Medical Emergency: Recognizing Retinal Detachment
If you’re having cataract surgery, you’re in good company. It’s the most frequently performed operation in the United States and is especially common for people over age 65. It is a very safe procedure, and complications are rare. However, about 1 to 2 percent of people who undergo cataract surgery will experience a retinal detachment—a serious condition that requires prompt medical attention.
What is retinal detachment?
In a normal eye, the retina, a thin, light-sensitive layer of nerve tissue lining the back of the eye, presses up against an underlying layer of cells known as the retinal pigment epithelium (RPE). But sometimes the retina can become detached from the RPE in a manner similar to peeling wallpaper (see illustration).
What causes the detachment?
Most commonly, a hole, tear or break in the retina enables fluid from the vitreous humor to seep in under the retina, causing it to separate from the RPE. A less frequent cause of retinal detachment is scar tissue on the surface of the retina that contracts, causing the retina to pull away from the underlying cells. In some cases, fluid leaks into the area underneath the retina, even though there are no retinal tears or breaks. In the setting of cataract surgery, it is believed that most retinal detachments begin with a separation of the vitreous gel from the surface of the retina. This vitreous detachment occurs frequently and is benign, except in those cases where the separation of the vitreous causes a small tear or hole in the retina. Fluid can then enter through the holes and elevate or detach the retina.
The greatest risk of retinal detachment after cataract surgery occurs among people who are also very nearsighted. Even in the absence of cataract surgery, being very nearsighted is the principal risk factor for retinal detachment. This is because the peripheral retina is thinner and detaches easier in individuals with very long, nearsighted eyes. Intraoperative complications of cataract surgery also can increase the risk of retinal detachment. Capsule-related complications, such as lens remnants left in the vitreous humor during cataract surgery, can raise the risk as well.
Although cataract surgery—or any eye surgery—and extreme nearsightedness are risk factors for retinal detachment, other factors can also impact your risk.
• Race and gender. Men are more likely than women and whites are more likely than blacks to have a retinal detachment.
• Family history. Having a first-degree relative (mother, father or sibling) who has had a retinal detachment makes it more likely that you will have one as well.
• Previous retinal detachment. People who have had a retinal detachment in one eye are at much increased risk for having the problem in the other eye.
• Other eye-health problems. Eye tumors, diabetic retinopathy and sickle cell retinopathy are associated with an increased risk.
• Eye injury. Retinal detachment can result from trauma to the eye.
Know the signs
The symptoms of a retinal tear or detachment can occur suddenly, or they may develop gradually over time. If you experience the new onset of any of the symptoms below, contact your ophthalmologist immediately. Prompt treatment offers the best chances of vision recovery.
Floaters. These are tiny spots and squiggles that may drift across your field of vision. Floaters are usually benign, but they may be a sign of a retinal tear or detachment. New-onset floaters, or a sudden change or worsening in them, are particularly concerning.
Flashes. These brief sparkles, often described as resembling lightning, can appear at the edges of your field of vision; flashes, too, can indicate a retinal tear or detachment, particularly if they occur in conjunction with new floaters. A streak of light that is seen only with the eyes open and exposed to light is common and usually related to reflections off the implant after cataract surgery. But flashing lights that seem to come out of nowhere may indicate pulling on or tearing of the retina.
A curtain. A dark shadow or curtain that covers part of your field of vision is a possible sign that a small retinal tear has developed into a retinal detachment. Even if you don’t experience any of these symptoms within 12 months of your cataract surgery, it’s important to remain vigilant; retinal detachment is a lifelong risk.
Small holes or tears in the retina may not require treatment; however, they should be monitored by your eye doctor. If treatment is necessary, laser surgery or cryopexy (a treatment that uses a freezing metal probe) can be used to create tiny burns in the retina that help prevent fluid from moving under the retina and fuse the retina back in place.
If the retina has detached, you’ll need to undergo more extensive surgery. Treatment is usually more successful at restoring vision when it occurs before the central part of the retina (called the macula) detaches. That’s why it is so important to contact your ophthalmologist immediately if you experience any of the symptoms above.
There are three main surgical procedures used to treat a retinal detachment:
Scleral buckle. This implant is made of silicone sponge or rubber and wraps completely or partially around the outer layer of the eye. It holds the retina in place by reducing tension and pulling on the retina. The implant, which cannot be seen after surgery, is usually left in place permanently.
Vitrectomy. The vitreous humor, the clear gel fluid that fills the eye cavity, is removed and the retina reattached. A gas or a silicone oil bubble is inserted to hold the retina in place during healing. A scleral buckle may be installed at the same time a vitrectomy is performed.
Pneumatic retinopexy. During this procedure, the doctor will inject a small bubble of gas into the vitreous cavity. The gas bubble then pushes the retina back in place so it rests against the RPE.
As part of all these procedures, laser surgery or cryopexy is used to prevent further tearing and to fuse the retina in place.