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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."