November 20, 2019
For an ophthalmologist, retinal detachment surgery is one of the most significant and common surgical procedures. Retinal detachment involves a wide pathological spectrum and features a continual challenge. Ophthalmology is a field of medicine that requires a specialized handicraft skill. But compared to a handyman, ophthalmologists work with a living organ and not lifeless objects. However, if you happen to need an eye specialist in Singapore you can check with Dr. Claudine Pang at Asia Retina Eye Surgery Centre, located at #15-10 The Paragon, 290 Orchard Rd, Singapore 238859 which can do the surgery if needed.
Being the light-sensitive layer of tissue, the retina borders the inner side of the eye and transmits visual information via the optic nerve to the brain. When retinal detachment happens, it is hauled or raised from its usual location. Retinal detachment (RD) is the separation of the neurosensory retina from the retinal pigment epithelium (RPE).
If not medicated immediately, permanent vision loss could happen to the patient. There are also instances where minor areas of the retina could be ripped. These minor areas, commonly known as retinal tears or retinal breaks, can result in retinal detachment.
Symptoms of Retinal Detachment
Blurred vision, vision field loss, floaters (“bugs”), and flashes of light are the most common symptoms of retinal detachments. With certain movement of vitreous and supple and moist look, the detachments are bulbiform or a flat elevation of the retina. After a thorough examination of the entire retina, retinal breaks could be identified.
Different Types of Retinal Detachment
Retinal detachment is differentiated based on pathology and various treatments can be performed accordingly. Rhegmatogenous retinal detachment is the result of retinal breaks, while non-rhegmatogenous retinal detachment is the result of other ocular disease or systemic illness.
- Rhegmatogenous – This is the typical form of retinal detachment observed among patients. This happens when the retina tears or breaks resulting in its partition from the retinal pigment epithelium (RPE) that sustains the retina through its pigmented cell layer. Then, this partition is filled with fluid.
- Tractional – This form of retinal detachment is less observed among patients. This occurs when scar tissue on the retina’s exterior layer shrinks and triggers its separation from the RPE.
- Exudative – This type of detachment takes place when fluid seeps out into the region beneath the retina. This retinal detachment is often induced by infection in the retina, comprising retinal inflammatory conditions and eye injuries or eye traumas.
Retinal Detachment Surgery: Common Treatment Procedures
Proper cryopexy may ensure enough adhesion of the neural retina to RPE. Cryopexy is a procedure that freezes the region around the holes in the retina. Under binocular indirect ophthalmoscope, the choroid and the sclera pressed closer to the detached retina by the cryoprobe can be observed. The choroid turns its colour from orange to yellow first, then white during cryopexy. Then the retina begins to change to white. Freezing should be discontinued when the retina has a modified colour.
Another way of treating retinal detachment is through using a scleral buckle, a small synthetic band, which is linked to the eyeball’s external surface to lightly push the eye’s wall against the torn or broken retina. For extreme cases of retinal detachment, vitrectomy is often needed.
Undergoing a retinal detachment surgery early can significantly enhance the vision of most patients with this condition. However, some patients will require more than one surgical operation to completely heal the detached retina. When performing a vitrectomy, the surgeon creates a very small incision in the sclera or the white of the eyes. After that, to eliminate the vitreous, a small tool is positioned into the eye. Then to change the vitreous, the eyes are treated with a salt solution.
Vitrectomy As a Retinal Detachment Surgery
Before incorporating as a routine procedure, vitrectomy was only performed for severe cases and complications due to PVR, vitreous haemorrhage, giant tears, and so forth. It was after the 1980s when this type of surgical operation has become extremely famous, specifically for the treatment of pseudophakic eyes.
Advantages of Vitrectomy
Vitrectomy offers a lot of advantages which includes the careful usage of adhesive therapy, removal of traction forces from transvitreal and periretinal membranes and media opacities, retina’s internal intraoperative reattachment, and enhanced localization and visualization of retinal tears and breaks. These procedural steps are usually completed without the complications that are commonly observed in scleral buckling.
Disadvantages of Vitrectomy
The main disadvantage of vitrectomy is the growth of nuclear sclerotic cataracts in phakic eyes.
After many years following the surgery, increasing studies suggest that in pseudophakic vitrectomized eyes, open-angle glaucoma may form. The expense of this option is significantly greater than with scleral buckling or PR.
Although more studies are required to evaluate the effects of vitrectomy, its failure may lead to the advancement of comparatively serious types of PVR. Additional information is still needed regarding the exact causes of failure after doing the vitrectomy procedure. As more procedures and more data is acquired with this considerably novel technique, more solutions and discoveries will be studied and analyzed.
Vitrectomy Techniques for Routine Retinal Detachments
Vitrectomy is frequently achieved using a laser photocoagulator, an endoillumination, an accessory viewing system, an operating microscope, and an automated vitreous cutter. The required equipment is significantly higher and more expensive than those needed in scleral buckling and pneumatic operation.
Results of Vitrectomy
The success of a vitrectomy procedure varies considerably ranging from 65% to 100% in various studies. The average of a successful retinal reattachment surgery is 85%, a percentage that is relatively similar to the one observed in scleral buckling surgery. A recent study was performed to compare the results of the two procedures. However, the randomized and controlled study with some supplementary non-controlled data gave complicated and variable results. Therefore, depending upon case selection, a conclusion on the effectiveness of vitrectomy is difficult to obtain as the results vary significantly.
There are many variables affecting postoperative vision but among all of the variables, measuring preoperative vision is the most significant. However, experiments differentiating postoperative vision using the varied techniques have not been done. From previous studies, the visual results of the patients resemble those who have done scleral buckling or pneumatic retinopexy. Among those tested, the substantial proportion of patients who had macula-off detachments observed a notable visual recovery.
Complications of Vitrectomy
Progressive nuclear sclerosis is the most significant and typical complication observed in phakic eyes. This is usually anticipated to happen in the substantial proportion of the cases. Excluding nuclear-sclerotic-induced myopia cases, the studies showed that it is uncommon to have complications related to altered refractive error and strabismus after vitrectomy.
At the late stage, proliferative vitreoretinopathy (PVR) is the most typical reason for retinal re-detachment. This has the possibility of happening in both scleral buckle and vitrectomy. PVR may also have a chance to happen even if the retina is reattached and the primary retinal breaks are closed. This may cause re-emergence of retinal detachment, epi-macular membrane, more retinal breaks or reopening of primary breaks. Aside from PVR, the most significant eye complications after vitrectomy include iatrogenic retinal breaks, newly formed breaks, circumvented breaks, and PVR. The last three complications are also the types of retinal detachment complications observed as the disease progresses.
In addition, all common complications that are often observed in scleral buckling typically do not happen with vitrectomy. These include fish-mouthing of retinal breaks, implant extrusion, suture needle scleral perforation, and problems with intravitreal gas injections and external/exterior subretinal fluid drainage. However, complications such as endophthalmitis, epimacular proliferation, choroidal detachment, increased intraocular pressure, PVR, recurrent retinal detachment has the possibility to happen in both vitrectomy and scleral buckling.
Vitrectomy is considered as a valuable procedure in the restoration of complex retinal detachment cases. By implementing micro incisional techniques, this type of retinal detachment surgery offers a less severe method for the cure of non-complicated cases. Also, it is often observed as an effective method in the treatment of retinal detachment and is increasingly used to medicate routine retinal detachment patients, specifically nonphakic cases.
Allowing the unfolding of giant tears, intraoperative retinal reattachment with the aid of gas or perfluorocarbon liquids, and the elimination of opacities and membranes, vitrectomy employs wide-angle viewing, high magnification, vitreous cutting abilities, and endoillumination. In addition, vitrectomy created possibilities of using total gas fill or silicone oil in postoperative intraocular tamponade during the procedure. However, the main disadvantage is that cataracts often progress after vitrectomy in phakic eyes.