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

Retinal Detachment | Jireh DesignsNFL 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;

  1.  A retinal tear was discovered and treated around October 31.
  2. A second operation was performed a week later.
  3.  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.




Excercise After PVD is Safe

Retinal Detachments and Retinal Tear

I believe exercise after sustaining a posterior vitreous detachment (PVD) to be safe.  Many doctors recommend a “no exercise” period after a PVD to decrease the risk of retinal tear and retinal detachment.  This does not make sense to me.

PVD Causes Retinal Tear

A retinal tear may occur after a posterior vitreous detachment, but in my opinion, the chance of a tear occurring is the same whether or not you exercise.

The vitreous normally separates, or detaches, from the retinal surfaces with age.  It happens to everyone as we get older.  A PVD will occur earlier in life due to increased nearsightedness, previous eye surgery, certain trauma, etc.  After a PVD occurs, there are physical changes within the eye.

The vitreous now occupies less space within the eye.  The vitreous does not separate completely from the retinal surface and remains adherent in certain areas.  The vitreous moves back and forth with eye movement, yet tethered to the retina in the areas which remain attached.  This is where the retina can tear.

Statistically, a retinal tear will occur during the first six weeks of onset of a PVD.

Does Exercise Increase the Chance of Retinal Tear

The concern about exercise is related to increased motion/bouncing of the eye.  The thought is that increased movement increases the chance of retinal tear.

This might be a valid concern except for two arguments;  1) each evening during REM sleep (a necessary stage of sleep), the eyes beat back and forth faster than any activity we perform while awake, and 2) after the six week period, there is no known “healing” of the retina.

REM (rapid eye movement) occurs every evening and involves continuous beating of your eye back and forth.  While the speed of the eye movements (think of what your eyes do when you reach the end of a sentence) approaches that of reading, the extent to which the eyes move and the duration supersede these reading movements.

Thus, every night your eyes sustain greater forces during REM than while you are awake.

Also, there are no known physical changes to either the retina or vitreous after six weeks.  For instance, the retina does not become stronger or thicker after a PVD, hence the chance of tearing should be the same.

Weightlifting is definitely safe.

What Does this Mean?

Remember, this is my opinion.  If  you were my patient (and I remind  you that you are not my patient just by reading this article), I’d advise you exactly as I’ve written here.  For the rest of you, I think my arguments allowing exercise are pretty valid and you should discuss with your own doctor.

Lastly, if we are at risk for developing a tear, wouldn’t you want it to occur while we are being vigilant?


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
Fairfax, Virginia





Retinal Tears and Vitreous Hemorrhage

Vitrectomy for Retinal Tear to Remove Vitreous HemorrhageA vitreous hemorrhage may be caused by a retinal tear.  Sometimes there is so much blood in the eye that direct examination is impossible and we can only guess at the most likely cause.  It is the most difficult situation for me to handle as a doctor.

Patients lose significant vision as the blood in the middle of the eye physically blocks all light from hitting the retina.  While this is usually not permanent visual loss, the blood makes it difficult to make a definitive diagnosis as it can be impossible to see the retina.

Normally, without blood in the eye, a retinal tear may be easily diagnosed and treated with laser.

While there are other causes of vitreous hemorrhage, such as diabetic retinopathy, retinal vascular disease and others.  Still, a retinal tear causing the vitreous bleeding is quite likely.

Retinal Tears Cause Retinal Detachments

A retinal tear can cause a retinal detachment.  A retinal detachment is potentially blinding.

In cases of vitreous hemorrhage, the patient cant’ see “out” and I can’t see “in.”  My ability to examine the eye is hindered.

Options at this point are to observe (i.e. do nothing).  Observing the eye is okay as the blood is doing no harm.  But what if there is a retinal tear?  A retinal detachment could occur if there is an undiagnosed retinal tear.

Other tests, such as an ultrasound can often detect a large tear, but it is not as good as directly examining the eye.  Operating to remove the blood to facilitate proper examination is an option, too.

What Does This Mean?

I am getting older, more aggressive, but smarter.

As I have aged, i.e. gained more experience, I have become more comfortable operating in these cases.  When I was younger, I would often hesitate because I was uncomfortable offering surgery in a situation where surgery might not be necessary, but I’ve learned (through experience) that watching a waiting can be more problematic.

Most of the time I recommend operating to at least remove the blood and confirm a diagnosis.  The risks of modern vitrectomy are quite low, while the risk of a retinal detachment occurring while we are waiting is quite possible.

Vitrectomy surgery is usually performed as an outpatient.  If a tear is indeed present, it can be treated simultaneously.

At the very least, a diagnosis can be made and a potentially blinding condition avoided.

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Does Sleep Cause Retinal Detachments?

I believe that REM sleep causes retinal tears and then subsequent retinal detachments, that is, I think most of the damage occurs while you are sleeping.   While this would be hard to ever prove, there are some compelling arguments for my hypothesis.

What is REM sleep?

Rapid Eye Movement (REM) is a stage of sleep that occurs every night.  During this stage of sleep, the eyes beat back and forth, moving to and fro with great force and speed (hence “rapid”).  It is a normal physiologic stage of sleeping.  As the eyes beat back and forth, forces are created inside the eye with this rapid, repeated movement (similar to shaking a bottle soda to get it to “explode”).  These forces can not be reproduced voluntarily when awake, that is, these forces are the strongest when sleeping.

Retinal Tears Cause Retinal Detachments

Most retinal detachments start with a tear, or hole, in the retina.  The tear allows fluid to get underneath the retina, causing a retinal detachment.

A common cause of a retinal tear is the development of  a posterior vitreous detachment (PVD).   A posterior vitreous detachment occurs normally in everyone, especially as we get older.  The vitreous, the gel like material that fills the eye, normally separates from the surface of the retina.

Frequently, patients complain of new floaters or a “cob-web” developing in their vision when a PVD develops.  During the first six weeks of occurrence, patients are at highest risk for developing a retinal tear.


The gel, now separated from surface of the retina, can now “slosh” back and forth inside the eye.  Portions of the vitreous;  however, remain adherent to the retina.  While this gel moves back and forth, pulling on the retina, a retinal tear can form.

Combine REM Sleep with a PVD

A patient with a PVD undergoing REM sleep experiences tremendous new forces inside the eye as the gel is sloshing around AND the eyes are beating back and forth at a rapid rate.  Again, the forces generated inside the eye during these rapid motions can not be reproduced while awake  (i.e. you can not reproduce these forces while awake).

It may be at this time that retinal tears develop and cause a retinal detachment.

What Does This Mean? Again, this is my suspicion.  It may be hard to prove.  There is; however, a very practical side to this theory.

This means that nothing can be done to prevent a retinal tear from happening after a posterior vitreous detachment (PVD).  This means that a patient does not have to refrain from any “normal” activities when a PVD occurs.

In my view, a retinal tear is beyond the control of the patient.  A patient can not alter his or her behavior to prevent a tear from forming…unless you refrain from sleep.

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"Top Ten" Eye Emergencies: Part 1

Any vision loss can be scary.  Sudden vision loss is even more frightening.  There are really only a couple of “true” retinal eye emergencies.  I’ve listed the “top ten,”  remember that there are many ways to define an emergency.  All involve loss of vision, or at least a change in vision, and that alone probably qualifies as an “emergency.”  By the way, if you have sustained any of these symptoms, please call your doctor.  This article, and web site, is not intended to replace medical advice.

So here goes;  my “Top Ten” Retinal Emergencies;

10.  Vitreous hemorrhage – the symptoms of a vitreous hemorrhage can range from the onset of sudden floaters to rather impressive loss of vision, depending upon the amount of bleeding into the vitreous.

9.  Vascular Occlusions – either vein occlusions or artery occlusions.  Patients experience sudden loss of vision.

  • Causes
  • Vein Occlusions – may be associated with hypertension or diabetes, often healthy individual
  • Artery Occlusions – look for cardiovascular disease/stroke
  • Concerns – may develop “neovascular” glaucoma
  • Comments – treatments include laser treatment, Ozurdex (vein).

8.  Submacular Hemorrhage – sudden bleeding underneath the macula/retina.  Causes a dark area in the vision.  Usually the peripheral vision is normal.

  • Causes – valsalva, trauma, macular degeneration
  • Concerns – source of the bleeding
  • Comments – valsalva (aka straining) has the best prognosis, remember blood underneath the retina is not toxic

7.  “Wet” Macular Degeneration – rapidly (days to weeks) decreasing vision, distortion.

  • Causes – fluid/blood accumulating in the macula
  • Concerns – look for abnormal blood vessels (neovascularization)
  • Comment – fluorescein angiography is helpful

6.  Uveitis/Iritis – this is inflammation inside the eye, not unlike arthritis.  Patients may experience pain, sensitivity to light, decreased vision.  Eye may turn red.

  • Causes – endogenous, some rheumatologic diseases, trauma
  • Concerns – relief of pain, may look for associated systemic disease
  • Comment – usually steroids play a big role in controlling this

To Be Continued…

Floaters, Are They Normal or due to Diabetic Retinopathy?

Floaters are generically defined as black spots in your vision.  They move to and fro with eye movement.  Most of the time they are small, tiny and black, but really can be large and translucent, too.  From a doctor’s standpoint, size does not matter.  New floaters can mean a retinal tear and the development of a retinal detachment.

Floaters can develop from a variety of causes such as a posterior vitreous detachment (PVD) or a retinal tear.  A posterior vitreous detachment (PVD) is a normal occurrence and happens more frequently as we age, with increased near-sightedness (eye slightly larger) and with trauma.  The vitreous is the “gel” that fills most of the eye.  With time it will separate from the surface of the retina and usually produces the sudden onset of new floaters  (For additional article on floaters/flashes, click here).

A PVD can cause a retinal tear.  It usually does not, but it can.  New floaters require a dilated eye exam to exclude a tear in the retina.  Patients are usually at highest risk for developing a tear following a posterior vitreous detachment for the first 6 weeks following symptoms.  Retinal tears can develop into a retinal detachment if not treated.

Occasionally, a vitreous hemorrhage can result from a retinal tear.  So, add this to the list of causes, too.

Floaters and Diabetic Retinopathy In a patient with diabetic retinopathy, new floaters can be related to a PVD or retinal tear just as any other person without diabetes.  New floaters; however, can also be related to the diabetic retinopathy and are caused by a vitreous hemorrhage.  Bleeding into the vitreous is caused by the presence of abnormal (aka neovascularization) blood vessels on the surface of the retina.  This signals the development of proliferative diabetic retinopathy.

What to you need to do? In any case, alert your doctor to your new symptoms.  It is recommended that you get a dilated eye exam to look for a posterior vitreous detachment (PVD), vitreous hemorrhage or retinal tear.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Retinal Tears and Retinal Detachments

I just operated on a patient for a retinal detachment in his left eye. He had a previous retinal detachment repaired about 3 years ago. Three years ago, I repaired the retinal detachment by performing a vitrectomy in combination with a scleral buckle. When informed about the need for surgery in the left eye, due to the new retinal detachment, he asked if I had to perform a scleral buckle. He was elated when I said “no.”

How I explain retinal tears causing retinal detachments.    Retinal detachments develop from a retinal tear (or retinal hole). The tear results from the vitreous pulling on the retina (Imagine your eye as a room, the wallpaper lines the room just as the retina lines the inside of your eye.   If you put a piece of tape on the wallpaper of your room and pulled, you would tear the wallpaper).  The tear allows fluid to get underneath the retina/wallpaper.  This is a retinal detachment.

Scleral buckles have drawbacks.  I am not going to Google “scleral buckle,” but it has been the mainstay of treatment for retinal detachments for over 100 years.  Basically, it works well.  The idea of the buckle is to narrow the diameter of the eye to relieve stresses in the vitreous. In effect, you cause slack to develop in the vitreous so that the vitreous can no longer pull on the tear or retina.  Let’s say the success rate of scleral buckles is about 90%.  These are very good odds at preventing blindness.  There are, however, many drawbacks to the procedure including; lengthy surgery, lots of trauma to the tissues around the eye, possible double vision (the muscles around the eye get manipulated) and increased nearsightedness (myopia develops from increasing the anterior to posterior length of the eye, remember you are squeezing the eye making it skinnier, but making it longer, too).  Read more about the mechanism of retinal detachment on my web page.

Vitrectomy only for retinal detachments.  Most of the time these days, I perform a vitrectomy using 25 gauge instruments to repair a retinal detachment.  In this scenario, the vitreous is simply removed from the eye.  The same result occurs; relief of stresses in the vitreous.  Instead of squeezing the eye, the vitreous strands are simply cut and removed.  Gas is placed into the eye at the end of the operation.  We estimate a 90-95% success rate!  Best of all, there is much less trauma to the tissue, no chance of double vision, little or no pain and no change in the shape of the eye!

What does this mean? Technology has allowed us to change the way we treat a potentially blinding problem.  The surgery is quicker, more comfortable and has fewer consequences.

Randall V. Wong, M.D.
Retina Specialist/ Ophthalmologist

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Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different's a different arrangement, but it allows more continuous care with many eye specialists. In addition, I am very accessible via the web. To schedule your own appointment, call any of the numbers below.

Virginia Lasik | Office of Anh Nguyen, M.D.
Randall V. Wong, M.D.
Contact: Layla

A: 431 Park Avenue, Suite 103 • Falls Church, Virginia 22046
Ph: 703.534. 4393
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Ashley (Surgery/Web)
Chrissy Megargee (Web)

A: 3930 Pender Drive, Suite 10 • Fairfax, Virginia 22030
Ph: 703.273.2398
F: 703.273.0239
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