light from a laser. After that, the surgeon will apply a ring/buckle made of silicone sponge or solid silicone around the sclera which is the outer layer of the eyeball. This is stitched onto the sclera and is positioned in such a way that it pushes in/buckles the sclera towards the centre of the eye. This results in pushing back together again the two detached layers of the retina.
2. Pneumatic retinopexy. This procedure uses an air bubble to put back together the two layers of the retina (pneumatic from the ancient Greek word pneuma which means air and retinopexy from the words retina and the Greek word pexy which means to stick together). During this operation the surgeon injects an air bubble into the middle of the eyeball. The head of the patient is positioned in such a way that the bubble lies on the inner layer of the retina and pushes the inner layer onto the outer layer so that the two layers are attached again. By applying pressure on the two layers the bubble also squeezes out any fluid that has accumulated between the two layers and allows the surgeon to close the breaks by scaring the retina with a cryoprobe or laser (as described in the scleral buckling operation). The air bubble will usually remain for about a week. During which time you need to avoid putting your head in certain positions, such us lying flat on your back because this can push the bubble to the front of the eye and prevent it from applying pressure on the retina. The eye gradually absorbs the air bubble.
3. Vitrectomy. During this operation the surgeon first removes the jelly ball (vitreous) from the centre of the eye. This technique is used in difficult and complicated cases of retinal detachment. The removal of the vitreous allows more space for the surgical manoeuvres that are needed to repair severe damage to the retina. At the end of the operation the vitreous is replaced with silicone oil.
Any alternatives?
There are no alternatives to surgery for retinal detachment. It is a condition that requires immediate surgical attention and intervention. Any delay reduces significantly the chances of successful repair.
Before the operation
Bring all your tablets and medicines with you to the hospital. On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible.
After - in hospital
Most patients experience little pain after an operation for retinal detachment but may have some swelling of the eye. You may be given tablets or an injection to control any pain or discomfort. You can wash, bathe, or shower normally after the operation, but you must not get water in your eye for a month. If you have your hair washed, have it done with your head leaning backwards. Do not use makeup on your eyelids for one month. You will normally be able to go home within 24 hours of your operation. You will be given a supply of eye drops, and shown how to put them in your eye. You will be given an appointment for the outpatient department for a check up one to two weeks after you leave hospital. The nurses will advise about sick notes, certificates, etc.
After- at home
Your eye will be covered by a pad and a protective plastic shield. This is to stop you touching your eye, especially when you are half asleep. Sometimes it takes a few days after the operation for the eye to settle down and the patient to see an improvement in vision. You MUST wear the eye shield to protect the affected eye at night, or if you sleep during the day. You will be told in the outpatient clinic when you can stop using the shield (normally about one month). During the day you can use any glasses you were using before the operation. Sunglasses are a good idea to protect your eyes from the glare. If you wear contact lenses, do not put one in the operated eye for eight weeks. Plan to go back to light work in about one to two weeks, and a more heavy/manual job in about three months.
If you had the pneumatic retinopexy operation you will be strongly advised to avoid air travel for at least three to four weeks. This is because the change in altitude during the flight can make the air bubble much bigger and this can cause serious problems in your eye.
You must be very careful when driving in the early stages after the operation because your sight may not be as good as you think it is. Ask the doctor whether your sight is good enough to drive. If in doubt, don't drive.
Possible complications
In the rare case that you have this operation under general anaesthetic, there is a very small risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
Complications are not common but can be problematic.
Bleeding in the eye can cause pain and affect your vision. This usually settles by itself but sometimes you will need surgery to fix the problem. The eye may also get infected. Drops of antibiotics and anti-swelling medication such as steroids will be needed to treat the infection.
One of the most common problems after an operation for retinal detachment is the development of further scarring of the retina. The bands of tissue which can develop because of the scarring can retract and cause a new detachment. In this situation, a vitrectomy to create space for surgical manoeuvres and another extensive operation to fix the new detachment may be needed.
Another complication after retinal detachment surgery (especially after scleral buckling) is the detachment of the choroid, the middle layer of tissue that lies between the sclera and the retina. Choroid detachments usually heal on their own within one to two weeks without further intervention.
The presence of a scleral buckle can increase the fluid pressure inside the eye and change the shape of the eye or affect the mucles that control eye movements. All these can clearly affect your vision and adjustments may be needed to ensure that any changes in your vision are corrected. Very rarely, the buckle can also become infected and, if the infection is not responding to antibiotic treatment it may need to be removed.
The operation for correction of retinal detachment is successful in about 85% of cases. Sometimes a second operation may be needed to improve the result of the first operation. The operation is more successful if the detachment is localised in the periphery of the retina and the central part of the retina (macula) is not affected. If the macula is affected, it is much more difficult to fix the problem and the risks of impaired vision after the operation are much higher.
General advice
These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.
