Step 1 – Learn the basics of retinal detachment
Step 2 – Learn about the surgery and what to expect
Step 3 – Learn about the other options
Step 4 – Learn about the potential risks of the procedure
Step 5 – Learn to maximize your results
The eye can be thought of as similar to a camera, with two main parts, a lens and a film. In addition, there is a gel called the vitreous that is located in front of the retina and is very firmly adherent to it. The film layer is called the retina and lines the back wall of the eye. The cells responsible for converting light to an electrical signal and producing vision are located in the outer layer of the retina. This layer receives blood flow from the outer wall of the eye. A retinal detachment is a separation of the outer layer of the retina from the wall of the eye.
The gel (vitreous) seperates from the back of the eye towards the front of the eye as a normal part of aging. As the gel separates, it is a tug of war between the retina and the vitreous. The vitreous may pull hard enough that it rips a hole in the retina. A hole in the retina allows the fluid portion of the vitreous to pass through the retinal hole and travel underneath the retina. This fluid separates the retina from its blood supply and causes the patient to see a dark area in the peripheral vision. If the fluid travels underneath the central vision then it causes blurriness of the central vision.
Pars plana vitrectomy is an outpatient surgical procedure which is performed in the operating room. It may be performed under twilight (awake, relaxed, and no pain) or general anesthesia. The retina specialist places 3 small ports that are less than 0.5mm in size through the white of the eye and into the vitreous cavity. Fluid is infused into the vitreous cavity while the surgeon uses a vitrectomy probe to carefully removes the vitreous. Special attention is placed to identify any areas where the vitreous is pulling on a retinal tear. Any such areas are addressed by removing the vitreous traction. This allows the retinal tear to sit flat against the eye and begin the healing process. The fluid in the back of the eye is then removed and slowly replaced with air. This allows any additional fluid between the retina and wall of the eye to be removed. Laser therapy is used to weld the retina around the retinal tears, and prevent fluid from collecting underneath them. The air is then removed and replaced by either a gas bubble or silicone oil. Both gas and silicone oil weigh less than the natural fluid produced in the eye, and thus float to the top of the eye. The patient will therefore be asked to maintain a specific position for approximately 5-7 days after surgery. The purpose is to allow the gas or oil to move into a position that it covers the retinal tears, and prevents fluid from collecting underneath it while the retinal laser takes effect.
There are two different types of self-absorbing gas: SF6 and C3F8. SF6 typically lasts approximately 2 weeks and C3F8 approximately 6-8 weeks. Patients will notice a clear area at the top of their visual field which represents the area of retina not covered by the gas bubble. This area will become larger over time until the gas bubble no longer covers the area of central vision. At this point, the central vision will slowly become clearer. This process will occur until the gas bubble resolves completely. The central vision is typically decreased or distorted if it was affected by the retinal detachment. This typically improves slowly over a period of several months.
It is not possible to see through the gas bubble. The central vision will become clearer (if pre-operatively involved by the retinal detachment) over several weeks to months. If the central vision is not involved, the primary visual improvement will be an improvement in the peripheral vision whch was previously affected by the retinal detachment.
Patients may not travel to high altitudes or fly when they have a gas bubble in the eye. The gas bubble expands rapidly in high altitudes causing high eye pressure and blindness.
Silicone oil is a great choice for patients who need a longer acting agent to prevent retinal re-detachment. It is not self-absorbing and may be removed safely at a later date. It is difficult to see through silicone oil and the vision is typically limited with the silicone oil in the vitreous cavity. The vision typically improves with removal of the silicone oil, but may be limited due to underlying damage from the pre-existing retinal detachment.
Scleral Buckle is an outpatient surgical procedure which is typically performed under general anesthesia. A silicone band or sponge is used to indent the outer wall of the eye towards the retinal tears. The apposition of the outerwall of the eye against the retinal hole prevents fluid from entering the retinal hole, and thus causes the retinal to reattach. Cryotherapy (freezing therapy) is typically applied to the retinal tears at the time of scleral buckling surgery. Occasionally, scleral buckling surgery may be performed at the same time as a pars plane vitrectomy.
Pneumatic retinopexy is a procedure used to repair select types of retinal detachments. It is an in-office procedure which is typically performed with topical (eye drops) anesthesia.
The retina specialists who recommends the treatment will discuss the risks, benefits, and alternatives to the procedure. It is up to the judgement of the physician to weigh the benefit of the procedure against the risks. It is only once the decision is made that the benefits outweigh the potential risks is the procedure offered to the patient.
Pars plana vitrectomy is reported to be successful in repairing retinal detachments approximately 90% of the time with 1 operation. Approximately 10% of patients need more than 1 surgery for final retinal reattachment. The risk of needing more than 1 surgery is higher for patients who have pre-existing proliferative vitreoretinopathy.
The most significant risk of pars plana vitrectomy is failure of the procedure to repair the detachment. In this case, another surgery, such as an additional pars plans vitrectomy (possibly with silicone oil) and/or scleral buckle is typically required.
Symptoms of retinal re-detachment include the sudden onset of many new floaters, new onset flashing lights, or noting a progressive decrease in the peripheral vision (like a curtain coming down at a play). This is urgent and the treating physician should be made aware the same day.
There is a small risk of infection following the procedure. If this is going to occur, it typically occurs 3-5 days following the procedure. Symptoms include redness around the eye that gets worse not better, extreme light sensitivity, and worsening pain. This is a medical emergency and requires immediate treatment by a retina specialist.
Patients who still have their nature lens will experience progression of their cataract following vitrectomy surgery. Approximately 90% of patients who are 50 years or older will require cataract surgery within 2 years.
All surgeries are associated with a number of other uncommon, but possible problems. Potential complications of pars plana vitrectomy include cataract formation, high eye pressure, bleeding within the eye, development of new retinal tears, proliferative vitreoretinopathy, and need for further procedures.
It is critical to the success of the procedure to maintain the positioning requested for 50 minutes per hour, 24 hours per day (including during sleep). Most physicians will recommend 1 week of positioning.
It is important to use eye drops as prescribed by your retina specialist. Patients may continue to use prescription eye drops (such as for glaucoma), unless otherwise told not to by their physician.
Traveling to high altitudes results in rapid expansion of the gas bubble and subsequent blindness. Patient may not travel to high altitudes until the gas bubble resolves.
Administration of nitric oxide for anesthesia may cause rapid expansion of the gas bubble and blindness. Patients should make their anesthesiologist aware they have a gas bubble in the eye if they are undergoing surgery.
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