Retinal detachment

Although retinal detachment is painless, several visual symptoms appear before it advances. These signs include: 

• Appearance of floaters (shapes or spots (visible as small dots or irregular strands, among others) drifting across the visual field).
• Appearance of flashes of light in one or both eyes.
• Blurring of vision.
• Appearance of a curtain-like shadow encompassing the field of vision.
• Gradual loss of peripheral vision.

If any of the above symptoms are noted, patients are advised to seek medical attention immediately or within a maximum of 48 hours. This will help rule out a retinal tear or detachment and minimise the long-term visual damage that the retinal detachment may cause.

Eye surgeons usually perform associated tests to confirm a retinal detachment or tear. Once this confirmation is obtained, the patient is referred to the hospital to undergo laser surgery or other surgical procedures to reattach the displaced retina. 

Retinal surgery to reattach the retina to the back of the eye and sealing any breaks or holes in the retina can prevent blindness. The sight has already been lost because of the detached retina. If the surgery is successful, it will usually bring back some but not all lost eyesight.

Preoperative preparation

As most surgical procedures to correct retinal detachment are performed after the administration of a local anaesthetic, the patient is awake throughout the operation. The local anaesthetic is injected into the area surrounding the eye to numb it and prevent any pain during the surgical procedure.

Procedures

One of the following procedures is used to repair retinal detachment:

• Cryopexy and scleral buckle: the retinal holes are sealed by placing ‘splints’ (buckles made of sponge or solid silicone material) along the wall of the eye. These buckles are positioned outside the sclera (the white of the eyeball) (under the skin of the eye). They remain fixed there permanently.
• Vitrectomy, cryopexy, and gas, air, or silicone oil injection: For vitrectomy operations, which are referred to as keyhole surgeries for the eye, tiny openings (less than 1 mm in size) are created in the eye by the surgeon, who then removes the vitreous humour. Next, the surgeon locates the retinal breaks and subjects them to treatment with laser or cryopexy (freezing), which causes adhesion and scarring that seals the breaks. Seal formation usually requires up to 10 days. Next, a gas bubble, air, or silicone oil (used as tamponades) is inserted into the eye to function as ‘splints’, holding the retina in place until the tears are sealed. This process is termed as “intraocular tamponade.” “Tamponade” (the use of a tampon) refers to the insertion of a plug tightly into an orifice or a wound to prevent haemorrhage. In ophthalmic medicine, tamponade agents, which provide surface tension across retinal breaks, enable surgeons to prevent further fluid leakage into the subretinal space until the leak can be permanently sealed (using cryopexy). The three types of gases used for intraocular tamponade include:
• C3F8 (octafluoropropane) is a long-acting, non-flammable, non-toxic, synthetic gas and can remain in the eye for up to 12 weeks
• SF6 (sulphur hexafluoride) is a highly stable gas and can remain in the eye for up to 4 weeks
• C2F6 (hexafluoroethane) is a non-flammable, inert gas and can remain in the eye for up to 8 weeks

Postoperative care

• Eye drops: They reduce inflammation (anti-inflammatory eyedrops) and prevent infection (antibiotic-based eyedrops).
• Avoiding rubbing the eye: This may increase the chances of infection and complications.
• Analgesics (such as paracetamol): This relieves pain or discomfort.

It is important to note that:

• Itchy and/or sticky eyelids and mild discomfort (gritty sensation caused by the stitches) are normal for 5–10 days after surgery.
• Some fluid leakage from around the eye is a common observation after surgery.
• Blurred vision after surgery is normal.
• In some cases, especially after a scleral buckle procedure, the area surrounding the eyes may show slight bruising.
• Rest is important for healing.

Any discomfort should ease after 1–2 days. The eye requires about 2–6 weeks to heal in most cases. An appointment with the treating doctor is usually scheduled within 7–14 days of surgery.

If the pain or blurry vision intensifies after the operation, the patient is advised to contact the hospital immediately as further treatments may be necessary.

Usually, retinal detachment surgeries are outpatient procedures. Thus, overnight hospital stays are not needed and recovery can take place at home.

Working and driving should be avoided during recovery. If a gas bubble was inserted into the eye during surgery, flying should be avoided for a certain period of time. This is because the pressurised environment in airplanes may cause the gas or air bubble to expand in size, increasing intraocular pressure and causing vision loss.

Posturing is the hardest, but the most crucial, part of recovery. If a gas bubble or silicone oil is inserted into the eye, the patient is asked to ‘posture’ for up to 7 days, i.e., lying or sitting to position the head in a manner that enables the bubble to float up and press the retina into position during the healing process. The surgeon will determine the necessity and appropriate position for posturing. With the dispersion of the gas bubble, a moving line will begin to appear in the field of vision. The vision above the line is clear, but that under the line will be blurry or fuzzy. Eventually, the gas will disperse until it gradually disappears. The type of gas used determines the duration for which it will stay in the eye.

Recovery of vision usually requires a few weeks after surgery. The insertion of a gas bubble will cause the vision to be very blurry immediately after surgery. However, this is normal; once the retina is attached, the vision will improve gradually over a period of several months.

Visual acuity tests are performed to ascertain whether glasses are needed to improve vision. The final quality of vision depends on the severity and nature of the original retinal detachment. With timely diagnosis and treatment, most of the central vision can successfully be restored. However, if the central vision is already poor during the diagnosis of a retinal detachment, restoring the central vision in its entirety may not be possible. Reading using the affected eye may be difficult. From a distance, faces or car number plates may be difficult to recognise. However, objects and people approaching from the sides may be visible; this is important, given that peripheral vision is critical for daily activities, such as climbing stairs and going out.

Given that each patient is different and that some cases of retinal detachment are more complicated to treat than others, retinal detachment surgeries are not always successful; further, in some instances, more than one operation may be required.

After a retinal detachment, the eye tries to heal this damage naturally. However, this healing process is counterproductive, as it leads to the formation of scar tissue inside the eye and causes the retina to contract. This is referred to as proliferative vitreoretinopathy (PVR), a condition associated with poor vision that can cause the retina to detach once again (after it was surgically reattached). Around 5–10% of patients display scar tissue formation or develop another retinal tear, both of which will require additional surgeries.