Retinal detachment

Retinal detachment is a separation of the light-sensitive membrane in the back of the eye (the retina) from its supporting layers.

Causes, incidence, and risk factors

The retina is a transparent tissue in the back of the eye. It helps you see the images that are focused on it by the cornea and the lens. Retinal detachments are often associated with a tear or hole in the retina through which eye fluids may leak. This causes separation of the retina from the underlying tissues. Retinal detachment often occurs on its own without an underlying cause. However, it may also be caused by trauma, diabetes, or an inflammatory disorder. It is most often caused by a related condition called posterior vitreous detachment. During a retinal detachment, bleeding from small retinal blood vessels may cloud the interior of the eye, which is normally filled with vitreous fluid. Central vision becomes severely affected if the macula, the part of the retina responsible for fine vision, becomes detached. The risk factors are previous eye surgery, nearsightedness, a family history of retinal detachment, uncontrolled diabetes, and trauma.

Symptoms

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

Signs and tests

Tests will be done to check the retina and pupil response and your ability to see colors properly. These may include:

Electroretinogram (a record of the electrical currents in the retina produced by visual stimuli) Fluorescein angiography Intraocular pressure determination Ophthalmoscopy Refraction test Retinal photography Test to determine your ability to see colors properly (color defectiveness) Visual acuity Slit-lamp examination Ultrasound of the eye

Treatment
Most patients with a retinal detachment will need surgery, either immediately or after a short period of time. (However, surgery may not be needed if you do not have symptoms or have had the detachment for a while.) Types of surgery include:

Cryopexy (intense cold applied to the area with an ice probe) to help a scar form, which holds the retina to the underlying layer Laser surgery to seal the tears or holes in the retina Pneumatic retinopexy (placing a gas bubble in the eye) to help the retina float back into place

Laser surgery is performed after pneumatic retinopexy to permanently fix it in place. This is often done in a doctor's office. More extensive detachments may require surgery in an operating room. Such procedures include:

Scleral buckle to indent the wall of the eye Vitrectomy to remove gel or scar tissue pulling on the retina

Expectations (prognosis)
What happens will depend on the location and extent of the detachment and early treatment. If the macula has not detached, the results of treatment can be excellent. Most retinal detachments can be repaired, but not all of them.

Complications
The unsuccessful reattachment of the retina results in loss of vision.

Calling your health care provider

A retinal detachment is an urgent problem that requires medical attention within 24 hours of the first symptoms.

Prevention
Use protective eye wear to prevent eye trauma. Control your blood sugar carefully if you have diabetes. See your eye care specialist at least yearly, especially if you have risk factors for retinal detachment.

Retinal detachment
Retinal detachment

Classification and external resources

Slit lamp photograph showing retinal detachment.

Retinal detachment is 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.[1]

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 theoptic 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.

Types

Rhegmatogenous retinal detachment A rhegmatogenous retinal detachment occurs due to a 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. Retinal breaks are divided into three types - holes, tears and dialyses. Holes form due to retinal atrophy especially within an area of lattice degeneration. Tears are due to vitreoretinal traction. Dialyses which are very peripheral and circumferential may be either tractional or atrophic, the atrophic form most often occurring as idiopathic dialysis of the young.

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. In evaluation of retinal detachment it is critical to exclude exudative detachment as surgery will make the situation worse, not better. Although rare, exudative retinal detachment can be caused by the growth of a tumor on the layers of tissue beneath the retina, namely the choroid. This cancer is called a choroidal melanoma.

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

A minority 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. [2] [edit]Frequency

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

The incidence of retinal detachment in otherwise normal eyes is around 5 new cases in 100,000 persons per year.[3] Detachment is more frequent in middle-aged or elderly populations, with rates of around 20 in 100,000 per year.[4] The lifetime risk in normal individuals is about 1 in 300.[5]

Retinal detachment is more common in people with severe myopia (above 56 diopters), in whom the retina is more thinly stretched. In such patients, lifetime risk rises to 1 in 20.[6]About two-thirds of cases of retinal detachment occur in myopics. Myopic retinal detachment patients tend to be younger than non-myopic ones.

Retinal detachment is more frequent after surgery for cataracts. The estimated long-term prevalence of retinal detachment after cataract surgery is in the range of 5 to 16 per 1000 cataract operations, [7] but is much higher in patients who are highly myopic, with a prevalence of up to 7% being reported in one study.[8] One study found that the probability of experiencing retinal detachment within 10 years of cataract surgery may be about 5 times higher than in the absence of treatment.[9]

Tractional retinal detachments can also occur in patients with proliferative diabetic retinopathy [10] or those with proliferative retinopathy ofsickle cell disease.[11] In proliferative retinopathy, abnormal blood vessels (neovascularization) grow within the retina and extend into the vitreous. In advanced disease, the vessels can pull the retina away from the back wall of the eye, leading to tractional retinal detachment.

Although retinal detachment usually occurs in just one eye, there is a 15% chance of it developing in the other eye, and this risk increases to 2530% in patients who have had cataracts extracted from both eyes.[6]

[edit]Symptoms

A retinal detachment is commonly preceded by a posterior vitreous detachment which gives rise to these symptoms:

flashes of light (photopsia) very brief in the extreme peripheral (outside of center) part of vision a sudden dramatic increase in the number of floaters a ring of floaters or hairs just to the temporal side of the central vision a slight feeling of heaviness in the eye

Although most posterior vitreous detachments do not progress to retinal detachments, those that do produce the following symptoms:

a dense shadow that starts in the peripheral vision and slowly progresses towards the central vision the impression that a veil or curtain was drawn over the field of vision straight lines (scale, edge of the wall, road, etc.) that suddenly appear curved (positive Amsler grid test) central visual loss

(None of this is to be confused with the broken retina which is generally the tearing of muscle and nerve behind the eye)

Treatment of Rhegmatogenous Retinal Detachment

There are several methods of treating a detached retina, each of which depends on finding and closing the breaks that have formed in the retina. All three of the procedures follow the same three general principles:

1. 2. 3.

Find all retinal breaks Seal all retinal breaks Relieve present (and future) vitreoretinal traction

Cryopexy and Laser Photocoagulation Cryotherapy (freezing) or laser photocoagulation are occasionally used alone to wall off a small area of retinal detachment so that the detachment does not spread. Scleral buckle surgery Scleral buckle surgery is an established treatment in which the eye surgeon sews one or more silicone bands (bands, tyres) to the sclera (the white outer coat of the eyeball). The bands push the wall of the eye inward against the retinal hole, closing the break or reducing fluid flow through it and reducing the effect of vitreous traction thereby allowing the retina to re-attach. Cryotherapy (freezing) is applied around retinal breaks prior to placing the buckle. Often subretinal fluid is drained as part of the buckling procedure. The buckle remains in situ. The most common side effect of a scleral operation is myopic shift. That is, the operated eye will be more short sighted after the operation. Radial scleral buckle is indicated to U-shaped tears or Fishmouth tears and posterior breaks. Circumferential scleral buckle indicated to multiple breaks, anterior breaks and wide breaks. Encircling buckles indicated to breaks more than 2 quadrant of retinal area, lattice degeration located on more than 2 quadrant of retinal area, undetectable breaks, and proliferative vitreous retinopathy. Pneumatic retinopexy This operation is generally performed in the doctor's office under local anesthesia. It is another method of repairing a retinal detachment in which a gas bubble (SF6 or C3F8 gas) is injected into the eye after which laser or freezing treatment is applied to the retinal hole. The patient's head is then positioned so that the bubble rests against the retinal hole. Patients may have to keep their heads tilted for several days to keep the gas bubble in contact with the retinal hole. The surface tension of the air/water interface seals the hole in the retina, and allows the retinal pigment epithelium to pump the subretinal space dry and suck the retina back into place. This strict positioning requirement makes the treatment of the retinal holes and detachments that occurs in the lower part of the eyeball impractical. This procedure is usually combined with cryopexy or laser photocoagulation. Vitrectomy Vitrectomy is an increasingly used treatment for retinal detachment. It involves the removal of the vitreous gel and is usually combined with filling the eye with either a gas bubble (SF6 or C3F8 gas) or silicon oil. Advantages of using gas in this operation is that there is no myopic shift after the operation and gas is absorbed within a few weeks. Silicon oil

(PDMS), if filled needs to be removed after a period of 28 months depending on surgeon's preference. Silicon oil is more commonly used in cases associated with proliferative vitreo-retinopathy (PVR). A disadvantage is that a vitrectomy always leads to more rapid progression of a cataract in the operated eye. In many places vitrectomy is the most commonly performed operation for the treatment of retinal detachment.

Results of Surgery
85 percent of cases will be successfully treated with one operation with the remaining 15 percent requiring 2 or more operations. After treatment patients gradually regain their vision over a period of a few weeks, although the visual acuity may not be as good as it was prior to the detachment, particularly if the macula was involved in the area of the detachment. However, if left untreated, total blindness could occur in a matter of days.

Risk factors and prevention

History of cataract surgery is an important risk factor for rhegmatogenous retinal detachment, which can manifest long after the operation has been completed. The risk is increased when there are complications during cataract surgery. Retinal detachment can be mitigated in some cases when the warning signs [12] are caught early. The most effective means of prevention and risk reduction is through education of the initial signs, and encouragement for people to seek ophthalmic medical attention if they suffer from symptoms suggestive of a posterior vitreous detachment.[13] Early examination allows detection of retinal tears which can be treated with laser or cryotherapy. This reduces the risk of retinal detachment in those who have tears from around 1:3 to 1:20. For this reason, the governing bodies in some sports require regular eye examination. Trauma-related cases of retinal detachment can occur in high-impact sports (eg boxing, karate, kickboxing, American football) or in high speed sports (eg automobile racing, sledding). Although some doctors recommend avoiding activities that increase pressure in the eye, including diving and skydiving, there is little evidence to support this recommendation, especially in the general population. Nevertheless, ophthalmologists generally advise patients with high degrees of myopia to try to avoid exposure to activities that have the potential for trauma, increase pressure on or within the eye itself, or include rapid acceleration and deceleration. Intraocular pressure spikes occur during any activity accompanied by the Valsalva maneuver, including weightlifting.[14] An epidemiological study suggests that heavy manual lifting at work may be associated with increased risk of rhegmatogenous retinal detachment.[15][16] In this study, obesity also appeared to increase the risk of retinal detachment.

What is the retina?

The retina is an extremely thin tissue that lines the inside of the back of the eye. When we look around, light from the objects we are trying to see enters the eye. The light image is focused onto the retina by both the cornea and the lens. This light striking the retina causes a complex biochemical change within layers of the retina and this, in turn, stimulates an electrical response in other layers of the retina. Nerve endings within the retina transmit these electrical signals to the brain through the optic nerve. Within specific areas of the brain, this electrical energy is processed to allow us both to see and to understand what we are seeing. The retina has been compared to the film of a camera. However, film, once used, has a permanent image on it. The retina continually renews itself chemically and electrically, allowing us to see millions of different images every day without them being superimposed. The retina is about the size of a postage stamp. It consists of a central area called the macula and a much larger peripheral area of the retina. The light receptor cells within the retina are of two types, called the rods and the cones. Rods allow us to see in conditions of reduced illumination. Cones provide us with sharpness of vision and color vision. The peripheral retina allows us to see objects on either side (peripheral vision) and, therefore, provides the vision needed for a person to move about safely. However, because this part of the retina contains a lesser concentration of cones, it does not allow for perception of visual detail. Its larger concentration of rods provides better vision during conditions of darkness. In contrast, the macula is a smaller, central area of the retina that contains a high concentration of cones. Accordingly, it enables clear central vision to see fine details for such activities as reading or threading a needle. The macula is particularly sensitive to circulatory changes, especially those that occur with aging, such as decreased blood flow. The retina contains a network of branching arteries, which supplies blood that carries the needed oxygen and nutrients to the retina, and a network of accompanying veins, which then carry the blood away together with the waste products of retinal metabolism.

Retinal Detachment Causes

Studies have shown that the incidence of retinal detachments caused by tears in the retina is fairly low, affecting approximately one in 10,000 people each year. Many retinal tears do not progress to retinal detachment. Nevertheless, many risk factors for developing retinal detachments are recognized, including certain diseases of the eyes (discussed below), cataract surgery, and trauma to the eye. Retinal detachments can occur at any age. They occur most commonly in younger adults (25-50 years of age) who are highly nearsighted (myopic) and in older people following cataract surgery.

What is a retinal detachment?

A retinal detachment is a separation of the retina from its attachments to the underlying tissue within the eye. Most retinal detachments are a result of a retinal break, hole, or tear. These retinal breaks may occur when the vitreous gel pulls loose or separates from its attachment to the retina, usually in the peripheral parts of the retina. The vitreous is a clear gel that fills two-thirds of the inside of the eye and occupies the space in front of the retina. As the vitreous gel pulls loose, it will sometimes exert traction on the retina, and if the retina is weak, the retina will tear. Most retinal breaks are not a result of injury. Retinal tears are sometimes accompanied by bleeding if a retinal blood vessel is included in the tear. Many people develop separation of the vitreous from the retina as they get older. However, only a small percentage of these vitreous separations result in retinal tears. Once the retina has torn, liquid from the vitreous gel can then pass through the tear and accumulate behind the retina. The buildup of fluid behind the retina is what separates (detaches) the retina from the back of the eye. As more of the liquid vitreous collects behind the retina, the extent of the retinal detachment can progress and involve the entire retina, leading to a total retinal detachment. A retinal detachment almost always affects only one eye at a time. The second eye, however, must be checked thoroughly for any signs of predisposing factors that may lead to detachment in the future.

What are retinal detachment symptoms and signs?

Flashing lights and floaters may be the initial symptoms of a retinal detachment or of a retinal tear that precedes the detachment itself. Anyone who is beginning to experience these symptoms should see an eye doctor (ophthalmologist) for

a retinal exam. In the exam, drops are used to dilate the patient's pupils to make a more detailed exam easier. The symptoms of flashing lights and floaters may often be unassociated with a tear or detachment and can merely result from a separation of the vitreous gel from the retina. This condition is called a posterior vitreous detachment (PVD). Although a PVD occurs commonly, there are no tears associated with the condition most of the time. The flashing lights are caused by the vitreous gel pulling on the retina or a looseness of the vitreous, which allows the vitreous gel to bump against the retina. The lights are often described as resembling brief lightning streaks in the outside edges (periphery) of the eye. The floaters are caused by condensations (small solidifications) in the vitreous gel and frequently are described by patients as spots, strands, or little flies. Some patients even want to use a flyswatter to eliminate these pesky floaters. There is no safe treatment to make the floaters disappear. Floaters are usually not associated with tears of the retina. If the patient experiences a shadow or curtain that affects any part of the vision, this can indicate that a retinal tear has progressed to a detached retina. In this situation, one should immediately consult an eye doctor since time can be critical. The goal for the ophthalmologist is to make the diagnosis and treat the retinal tear or detachment before the central macular area of the retina detaches.

What are retinal detachment causes and risk factors?

Studies have shown that the incidence of retinal detachments caused by tears in the retina is fairly low, affecting approximately one in 10,000 people each year. Many retinal tears do not progress to retinal detachment. Nevertheless, many risk factors for developing retinal detachments are recognized, including certain diseases of the eyes (discussed below),cataract surgery, and trauma to the eye. Retinal detachments can occur at any age. They occur most commonly in younger adults (25-50 years of age) who are highly nearsighted (myopic) and in older people following cataract surgery.

Which diseases of the eyes predispose to the development of a retinal detachment?

Lattice degeneration of the retina is a type of thinning of the outside edges of the retina, which occurs in 6%-8% of the general population. The lattice degeneration, so-called because the thinned retina resembles the crisscross pattern of a lattice, often contains small holes. Lattice degeneration is more common in people with nearsightedness (myopia). This tendency to lattice degeneration occurs because myopic eyes are larger than normal eyes and, therefore, the peripheral retina is stretched more thinly. Fortunately, only about 1% of patients with lattice degeneration go on to develop a retinal detachment. High myopia (greater than 5 or 6 diopters of nearsightedness) increases the risk of a retinal detachment. In fact, the risk increases to 2.4% as compared to a 0.06% risk for a normal eye at 60 years of age. (Diopters are units of measurement that indicate the power of the lens to focus rays of light.) Cataract surgery or other operations of the eye can further increase this risk in those with high myopia.

People taking certain kinds of eyedrops have an increased risk of developing a retinal detachment. Pilocarpine (Salagen), which for many years was a mainstay of therapy for glaucoma, has long been associated with retinal detachment. Moreover, by constricting the pupil, pilocarpine makes the diagnostic exam of the peripheral retina more difficult, possibly leading to a delay in the diagnosis.

Individuals with chronic inflammation of the eye (uveitis) are at increased risk of developing retinal detachment.

How does cataract surgery lead to a retinal detachment?

Cataract surgery, especially if the operation has complications, increases the risk of a retinal detachment. Cataracts are areas of cloudiness (opacities) that form in the lens. Following the introduction of extracapsular surgery, a modern method used almost exclusively today for the removal of cataracts, the risk of retinal detachment became far less. In

extracapsular cataract surgery, part of the capsule of the lens is left in place so that the vitreous gel is undisturbed. Phacoemulsification is a type of extracapsular cataract surgery that utilizes a very high speed ultrasonic instrument to break up and suck out the clouded lens of the eye. The capsule that is left in the eye may at a later time become cloudy, necessitating opening the capsule by using a laser. Opening the capsule increases the risk of retinal detachment. In intracapsular cataract surgery, the predominant surgical method used from 1965 to 1990, the entire lens was removed. The capsule at the back of the lens, therefore, was no longer present to hold the vitreous gel in place. Consequently, the vitreous gel moved forward, and the retina was subjected to increased pulling or traction on the retina from the vitreous, which led to tears of the retina. Today, if the capsule is broken, which can be a complication during extracapsular cataract surgery, the vitreous gel similarly can move forward and pull on the retina. This sequence can lead to a retinal tear and a detachment, especially during the first year after surgery.

What other factors are associated with a retinal detachment?

Blunt trauma, as from a tennis ball or fist, or a penetrating injury by a sharp object to the eye can lead to a retinal detachment.

A family history of a detached retina that is non-traumatic in nature seems to indicate a genetic (inherited) tendency for developing retinal detachments.

In as many as 5% of patients with a non-traumatic retinal detachment of one eye, a detachment subsequently occurs in the other eye. Accordingly, the second eye of a patient with a retinal detachment must be examined thoroughly and followed closely, both by the patient and the ophthalmologist. Diabetes can lead to a type of retinal detachment that is caused by pulling on the retina (traction) alone, without a tear. Because of abnormal blood vessels and scar tissue on the retinal surface in some people with diabetes, the retina can be lifted off (detached) from the back of the eye. In addition, the blood vessels may bleed into the vitreous gel. This detachment may involve either the periphery or central area of the retina.

Why is it mandatory to treat a retinal detachment?

A tear or hole of the retina that leads to a peripheral retinal detachment causes the loss of side (peripheral) vision. Almost all of those affected will progress to a full retinal detachment and loss of all vision if the problem is not repaired. The dark shadow or curtain obscuring a portion of the vision, either from the side, above, or below, almost invariably will advance to the loss of all useful vision. Spontaneous reattachment of the retina is rare. Early diagnosis and repair are urgent since visual improvement is much greater when the retina is repaired before the macula or central area is detached. The surgical repair of a retinal detachment is usually successful in reattaching the retina, although more than one procedure may be necessary. Once the retina is reattached, vision usually improves and then stabilizes. Successful reattachment does not always result in normal vision. The ability to read after successful surgery will depend on whether or not the macula (central part of the retina) was detached and the extent of time that it was detached.

What is the treatment for retinal detachment?

Retinal holes or tears can be treated with laser therapy or cryotherapy(freezing) to prevent their progression to a full-scale detachment. Many factors determine which holes or tears need to be treated. These factors include the type and location

of the defects, whether pulling on the retina (traction) or bleeding is involved, and the presence of any of the other risk factors discussed above. Three types of eye surgery are done for actual retinal detachment: scleral buckling, pneumatic retinopexy, and vitrectomy. Scleral buckling For many years, scleral buckling has been the standard treatment for detached retinas. The surgery is done in a hospital operating room with general or local anesthesia. Some patients stay in the hospital overnight (inpatient), while others go home the same day (outpatient). The surgeon identifies the holes or tears either through the operating microscope or a focusing headlight (indirect ophthalmoscope). The hole or tear is then sealed, either with diathermy (an electric current which heats tissue), a cryoprobe (freezing), or a laser. This results in scar tissue later forming around the retinal tear to keep it permanently sealed, so that fluid no longer can pass through and behind the retina. A scleral buckle, which is made of silicone, plastic, or sponge, is then sewn to the outer wall of the eye (thesclera). The buckle is like a tight cinch or belt around the eye. This application compresses the eye so that the hole or tear in the retina is pushed against the outer scleral wall of the eye, which has been indented by the buckle. The buckle may be left in place permanently. It usually is not visible because the buckle is located half way around the back of the eye (posteriorly) and is covered by the conjunctiva (the clear outer covering of the eye), which is carefully sewn (sutured) over it. Compressing the eye with the buckle also reduces any possible later pulling (traction) by the vitreous on the retina. A small slit in the sclera allows the surgeon to drain some of the fluid that has passed through and behind the retina. Removal of this fluid allows the retina to flatten in place against the back wall of the eye. A gas or air bubble may be placed into the vitreous cavity to help keep the hole or tear in proper position against the scleral buckle until the scarring has taken place. This procedure may require special positioning of the patient's head (such as looking down) so that the bubble can rise and better seal the break in the retina. The patient may have to walk, eat, and sleep with the head facing down for one to four weeks to achieve the desired result. Pneumatic retinopexy Pneumatic retinopexy is a newer method for repairing retinal detachments. It usually is performed on an outpatient basis under local anesthesia. Again, laser or cryotherapy is used to seal the hole or tear. The surgeon then injects a gas bubble directly inside the vitreous cavity of the eye to push the detached retina against the back outer wall of the eye (sclera). The gas bubble initially expands and then disappears over two to six weeks. Proper positioning of the head in the postoperative time period is crucial for success. Although this treatment is inappropriate for the repair of many retinal detachments, it is simpler and much less costly than scleral buckling. Furthermore, if pneumatic retinopexy is unsuccessful, scleral buckling still can be performed. Vitrectomy Certain complicated or severe retinal detachments may require a more complicated operation called a vitrectomy. These detachments include those that are caused by the growth of abnormal blood vessels on the retina or in the vitreous, as occurs in advanced diabetes. Vitrectomy also is used with giant retinal tears, vitreous hemorrhage (blood in the vitreous cavity that obscures the surgeon's view of the retina), extensive tractional retinal detachments (pulling from scar tissue), membranes (extra tissue) on the retina, or severe infections in the eye (endophthalmitis). Vitrectomy surgery is performed in the hospital under general or local anesthesia. Small openings are made through the sclera to allow positioning of a fiberoptic light, a cutting source (specialized scissors), and a delicate forceps. The vitreous gel of the eye is removed and replaced with a gas to refill the eye and reposition the retina. The gas eventually is absorbed and is replaced by the eye's own natural fluid. A scleral buckle is often also performed with the vitrectomy.

What are complications of surgery for a retinal detachment, and what is recovery like after retinal detachment surgery?

Discomfort, watering, redness, swelling, anditching of the affected eye are all common and may persist for some time after the operation. These symptoms are usually treated with eyedrops. Blurred vision may last for many months, and new glasses may need to be prescribed, especially because the scleral buckle may have changed the shape of the eye. The scleral buckle also can causedouble vision (diplopia) by affecting one of the muscles that controls the movements of the

eye. Other complications can include elevated pressure in the eye (glaucoma); bleeding into the vitreous, within the retina, or behind the retina; clouding of the lens of the eye (cataract); or drooping of the eyelid (ptosis). Additionally, infection can occur around the scleral buckle or even more widely in the eye (endophthalmitis). Occasionally, the buckle may need to be removed.

What are the results of surgery for a retinal detachment?

The surgical repair of retinal detachments is successful in about 80% of patients with a single procedure. With additional surgery, over 90% of retinas are reattached successfully. Several months may pass, however, before vision returns to its final level. The final outcome for vision depends on several factors. For example, if the macula was detached, central vision rarely will return to normal. Even if the macula was not detached, some vision may still be lost, although most will be regained. New holes, tears, or pulling may develop, leading to new retinal detachments. If a gas or air bubble was inserted in the eye during surgery, maintaining proper positioning of the head is also important in determining the final outcome. Close follow-up by an ophthalmologist, therefore, is required. Long-term studies have shown that even after preventive treatment of a retinal hole or tear, 5%-9% of patients may develop new breaks in the retina, which could lead to a retinal detachment. Overall, however, repair of retinal detachments has made great strides in the past 20 years with the restoration of useful vision to many thousands of people.

Retinal Detachment At A Glance

A retinal detachment is a separation of the retina from its attachments to the underlying tissue within the eye. Most retinal detachments are a result of a retinal break, hole, or tear. Most retinal breaks, holes, or tears are not the result of trauma but are due to preexisting factors such as high levels of myopia and prior ocular surgery. Flashing lights and floaters may be the initial symptoms of a retinal detachment or of a retinal tear that precedes the detachment itself. Early diagnosis and repair of retinal detachments are urgent since visual improvement is much greater when the retina is repaired before the macula or central area is detached. The surgical repair of a retinal detachment is usually successful in reattaching the retina.

Retinal Detachment

Results from separation of the sensory layer of the retina containing the rod and cones from the pigmented epithelial layer beneath. It may occur spontaneously because of degenerative changes in the retina (as in diabetic retinopathy) or vitreous humor, trauma, inflammation, tumor, or loss of a lens to a cataract. It is rare in children, the disorder most commonly occurs after age 40. Untreated retinal detachment results in loss of a portion of the visual field.

Assessment: 1. 2. Initially, the patient complains of flashes of light, floating spots or filaments in the vitreous, or blurred, sooty vision. Most of these phenomena result from traction between the retina and vitreous. If detachment progresses rapidly, the patient may report a veil-like curtain or shadow obscuring portions of the visual field. The veil appears to come from above, below, or from one side; the patient may initially mistake the obstruction for a drooping eyelid or elevated cheek. Straight-ahead vision may be unaffected in early stages but, as detachment progresses, there will be loss of central as well as peripheral vision. Diagnostic Evaluation: 1. Ophthalmoscopy or slit-lamp examination with full pupil dilation shows retina as gray or opaque in detached areas. The retina is normally transparent. Surgical Interventions: 1. Surgical intervention aims to reattach the retinal layer to the epithelial layer and has a 90% to 95% success rate. Techniques include: a. Photocoagulation, in which a laser or xenon are spot welds the retina to the pigment epithelium. b. Electrodiathermy, in which a tiny hole is made in the sclera to drain subretinal fluid, allowing the pigment epithelium to adhere to the retina. c. Cryosurgery or retinal cryopexy, another spot weld technique that uses a super cooled probe to adhere the pigment epithelium to the retina. d. Scleral buckling, in which the sclera is shortened to force the pigment epithelium closer to the retina; commonly accompanied by vitrectomy. Nursing Interventions: 1. Prepare the patient for surgery. Instruct the patient to remain quiet in prescribed (dependent) position, to keep the detached area of the retina in dependent position. Patch both eyes. Wash the patients face with antibacterial solution. Instruct the patient not to touch the eyes to avoid contamination. Administer preoperative medications as ordered. 2. Take measures to prevent postoperative complications. Caution the patient to avoid bumping head. Encourage the patient no to cough or sneeze or to perform other strain-inducing activities that will increase intraocular pressure. 3. Encourage ambulation and independence as tolerated. 4. Administer medication for pain, nausea, and vomiting as directed. 5. Provide quiet diversional activities, such as listening to a radio or audio books. 6. Teach proper technique in giving eye medications. 7. Advise patient to avoid rapid eye movements for several weeks as well as straining or bending the head below the waist. 8. Advise patient that driving is restricted until cleared by ophthalmologist. 9. Teach the patient to recognize and immediately report symptoms that indicate recurring detachment, such as floating spots, flashing lights, and progressive shadows. 10. Advise patient to follow up.

3.

I.

Definition

Retinal detachment is a separation of the retina from the choroid in the posterior eye. II. Risk Factors

 Trauma Age-related degenerative change Cataract removal III. Pathophysiology

Retinal layers separate from the choroid, creating a subretinal space. Vitreous fluid seeps between these layers, disrupting choroidal blood supply. Detachment may be partial, causing various degree of visual deficits, or total causing blindness in the affected eye. IV. Assessment/Clinical Manifestations/Signs and Symptoms

Recurrent flashes of light and floating spots Progressive blurring of vision in the affected eye, followed by visual field deficits, with the area of visual loss depending on the area of detachment. Anxiety, confusion, and fear of becoming blind Laboratory and diagnostic study findings Ophthalmoscopic examination may reveal an area of gray, opaque retina, possibly with folds, holes or tears. V. Medical Management

The treatment for a tear may be a cryopexy (freezing of the retinal area) or lase photocoagulation performed. Scleral bucking surgery is the most common method of treatment, requires that a piece of silicone, rubber or semihard plastic be placed against the outer surface of the eye and sutured into put. The piece pushes the sclera toward the middle of the eye, allowing the retina to settle back against the wall of the eye. Pneumatic retinopexy is used to reattach the retina, the physician uses a bubble of gas to push the two layers back together again. Vitrectomy is the possible procedure where the surgeon removes the vitreous fluid from the middle of the eye. The physician may then treat the retina with photocoagulation. At the end of the surgery, silicone oil or gas is injected into the ye to replace the vitreous fluid. VI. Nursing Diagnosis

Anxiety related to possible vision loss Disturbed sensory perception related to visual impairment Ineffective health maintenance related to knowledge deficit Risk for injury related to impaired vision Self-care deficit related to impaired vision VII. Nursing Management

Promote measures that limit mobility to prevent further injury. Position the client in bed preoperatively as prescribed (usually with the detached area dependent), and instruct the client to avoid lying face down, stooping, or bending. Enforce bed rest for 1 day postoperatively, with the client positioned supine or on the unoperated side unless otherwise directed. Promote measures that assist with the clients adaptation to the perceptual impairment. Preoperatively, patch both eyes if detachment threatens the macula. Administer sedation as prescribed, promote comfort and relaxation, and minimize eye strain. Administer prescribed medications, which may include adrenergic agonist agents (mydriatic) and anticholinergic (cycloplegic) agents.

Provide postoperative nursing care. Patch the affected eye for 1 to 4 hours Encourage visitors, socialization, sensory stimulation and diversionary activities. Administer mild analgesics for discomfort, and apply cool or warm compresses to edematous eyelids. Instruct the client on discharge instructions. Discuss allowed and restricted activities. Discuss prescribed positions. Instruct the client on the resumption of activity, including resuming activities of daily living gradually and as tolerated, commonly resuming light work in 3 weeks and normal activity in 6 weeks; avoiding heavy lifting, deep bending or stopping and avoiding bumping or otherwise injuring the head.

REFERENCES 1. 2. 3. 4. 5. http://www.ncbi.nlm.nih.gov/pubmedhealth http://en.wikipedia.org/wiki/Retinal detachment http://www.medicinenet.com/retinal_detachment/ http://nursingcrib.com/nursing-notes-reviewer/retinal-detachment/ http://www.nursing-nurse.com/management-of-retinal-detachment-340/