Running head: RETINAL DETACHMENTS AND THE CURRENT TRENDS OF

Retinal Detachments and the Current Trends of Treatment Shannon Sheffer Ferris State University English 321: Advanced Composition

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF Abstract

Retinal detachment is a sight threatening condition that affects approximately 1 in 10,000 people. Before 1920, this was a permanently blinding condition. In the last 50 years, techniques in scleral buckling, vitrectomy, laser, and retinopexy have made the repair of retinal detachments more treatable with better visual results. Visual restoration is a slow process after surgery and may take several months to be able to estimate the end amount of vision restored. This paper takes a look at what a retinal detachment is and how it can be managed and treated. Future research in surgical technology will need to focus on less invasive techniques.

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF Retinal Detachments and the Current Trends of Treatment Retinal detachments are a separation of the retina from the underlying layers within the

back of an eye. Most retinal detachments are caused from tears, breaks, or holes that allow fluid to move through the breaks and travel under the retina and lifts it up. These retinal detachments are created by a variety of factors. Some of these factors are hereditary, trauma, eye structure, or previous eye surgery. Successful repair of a retinal detachment is about having early detection. 80% of patients that had retinal detachments with early detection and a single surgical procedure had success in reattaching the retina (Ross & Stockl, 2000). Early detection of retinal detachments greatly increases the amount of vision that is restored after surgery. Surgical repair of detachments are the most recommended form of treatment now days, but the forms of surgery can vary. What is the retina? The retina is a delicate inner lining at the back of the eye. It is roughly 1 millimeter thick and the size of a postage stamp. It has the consistency of a piece of wet tissue paper. The retina is composed of multiple working parts that allow an individual to process what they are seeing and understand it. The images and lights that we see are focused to the retina from the cornea and lens. The lights hit the retina and cause the retinal layers to change, stimulating the nerves to process the image to the brain through the optic nerve. Within certain areas of the brain, this information is processed, allowing the person to understand what they are seeing. Some of these working parts include a macula, peripheral retina, and light receptors. The light receptors, called rods and cones, allow people to see in any type of light. Rods allow us to see in darker, less light situations. While cones provide us with sharp defined color vision. The peripheral retina allows for side or peripheral vision and has a low concentration of cones and

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF high amount of rods. So our peripheral vision is less detailed, but provides us with better vision in the night. The macula is our central vision with the greatest amount of cones. The macula helps with fine details such as reading or sewing a quilt. The macula is responsible for our central vision. It is the most sensitive to bodily changes such as nutrition, oxygen, and circulation. These are especially crucial with decreased blood flow due to aging. A network of branching arteries that supply blood, nutrition, and oxygen helps maintain the retina. The veins carry the blood away with waste and retinal metabolism (Ross & Stockl, 2000). What is a Retinal Detachment? When the vitreous humor separates or pulls away from the retina, a tear may occur if the

retina is weak in a spot or area. When one of these tears appears, it can allow fluid to go through the tear to lift the retina off the back wall of the eye. When this happens, it is called a retinal detachment. An ophthalmologist can diagnosis retinal tears or detachments during eye exams when pupils are dilated or by using ultrasound. Some of the factors that can cause a retinal detachment may be trauma, genetics, advancing age, myopia (nearsightedness), health, or previous eye surgery. Retinal detachments are categorized into 3 sections: exudative, tractional, and rhegmatogenous. An exudative detachment is caused by fluid entering the sub retinal space due to hydrostatic factors such as inflammation or neoplastic effusions (Gariano & Kim, 2004). Exudative retinal detachments usually resolve once proper treatment of the originating disease is complete. Overall, vision restoration is most often very good in these detachments. A tractional retinal detachment occurs via centripetal mechanical forces on the retina. Usually mediated by fibrotic tissue resulting from previous hemorrhages from surgery, injury, or inflammation (Gariano & Kim, 2004). To correct a tractional retinal detachment, the surgeon

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF

must try to release the scar tissue from the retina. For these patients, visual outcomes are usually poor. The most common detachment, rhegmatogenous, occurs when the vitreous humor pulls and separates from the retina causing tears or breaks. The vitreous humor is a hydrated gel that helps maintain the structure of the eye. As we age, the vitreous beings to liquefy and shrink, separating from the retina. If the retina is weak in areas, this separating may cause a tear or break in the retina and a rhegmatogenous retinal detachment may occur. These tears may occur without symptoms, but often photopia and floaters are noted by patients (Waylward, 2001). Another type of detachment that was not mentioned may be through a traumatic event. A trauma to an eye can have grave results. At the moment of impact, rapid compression and decompression of the globe may generate sufficient vitreoretinal traction to produce retinal tears. Alternatively, retinal detachment may occur weeks, months, or even years after trauma because vitreous contraction is accelerated by inflammation and blood-borne mediators that access the vitreous cavity at the time of injury (Gariano & Kim, 2004). It is recommended that anyone that has had an injury to an eye, see your eye doctor for an exam to rule out any detachment or other eye condition. What causes Retinal Detachments and what are the signs and symptoms? The vitreous humor is made of water, collagen, and hyaluronic acid. Collagen is a protein which connects to hyaluronic acid. While we age, the collagen-hyaluronic acid connection starts to liquefy and shrink pulling away from the retina (Calderon & Shechtman, 2008). This does not always result in retinal tears or breaks, however inflammation or myopia may cause the retina to weaken while the vitreous is shrinking and pulling away.

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF Some of the early warning signs of a retinal detachment are flashing lights, new and

worsening floaters, blurred vision, a shadow in the periphery of ones field of vision or complete loss of peripheral vision, or a curtain moving across the field of vision (Gariano & Kim, 2004). Some patients describe floaters as looking like cobwebs, flies, or hair like objects. Flashes of light do not always represent retinal breaks or tears, but indicate traction on the retina stimulating the photoreceptors (Calderon & Shecktman, 2008). A retinal detachment is diagnosed by an ophthalmologist by using an indirect or direct ophthalmoscope, split lamp, fluorescein, angiography, or ultrasound. All of these tools are used in helping the doctor diagnosis any problems and degree of severity. What types of Treatments are Recommended? Once your ophthalmologist has diagnosed the retinal detachment, a variety of treatments may be available. For most patients, surgical intervention is required to repair the detachment. For the surgeon to be able to reattach the retina, surgical treatments may be scleral buckling, vitrectomy, pneumatic retinopexy, laser, or silicone oil. A pars plana vitrectomy is when a surgeon removes the vitreous humor with small gauged instruments. These instruments are introduced into the posterior eye by making small incisions into the sclera. By cutting and aspirating out the vitreous, this allows the retina to flatten out again to the back of the eye (Morishita, Yoshitake, Hirose, & Oh, 2011). Scleral buckling may be added along with the vitrectomy. This is a silicone band that is weaved around the eye under the rectus muscles. This band is placed if the surgeon is unable to reach the inferior detachments with other means (Siqueira, Gomes, Dalloul, & Jorge, 2007). After the surgeon has removed the vitreous humor and decided if a scleral buckle is warranted, the surgeon may decide laser treatment is needed. The laser treatment helps hold the

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF retina back to the wall of the eye by tacking it down. It does this by ultimately burning spots into the retina and causing scarring to occur. By administering laser treatment, this helps with preventing further tears or detachments in the area of laser. Pneumatic retinopexy is an injection of intraocular gas into the eye. This gas is injected

at the end of the surgical procedure to help keep the retina flat and attached. The gas bubble will be in place for 2-6 weeks depending upon which gas the surgeon prefers. This is determined by how the patients retina has reattached and how long the surgeon thinks that extra pressure from the gas should stay in place. Special positioning of the patients head is going to be required after the gas is injected for the first few days after surgery. Patients should also refrain from flying in airplanes or traveling at high altitudes. This rapid increase of altitude can cause dangerous increase in eye pressures. The patients ophthalmologist will communicate this length of time to the patient at the end of the procedure. If pneumatic retinopexy is not desired, another option may be silicone oil. The silicone oil replaces the vitreous, but is denser, allowing the extra bulk to be applied to the treated detachment (Lin, Wang, Jiang, Long, Liu, Wang, Jin, Yi, Gao, 2011). This oil is not a permanent implant, so the patient will have to come back to the operating room to have it removed at a later date. All of the treatments listed help reattach by sealing the retina back to the wall of the eye. Each will help prevent fluid from traveling from the posterior eye through tears, holes, or breaks to the underside of the retina. Most of these treatments do this by causing a scar to form, ultimately scarring the retina back to the wall of the eye and hopefully preventing future retinal detachments. Treatment pathway depends on what the surgeon recommends and the patient wants.

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Conclusion All of the collected information from these articles has helped prove that retinal detachments are a very serious eye condition with multiple treatment options. Each treatment option is questionable for a retinal surgeon on which one best fits the patients needs and condition the best. Although many strides have been made in the advancement of retinal detachment treatments, there is still more being discovered every day. Early diagnosis and treatment of retinal detachments are a serious necessity since a patients visual restoration all depends on the severity of the damaged retina. Overall, great leaps have been made in the last 50 years, but future research is needed in developing techniques that are less invasive for these patients. Accelerated scientific discoveries are likely to help bring new ideas and new techniques to all retina surgeons to prevent, identify, and treat retinal detachments. Now days, people are looking to have quick surgery and recovery time without having to have a long recovery of vision and with further technology break through, this will be able to happen.

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF References Calderon, D.E., & Shechtman, D.L. (2008). Posterior vitreous detachment: A common process with ocular morbidity. Review of Optometry. 145(11). Gariano, R.F., & Kim, C. (2004). Evaluation and management of suspected retinal detachment. American Family Physician. 69(7), 1691-1698. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15086041. Knapp, A. (1943). Retinal detachment and trauma. Trans American Ophthalmology Society. 41, 186-197. Retrieved from http://ncbi.nlm.nih.gov/pubmed/16693312. Lin, X., Wang, Z., Jiang, Z., Long, C., Liu, Y., Wang, P., Jin, C., Yi, C., Gao, Q. (2011). Preliminary efficacy and safety of a silicone oil-filled foldable capsular vitreous body in

the treatment of severe retinal detachment. Retina. dio: 10.1097/IAE.0b013e31822b1f80. Morishita, S., Kita, M., Yoshitake, S., Hirose, M., & Oh, H. (2011). 23-gauge vitrectomy assisted by combined endoscopy and a wide-angled viewing system for the retinal detachment with severe penetrating corneal injury: a case report. Clinical Ophthalmology, 5, 1767-1770. dio: 10.2147/OPTH.S25373. Ross, W.H., & Stockl, F.A. (2000). Visual recovery after retinal detachment. Current Opinion Ophthalmology. 11(3), 191-194. Schwartz, S.G. & Flynn, H.W. (2008). Pars plana vitrectomy for primary rhegmatogenous retinal detachment. Clinical Ophthalmology, 2(1), 57-63. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19668388. Siqueira, R.C., Gomes, C.V., Dalloul, C., & Jorge, R. (2007). Vitrectomy with and without scleral buckling for retinal detachment. Arquivos Brasilerios de Oftalmologia, 70(2), 298-302. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17589703.

RETINAL DETACHMENTS AND THE CURRENT TRENDS OF Waylward, G. (2001). Screening for retinal detachment. Journal of Medical Screening. 8(3), 116-118. dio: 10.1136/jms.8.3.11

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