The retina is an inner light-sensitive layer of tissue within the eye. The retina serves as a projector screen for the brain when an image is projected onto the retina, triggering nerve impulses to the visual centers through the optic nerve. Vision can become impaired when the retina is damaged. However, repairing the retina is possible.
Retinal Detachment Surgery
Detached retina means the light-sensitive tissue in the back of the eye has separated from its supporting layers.
detachment surgery operations are urgent. A detached retina lacks oxygen, which causes cells in the area to die. This can lead to blindness.
If holes in the retina are found before a detachment occurs, an opthalmologist can close the holes using a laser. This is usually done in the doctor's office.
If the retina has just started to separate, a procedure called pneumatic retinopexy may be done to repair it. Pneumatic retinopexy (gas bubble placement) is also usually an office procedure. The health care provider injects a bubble of gas into your eye. You will be positioned so the gas floats up against the hole in the retina and pushes it back into place. The surgeon will use a laser to permanently seal the hole.
More severe detachments require more advanced surgery. There following procedures are done in a hospital or outpatient surgery center:
- The scleral buckle method bends the wall of the eye inward so that it meets the hole in the retina. Scleral buckling can be done under local or general anesthesia
- The vitrectomy procedure uses very small instruments inside the eye to pull the retina forward. Most vitrectomies are done under local anesthesia.
For some complex detachments, both procedures may be done during the same operation.
Why the Procedure is Performed
Retinal detachments do not improve without treatment. Repair is necessary to prevent permanent vision loss.
The urgency of the surgery depends on the location of the detachment. If the detachment has not affected the central vision area (the macula), surgery should be done quickly, usually the same day. This is necessary to prevent further detachment of the retina.
If the macula detaches, the surgery can still be done, but the visual result will not be as good. If the macula has already detached, there is less urgency. Surgeons can wait a week to 10 days to schedule surgery.
Risks for retinal detachment surgery may include:
- Detachment not completely fixed (may require additional surgeries)
- Increase in eye pressure (elevated intraocular pressure)
General anesthesia may be required. The risks for any anesthesia are:
- Reactions to medications
- Problems breathing
The chances of successful reattachment of the retina depend on the number of holes, their size, and whether there is scar tissue in the area.
Most of the time, the retina can be reattached with only one operation, although some people need several surgeries. Less than 10% of detachments cannot be repaired. Failure to repair the retina always leads to poor or no vision in the eye.
After surgery, the quality of vision depends on where the detachment occurred:
- If the central area of vision was not involved, vision will usually be very good.
- If the central area of vision was involved for less than 1 week, vision will usually be improved, but not 20/20 (normal).
- If the central area of vision was detached for a long time, vision will return, but it will not be sharp.
- The procedures usually do not require an overnight hospital stay.
- You will need to limit activities for some time.
- If the doctor repaired the retina using the gas bubble procedure, you must keep your head face down or turned to one side for several weeks. It is important to maintain this position so the gas bubble pushes the retina in place.
- Patients with a gas bubble in the eye may not fly.
Vitrectomy for Diabetic Retinopathy
Diabetic retinopathy is progressive damage to the eye's retina caused by long-term diabetes. It can cause blindness.
Diabetic retinopathy is caused by damage to blood vessels of the retina, the light-sensitive outer layer of the eye.
It is classified as non-proliferative or proliferative.
- Non-proliferative diabetic retinopathy is the early stage of the disease and is less severe. The existing blood vessels in the eye start to leak fluid into the retina, which leads to blurred vision.
- Proliferative retinopathy is the more advanced form of the disease, and more severe. New blood vessels start to grown within the eye. These new vessels are fragile and can bleed (hemorrhage), which may cause vision loss and retinal scarring.
Diabetic retinopathy is the leading cause of blindness in working-age Americans. People with both type 1 diabetes and type 2 diabetes are at risk for this condition.
The likelihood and severity of retinopathy increase the longer you have diabetes, and is likely to occur earlier and be more severe if your diabetes is poorly controlled. Almost everyone who has had diabetes for more than 30 years will show signs of diabetic retinopathy.
One of the first symptoms of diabetic retinopathy is poor night vision. Other symptoms include:
- Blurred vision
However, many people have no symptoms before major bleeding occurs in the eye. This is why everyone with diabetes should have regular eye exams.
Exams and Tests
In nearly all cases, diabetic retinopathy can be diagnosed with an eye exam. A retinal photography test may also be used.
The goal of treatment is to control your blood sugar, blood pressure, and cholesterol.
Treatment, however, usually does not reverse existing damage, but will keep the disease from getting worse. Drugs that keep abnormal blood vessels from growing in patients with proliferative diabetic retinopathy are under development.
Laser surgery may be used to keep vessels from leaking or to get rid of abnormal fragile vessels.
A surgical procedure called vitrectomy is used when there is bleeding (hemorrhage) into the eye. It may also be used to repair retinal detachment.
- American Diabetes Association - www.diabetes.org
- National Diabetes Information Clearinghouse - www.diabetes.niddk.nih.gov
- Prevent Blindness America - www.preventblindness.org
Patients who have good control of their blood sugar and blood pressure may improve their outcomes.
Diabetic retinopathy can lead to blindness without treatment.
When to Contact a Medical Professional
Call for an appointment with an ophthalmologist (eye doctor) if you have diabetes and you have not seen an ophthalmologist in the past year.
People with diabetes should see an ophthalmologist to have their eyes dilated once a year. This lets the doctor see the retina. Frequent eye exams and laser surgery, if necessary, can prevent blindness in most cases.
In nearly all cases, diabetic retinopathy can be diagnosed with an eye exam. A retinal photography test may also be used.
A macular hole is a small break in the macula, located in the center of the eye's light-sensitive tissue called the retina.
What Causes a Macular Hole?
Most of the eye's interior is filled with vitreous, a gel-like substance that fills about 80 percent of the eye and helps it maintain a round shape. The vitreous contains millions of fine fibers that are attached to the surface of the retina. As we age, the vitreous slowly shrinks and pulls away from the retinal surface. Natural fluids fill the area where the vitreous has contracted. This is normal. In most cases, there are no adverse effects. Some patients may experience a small increase in floaters, which are little "cobwebs" or specks that seem to float about in your field of vision.
However, if the vitreous is firmly attached to the retina when it pulls away, it can tear the retina and create a macular hole. Also, once the vitreous has pulled away from the surface of the retina, some of the fibers can remain on the retinal surface and can contract. This increases tension on the retina and can lead to a macular hole. In either case, the fluid that has replaced the shrunken vitreous can then seep through the hole onto the macula, blurring and distorting central vision.
Macular holes can also occur from eye disorders, such as high myopia (nearsightedness), macular pucker, and retinal detachment; eye disease, such diabetic retinopathy and Best's disease; and injury to the eye.
What Are the Symptoms of a Macular Hole?
Macular holes often begin gradually. In the early stage of a macular hole, people may notice a slight distortion or blurriness in their straight-ahead vision. Straight lines or objects can begin to look bent or wavy. Reading and performing other routine tasks with the affected eye become difficult.
Are There Different Types of Macular Holes?
Yes. There are three stages to a macular hole:
- Foveal detachments (Stage I). Without treatment, about half of Stage I macular holes will progress.
- Partial-thickness holes (Stage II). Without treatment, about 70 percent of Stage II macular holes will progress.
- Full-thickness holes (Stage III).
The size of the hole and its location on the retina determine how much it will affect a person's vision. When a Stage III macular hole develops, most central and detailed vision can be lost. If left untreated, a macular hole can lead to a detached retina, a sight-threatening condition that should receive immediate medical attention.
How is a Macular Hole Treated?
Although some macular holes can seal themselves and require no treatment, surgery is necessary in many cases to help improve vision. In this surgical procedure--called a vitrectomy--the vitreous gel is removed to prevent it from pulling on the retina and replaced with a bubble containing a mixture of air and gas. The bubble acts as an internal, temporary bandage that holds the edge of the macular hole in place as it heals. Surgery is performed under local anesthesia and often on an out-patient basis.
Following surgery, patients must remain in a face-down position, normally for a day or two but sometimes for as long as two-to-three weeks. This position allows the bubble to press against the macula and be gradually reabsorbed by the eye, sealing the hole. As the bubble is reabsorbed, the vitreous cavity refills with natural eye fluids.
Maintaining a face-down position is crucial to the success of the surgery. Because this position can be difficult for many people, it is important to discuss this with your doctor before surgery.
What are the Risks of Surgery?
The most common risk following macular hole surgery is an increase in the rate of cataract development. In most patients, a cataract can progress rapidly, and often becomes severe enough to require removal. Other less common complications include infection and retinal detachment either during surgery or afterward, both of which can be immediately treated.
For a few months after surgery, patients are not permitted to travel by air. Changes in air pressure may cause the bubble in the eye to expand, increasing pressure inside the eye.
How Successful is this Surgery?
Vision improvement varies from patient to patient. People that have had a macular hole for less than six months have a better chance of recovering vision than those who have had one for a longer period. Discuss vision recovery with your doctor before your surgery. Vision recovery can continue for as long as three months after surgery.
What if I Cannot Remain in a Face-down Position After the Surgery?
If you cannot remain in a face-down position for the required period after surgery, vision recovery may not be successful. People who are unable to remain in a face-down position for this length of time may not be good candidates for a vitrectomy. However, there are a number of devices that can make the "face-down" recovery period easier on you. There are also some approaches that can decrease the amount of "face-down" time. Discuss these with your doctor.
Is My Other Eye at Risk?
If a macular hole exists in one eye, there is a 10-15 percent chance that a macular hole will develop in your other eye over your lifetime. Your doctor can discuss this with you.
Epiretinal membrane is a disease of the eye in response to changes in the vitreous humor or less commonly, diabetes. It is also called macular pucker. With age, the vitreous humor liquifies and pulls away from the retina, creating a posterior vitreous detachment (PVD). After a PVD occurs, a tansparent layer of cells can form in the macula. This can create tension on the retina like a scar tissue which may bulge and pucker, or even cause swelling or macular edema. often this results in visual blur. The distortion can make objects look different in size. Once present, the macular pucker will remain in most patients. Worsening of vision with macular pucker can be treated with vitrectomy surgery.
Surgeons can often remove or peel the membrane through the sclera using a procedure called a vitrectomy. Surgery is not usually recommended unless the distortions are severe enough to interfere with daily living.
- Elevated eye pressure
- Retinal detachment
Cataracts can frequently develop following vitrectomy surgery, requiring cataract surgery.