How are retinal tears and detachments treated?
If you have a retinal tear, laser treatment would be required in the first instance. The laser technique used creates tiny spots of ARGON laser around the tear. The tear is usually around 0.5mm in length and these laser spots circumscribe this area to create heat spots forming a scar around the tear. Effectively, the scarring seals the tear and prevents fluid from entering behind the retina. In this way, this treatment prevents retinal detachment.
A complete retinal detachment requires urgent surgery to re-attach the retina to the back of the eye. Treatment for a retinal detachment is considered an emergency because a detachment occurs within hours (between 24 hours and a few days) and if left untreated fluid may enter beneath the macula and cause serious damage to your eye. If this happens, the prognosis for vision recovery diminishes. Operations are available to help at this stage, but it is advisable to treat a retinal detachment urgently.
There are three possible techniques for reattaching the retina to the back wall of the eye: the external and conventional – ‘buckle’ therapy (scleral buckling), vitrectomy surgery and Pneumatic Retinopexy.
Buckle therapy (scleral buckling) for detachment
This therapy has been available since the late 1960s with incremental updates to the techniques used since that time.
Buckle therapy applies pressure to the exterior of the eye using a buckle, which comprises fine bands of silicone rubber or sponge that are stitched onto the outside white of the eye (the sclera or wall of the eye) in the area where the retina has detached. This creates a belt effect that presses the wall of the eye so that it lies against the retina inside. By doing so, the buckling procedure closes the retinal break/hole. Any fluid that has collected underneath the retina is reabsorbed by the eye’s own natural processes and the retina reattaches. The bands can be left on the eye and should not be noticeable after the operation.
Buckle therapy is appropriate for around 5% of patients, whereby results are better. Buckle therapy might also be an option for patients who have an inferior retinal detachment (this occurs in the lower region of the eye) because vitrectomy can be inappropriate in these patients. Newer techniques using heavy silicone oil (Ala Heavy) have now been introduced to help treat these types of retinal detachments by vitrectomy surgery. Occasionally, a combination of techniques may need to be used.
Vitrectomy surgery for retinal tears and detachments
The majority of retinal tears and detachments are treated with keyhole surgery known as vitrectomy surgery.
Vitrectomy involves giving a local or general anaesthetic, and you can expect the entire surgery to take approximately 40 minutes, not too dissimilar in duration to a cataract operation. Vitrectomy surgery is a day case procedure conducted in a hospital theatre, a short walking distance from The Harley Street Eye Clinic.
Firstly, the vitreous jelly is extracted which means the source of the pull on the retina is removed and your ophthalmic surgeon has access to the back of your eye where the retina is located.
Secondly, any fluid collected beneath the retina is drained off internally.
Finally, the tear on the retinal surface is closed with cryotherapy (freezing treatment) so the retina flattens against the wall of the eye. Cryotherapy involves placing a probe over the area with the retinal tear and turning it on for a few seconds causing a small area to be frozen. You will experience a cold sensation in that area. The complete procedure takes approximately 30 – 40 minutes.
As an alternative to cryotherapy, a laser may be used to heal the retinal tear. The laser is delivered using a keyhole and microscopic instruments. The laser applies energy to the edge of the tear and effectively ‘sticks’ the retina to the wall of the eye.
After flattening of the retina, a bubble of gas or oil is injected into the eye, to help seal the retina and promote healing. It is effectively like a plaster within the eye.
If gas is chosen, then the advantage is that the bubble dissipates by itself within two weeks, but the disadvantage is a restriction on flying until the gas has fully cleared. If oil is chosen, patients have the advantage of being able to fly but oil requires surgical removal 3 – 12 months later after the retina has healed.
Occasionally you might be required to position yourself in a certain way for defined periods of time (for example half an hour per day). This is termed posturing and allows the gas or oil bubble to position in the optimal place within the eye to facilitate healing. Our recommendation is usually only for 2- 3 days.
At The Harley Street Eye Clinic, Mr El-Amir prefers to use sutureless (stitch-free) vitrectomy allowing the patient to experience a speedier recovery with less pain and discomfort. However not all patients are suitable for this type of surgery. At The Harley Street Eye Clinic, sutureless vitrectomy is day-case and uses local anaesthesia. For patients who prefer general anaesthesia, this is also offered. For this type of keyhole surgery, Mr El-Amir uses 23, 25 and 27 gauge vitrectomy systems that comprise state-of-the-art instruments measuring a mere hair’s breadth in diameter.
A small bubble of gas will be injected into the eye (with the hole created to do this permanently sealed by a precision laser). This bubble will cause enough pressure in the eye to repair the detachment.
It is important to choose the right type of operation to ensure the best results possible. Here at The Harley Street Eye Clinic our ophthalmic surgeon can discuss the options that are best suited to your situation.
What can you expect after vitrectomy surgery for retinal detachment?
Post-surgery, the quality of your vision will be dependent on where the retinal detachment was located. If the macula was involved for less than one week then vision will improve but it will not be back to normal completely. If the macula was detached for a long time then some vision will return but it will be impaired. If the macula was not involved in the detachment then vision recovery is very good.
Most detachments require only one surgery to reattach the retina, but less than 10% of detachments may require a second more invasive/radical surgery in order to reattach it.
Occasionally patients who experience vitrectomy surgery require ‘posturing’ after surgery, for example, face down or right cheek to pillow. The reason for this is to make the oil bubble float to where the tear is and to help close the tear. Mr El-Amir believes other elements of the complete surgical procedure are equally if not more important than posturing, and as such your need for posturing will be assessed on an individual basis. Posturing may only be necessary for 2-3 days in a minority of patients.
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