Retinal Detachment Repair
June 6, 2020
San Diego County Optometric Society Newsletter: Retina Corner
By Nikolas J.S. London, MD FACS
President and Director of Clinical Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla
Dear SDCOS membership,
One of my favorite surgeries to perform is repairing retinal detachments. It is a wonderful feeling to be able to tell a patient, sitting in my exam chair and terrified of the vision they have lost or feel is slipping away, that they will be ok, that in the vast majority of cases I can fix the problem and restore their sight. In fact, retinal detachment repair is perhaps the defining procedure of the vitreoretinal surgeon. It is one of the things we focus on in fellowship training with countless surgeries performed to hone our surgical skill. This month, I would like to go through our various approaches, and, if you will bear with me, I think it might be helpful to go through them similar to how I describe them to my patients.
With that patient sitting in the chair, the first thing I tell them is that everything is going to be ok. After I reassure them, I like to explain all the options to my patients regardless of whether or not they all apply to them. My thought is that this mini lecture will be empowering in a time where they must feel extremely vulnerable, even though the vast majority will simply go with the option I recommend. First, I explain how retinal detachments happen. I point to the model on my desk, orient them to the front and back of the eye and point out the cornea, lens, vitreous, and retina. Next, I describe the retina as a very thin and delicate tissue that lines the inner back wall like wallpaper made out of Kleenex lining the inside of a fishbowl. In front of the retina, I tell them, is the vitreous gel, which is transparent and resembles uncooked egg white. This gel is composed of water, collagen, and hyaluronic acid, and has a condensed collagen “skin” on the outside – like the latex on the edge of a water balloon. I describe how as we age the collagen breaks down, the vitreous liquifies, and the “skin” of the vitreous separates from the retina – similar to peeling tape off of that delicate wallpaper. You can imagine that if the adhesive is too strong the tape might rip the wallpaper. If this happens to the retina you have a retinal tear, and if the liquified vitreous gets through the tear and under the retina, you have a retinal detachment.
With this background, I then explain our options for repair. I explain that all we really need to do is to seal the retinal break(s). If we can do that, the fluid should resolve spontaneously. The three options include pneumatic retinopexy, vitrectomy, and scleral buckling. It is important to explain the advantages and disadvantages of each, to help the patient decide the best approach for them. These are summarized in the table below. I also explain each procedure briefly. Pneumatic retinopexy can be done in the office and has a fairly high success rate with excellent visual outcomes. It involves using laser and/or cryotherapy to create a scar around the tear, sealing the retina to the RPE, and injecting a gas bubble into the eye to flatten the tear and allow the scar to heal. As the gas bubble is relatively small, excellent post-operative positioning is critical, and can be challenging for some patients. Vitrectomy is a surgical procedure where the vitreous is removed, the subretinal fluid is actively removed, laser is used to barricade the tear, and a large gas bubble is placed. This is an excellent procedure for most cases, is very effective and minimizes positioning, but requires scheduling in an operative room, is expensive for uninsured patients, and has guarantee of accelerating cataract formation. Lastly, a scleral buckle involves suturing a small silicone band to the external surface of the eye to physically indent the retina in the area of the tear as well as cryotherapy to create the scar. It has a success rate similar to vitrectomy, and avoids cataract acceleration, but has a longer surgical time and healing process, and changes the refractive status of the eye, which can be frustrating for pseudophakic patients.
Once we decide on the best procedure it is time to repair the detachment. I will save the details of these procedures for another time, but would be more than happy to explain them to anyone interested. We also have great videos of vitrectomy and scleral buckling, and a chapter I wrote on pneumatic retinopexy I’d be happy to share. Even better, let me know if you would like to join me in the OR to see a case!
Thanks again for reading – I hope that this was helpful to you and your patients. Please don’t ever hesitate to contact me.
Best wishes, and until next time,