Category: Retinal Detachments

Total Retinal Detachment Repaired with 25 gauge Vitrectomy

Post author By Randall Wong, M.D.
Post date February 13, 2019

Retina Specialist | Retinal Detachment | Northern Virginia | Washington DC

Vitrectomy for Retinal Detachment

Vitrectomy alone has become very popular for repairing a retinal detachment. Other choices include pneumatic retinopexy (an in-office procedure), scleral buckle, or vitrectomy with scleral buckle.

Retina specialists differ in their own preference for certain techniques. I often choose vitrectomy alone or vitrectomy with scleral buckle. These are the two most successful methods. Remember, retinal detachments aren’t always fixed the first time and are sometimes not fixable.

The vitrectomy requires installation of 3 ports or trocars. Two ports are reserved for each hand and the 3rd port is hooked up to a tube which keeps the eye pumped with either saline or air.

With 25 gauge vitrectomy systems, as in this case, the blue trocars are simply pushed into the eye. The holes are so small that they are regarded as self-sealing. Sutures are not required at the end of surgery and healing is much faster.

The first step of the vitrectomy is to remove the vitreous. You can note a PVD, complete detachment of the retina, two holes/tears and detachment of the macula. The patient barely has a cataract and has not had cataract surgery. As I move around the eye, I am also examining the retina looking for all possible tears or holes which led to this “rhegmatogenous” retinal detachment.

Rhegmatogenous retinal detachment are the most common and are caused by holes, or “rhegma,”

Macular Detachment

At the start of the operation, note how difficult it is to see the macula. As the retina becomes “less detached” the typical brown/yellow appearance of the macula becomes more apparent. The macula is the functional center of the retina and provides the capability of us to see 20/20. The remaining portions of our retina provide peripheral vision.

Macular detachment can alter the visual outcome of surgery.

Fluid-Air Exchange

After I have identified the two tears and marked them with cautery (turning the tissue white), I also created a 3rd hole called a retinotomy.

Drainage of the sub-retinal fluid occurs through the 3rd hole (retinotomy). Sometimes if a hole or tear is more conveniently located, I can skip the part of a retinotomy. At the end of the fluid-air exchange, the retina is completely attached.

The gas will be absorbed slowly over the next two weeks. Retina specialists vary as to the type of gas and mixture (concentration) used. I commonly use 16% SF6. Other gases/mixtures can take longer.

As the gas is absorbed, there is always a concern of the retina detaching again.

Laser Treatment

Having identified and marked all the tears, I can easily see where to use/aim the laser. When the fluid-air exchange is completed, unmarked retinal holes can become invisible.

The idea of laser is to induce scar formation to the layer underneath. This prevents redetachment from the same tears as the gas is absorbed by the eye.

The key to successful retinal detachment surgery is identifying all the tears and treating them all successfully.

Air-Gas Exchange

The very last step of the operation involves replacement of the air with a special inert gas.

The gas will be absorbed slowly over the next two weeks. Retina specialists vary as to the type of gas and mixture (concentration) used. I commonly use 16% SF6. Other gases/mixtures can take longer.

As the gas is absorbed, there is always a concern of the retina detaching again.

Tags Retinal detachment, Video, Woodburn Surgery Center

Retinal Detachments

NFL Coach Zimmer Gets Retinal Detachment | What Can We Learn?

Post author By Randall Wong, M.D.
Post date December 15, 2016
2 Comments on NFL Coach Zimmer Gets Retinal Detachment | What Can We Learn?

NFL coach of the Minnesota Vikings, Mike Zimmer, just had a retinal detachment to his right eye.

He has had several “surgeries” over the past 30 days to the same eye. While the exact details are not known, there is a lot we can learn from his recent experience.

What we do know is;

A retinal tear was discovered and treated around October 31.
A second operation was performed a week later.
Emergency surgery for a retinal detachment was performed on November 30.

Retinal Tears Cause Retinal Detachment

All retinal detachments start with a retinal tear. It has been my experience that most retinal tears simply “happen” and without trauma.

Retinal tears can happen to anyone. Retinal tears usually, but not always, are associated with sudden onset flashes and floaters, but they can be asymptomatic.

This may have happened with Coach Zimmer. Several accounts stated that his retinal tear was discovered after he scratched his cornea.

No, corneal abrasions can not cause retinal tears.

Treatment of Retinal Tears

The ideal treatment of a retinal tear is laser. If laser is not an option, due to the location of the retinal tear, cryotherapy, or freezing, is an excellent treatment.

Both work equally well in treating retinal tears in situations where there is no element of retinal detachment. Cryotherapy may be more uncomfortable.

I do not know if the second surgery was needed because additional tears were discovered or he developed a retinal detachment.

What is important to highlight is that additional retinal tears can occur and/or a retinal detachment could develop after treatment of an initial tear.

Treatment of Retinal Detachments

There are several ways to treat a retinal detachment. Depending upon the location of the retinal tear causing the detachment, intraocular gas may be injected into the eye which requires specific head positioning afterwards to keep the gas pushing on the retinal tear. This is an “in office” procedure.

Two other ways to fix a retinal detachment include a vitrectomy and/or scleral buckle. These may be used along with intraocular gas, too.

Regardless of the procedure, if intraocular gas is used to repair the retinal detachment, airplane flight or traveling to higher elevations is not possible.

Too rapid a decrease in atmospheric pressure can lead to expansion of the gas inside the eye. If this occurs too rapidly, the eye can not adjust to the increase in eye pressure caused by the expanding gas. The high pressure could prevent normal blood flow into the eye.

This explains a few remarks about his driving to Florida for the game against the Jaguars. No remarks about head positioning.

“Emergency Surgery”

Not all retinal detachment surgery is an emergency. A retinal detachment starts off small and can spread. If the macula, the functional center of the retina is attached, but may become detached by waiting, it can be an emergency.

I wish Coach Zimmer well. I wanted to highlight his retinal detachment to emphasize a few points about retinal detachments in keeping with the headlines.

Tags Mike Zimmer, Minnesota Vikings, Retinal detachment, retinal tear

Retinal Detachments Video

Retinal Detachment | Signs, Symptoms and Treatment

Post author By Randall Wong, M.D.
Post date April 28, 2016
1 Comment on Retinal Detachment | Signs, Symptoms and Treatment

Welcome! I’m Randy Wong. Thank you very much for watching this video. Today we are going to talk about retinal detachments.

We are going to talk about;

The definition of a retinal detachment
What it can cause – the signs and symptoms
Surgery to fix a retinal detachment
Timing – when is the best time for surgery?

I hope you enjoy this.

Rhegmatogenous Retinal Detachment

Today we are going to talk about 1 of 2 types of retinal detachments. We are going talk about rhegmatogenous retinal detachments and, by definition, that means the detachment is caused either by a retinal hole or retinal tear.

The hole or tear allows the fluid from the middle of the eye to communicate to a space underneath the retina. So therefore if fluid accumulates underneath the retina through this hole or tear, the retina detaches.

Keep in mind a retinal detachment is potentially blinding. So as we will talk about later, there is some urgency, or sometimes it’s an emergency, to fix a retinal detachment.

Symptoms of a Retinal Detachment

Symptoms of a retinal detachment include loss of your peripheral vision and usually the peripheral, or side vision, is involved first and the loss of vision moves centrally.

Flashes and floaters are also commonly associated with a retinal detachment because those are usually signs of a retinal tear that you may have sustained.

So, the recommendations are that new flashes and new floaters should be examined by your doctor and your doctor ought to be looking for a retinal tear because it is our job to try and prevent you from getting a retinal detachment if we can diagnose a retinal tear.

Again, symptoms of a retinal detachment include; loss of peripheral vision, especially if the vision loss is moving centrally, new flashes and new floaters.

What Do You Do? (When to call your eye doctor)

What should you do if you think you are having a retinal detachment? Maybe you’ve noticed an increase in flashes, an increase in the number of floaters or you are losing your peripheral vision.

My suggestion would be to let your own eye doctor know that you are having these new symptoms.

Once you arrive at your eye doctor’s office you need to get your pupils dilated. By dilating your pupils your doctor can directly examine your retina and if he diagnoses, or she diagnoses, you with a retinal detachment, you are going to need surgery.

Unfortunately, there are not any drops or medicines to fix a retinal detachment.

Retinal Detachment | Surgery

There are three ways or three methods to fix a retinal detachment. The first is called a pneumatic retinopexy. The second is an operation called a scleral buckle and the third is an operation called a vitrectomy.

Pneumatic Retinopexy

A pneumatic retinopexy involves injection of gas into your eye. The gas is used as a tool to help reattach your retina. With a pneumatic retinopexy, depending upon the location of the tear, you may have to hold your head in a certain position.

This is sometimes face down, this is sometimes keeping your head straight up or to the right or to the left. Again, the positioning depends upon the location of the tear.

A pneumatic retinopexy can be done in the office and can be very effective in fixing retinal detachments.

Scleral Buckle

A second way to fix a retinal detachment is with a scleral buckle. A scleral buckle involves placing a silicone band or rubber around the outside of your eye.

Don’t worry, it will be completely unnoticed once you’ve healed up. It’s intended to stay there.

A scleral buckle is a very effective way to repair a retinal detachment and has been around for several generations. It does require surgery and the most common complication of scleral buckle surgery is the increase in nearsightedness after the operation because your eye is actually made slightly longer.

Vitrectomy

A third way to fix a retinal detachment is with a vitrectomy. Remember a scleral buckle involves placing an element or a piece of rubber around the outside of your eye.

A vitrectomy involves going inside the eye to remove the vitreous and the fluid underneath the retina. Many times gas is also put into the eye at the end of the operation and just like pneumatic retinopexy you may have to hold your head in a certain position.

Vitrectomy and Scleral Buckle

So there are three ways to fix a retinal detachment: either with pneumatic a retinopexy, a scleral buckle or a vitrectomy.

Now, many times, surgeons may decide to combine both a scleral buckle and vitrectomy. This is really personal preference and all surgeons have different indications as to when to perform both.

Timing of Retinal Detachment Surgery

The timing of retinal detachment surgery is really dependant upon whether or not the macula, which is the functional center of your retina, is, what we call “threatened.”

Another way to look at it is;

“What’s the chance of you losing your central vision if we delay surgery”? If you have a retinal detachment which is not threatening your macula, therefore, it’s not threatening your central vision. Waiting a day, or longer, probably is appropriate.

Another situation is where the macula is already detached which would mean that your central vision is already lossed. Again, this is an urgent situation but not an emergent situation.

Probably the only time where retinal detachment surgery is an emergency is when you still have 20/20 vision, that is, your central vision is intact, but your doctor feels that if your retinal detachment were to enlarge your central vision might be in jeopardy.

Summary of Retinal Detachments

To summarize, we’ve talked about retinal detachments, specifically we’ve talked about rhegmatogenous retinal detachments and those are retinal detachments that involve a hole or tear in the retina.

We talked about symptoms of retinal detachments; new onset flashes, new onset floaters or loss of your peripheral vision.

We talked about surgery. The three options are pneumatic retinopexy, scleral buckle and/or vitrectomy.

We talked briefly about the timing of surgery…it’s all dependent if your central vision, or your macula is involved.

Thank you for watching!

I’m Randy Wong. I’m a retina specialist in Fairfax, Virginia. Thank you very much for watching this video. I hope you enjoyed it.

By the way, if you have any questions or comments, please leave them at the end of this video on YouTube or at the end of the article if you are reading this on one of my blogs.

We will see you again!

Tags Retinal detachment, Video, vitrectomy

How I Practice Retinal Detachments

Scleral Buckle and Vitrectomy to Fix Retinal Detachments

Post author By Randall Wong, M.D.
Post date May 10, 2015
No Comments on Scleral Buckle and Vitrectomy to Fix Retinal Detachments

There are several ways to fix retinal detachments. The most popular operations include vitrectomy and scleral buckle. These two procedures may be used singly, or in combination.

Nowadays, most retina specialists choose to repair retinal detachments using vitrectomy (and gas) alone. While the scleral buckle has been around for several generations, I rarely use it alone to fix a retinal detachment.

Most often I use just vitrectomy, but when do I use BOTH vitrectomy and scleral buckle for repair of retinal detachments?

First of all, there is no dogma. I’ve developed my own indications for using both procedures. Hence, the elegance of “the practice of medicine.”

No Retinal Tear

All rhegmatoneous retinal detachments, by definition, are caused by a retinal tear or retinal hole. This the more common type of retinal detachment.

One of the keys to successful surgery is find the retinal tear or retinal hole causing the retinal detachment.

Sometimes, despite my best efforts, I can’t locate the tear causing the retinal detachment.

Placing a scleral buckle increases the likelihood of successful reattachment AND the likelihood the retina remains attached.

Multiple Retinal Tears

Only one retinal tear is “required” to cause a complete retinal detachment. In most cases, I find only one or two tears. There are occasions where multiple retinal tears are found and in these cases, I am more than likely to use both vitrectomy and scleral buckle.

Also, in cases where the retina detaches again…I’ll choose to add the scleral buckle.

Old Inferior Retinal Detachments

In my opinion the most difficult situation to repair is a chronic (been there a long time, e.g. several months) retinal detachment located in the inferior portion of the retina (i.e. bottom).

Fluid underneath the retina tends to get thicker with time. Usually the “subretinal” fluid is very watery (because it is basically water). With time, however, this fluid accumulates protein and starts to thicken.

This thicker fluid is more difficult to remove. Patients must keep a strict “face down” head position, but the chance of re-detachment increases due to these two factors.

Again, scleral buckles improve the initial success rate!

Scleral Buckle Has Side Effects

There are several side effects of scleral buckle;

1. Increased myopia (nearsightedness) – by placing a buckle around the eye, the eye elongates, thus causing an increase in myopia. Sometimes this can be dramatic and is difficult to correct with glasses or contacts.

If the refractive error is too different between the two eyes, your brain won’t tolerate this situation and you may see double.

2. Possible Double Vision – the scleral buckle involves manipulation of the extraocular muscles – the muscles attached to the outside of the eye which are responsible for eye movements. In theory, this could cause damage to one of the muscles. It doesn’t happen very often, but it can. I’ve found it to be surgeon related.

3. Healing – the post-operative period is a little more complicated than when just performing a vitrectomy alone. There is more swelling due to the surgery performed on the outside of the eye. There may be additional discomfort (shouldn’t be frank pain).

4. Time – while not really a side effect, the extra time required by your retina specialist to install a scleral buckle varies greatly. This can add as little as 10 minutes to the procedure or increase the operating time to hours.

What Does this Mean?

These are my basic considerations when deciding to repair a retinal detachment with BOTH scleral buckle and vitrectomy.

While the success rate (in my opinion) is higher, we need to consider the risks and benefits overall.

I hope this was somewhat helpful in explaining a very complex and curious situation.

I look forward to hearing from you!

Tags Retinal detachment, scleral buckle, vitrectomy