Tag: vitrectomy

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

Retinal Detachments Surgery

Scleral Buckle vs. Vitrectomy

Post author By Randall Wong, M.D.
Post date September 3, 2014
20 Comments on Scleral Buckle vs. Vitrectomy

This is a recent question I received via email. It brings up a few good points about choosing scleral buckle vs. vitrectomy to repair a retinal detachment. I receive many questions via the comments section after an article. This time, I’m trying something new and making the question a part of the post.

Dear Dr. Randall Wong,

I am not sure whether you do online diagnosis if I send you some
diagnostic data (fundus photo) from my retina doctor. I know online
exam will never be complete, but I wanted the opinion from a highly
regarded retina doctor like yourself.

I was diagnosed with a retinal detachment on the nasal inferior side.
This is a macula on retinal detachment. My doctor used laser to
prevent the detachment from spreading further into the macula. He
couldn’t completely seal off the rest because of the subretinal
fluids. After about 1 week of subretinal fluid not going away, he
recommended scleral buckle surgery but allowed me to look for a second
opinion.

I did ask about Vitrectomy and he said, there’s high risk for
cataracts and it is more expensive than scleral buckle due to the high
end equipment used.

What is your take on my type of retinal detachment? Should I do
Scleral Buckle or Vitrectomy? I would gladly send my data over to you
if you request them.

Thank you for your time,

Laser Treatment for Retinal Detachment

In this case, it seems that a laser was first attempted to “wall off” the retinal detachment and prevent it from spreading. The rationale for doing so is similar to containing a forest fire…dig ditches around the fire to prevent the spread.

I personally rarely treat retinal detachments in this fashion. I don’t feel that there is anything wrong, but I’ve seen too many “walled off” retinal detachments spread, albeit years after the retinal detachment.

In my opinion, simply lasering around the retinal detachment does not fix the problem.

Vitrectomy and Cataracts

Without complicating the matter too much, vitrectomy to repair retinal detachment requires the use of intraocular gas and head positioning after the surgery. Often, the gas can cause cataract though vitrectomy is an excellent choice for fixing the retinal detachment.

I can’t make a remark about the cost. You’ll have to check in your own particular area. I think insurance companies may pay the same or similar rates based upon the fact that the same procedure code is used for scleral buckle and vitrectomy.

Scleral Buckle

There are two ways to use a scleral buckle to repair retinal detachment; with gas and without.

Scleral Buckle With Gas

After placing the scleral buckle around the eye, gas is injected at the end of the case. After the gas is injected, proper head positioning is required to keep the gas pressing on the retinal tear. Remember, the gas can cause cataract.

Scleral Buckle Without Gas

This is the original method used (way back when) to repair a retinal detachment. The scleral buckle is placed around the eye, no gas is injected and the retina often reattaches. In this way, gas is avoided and so is early development of a cataract.

What Does This Mean?

I can not make an online diagnosis nor review your case.

For me to make a diagnosis online, without examination, would be impossible. I get many, many requests for a specific opinion and diagnosis based upon an email or comment on the website. It’s impossible. I also want to avoid the liability.

In this case, for instance, I can talk about retinal detachments and my approach to repairing them, but without making specific judgements about this specific patient.

Overall, I can NOT review your specific documentation or studies. It simply takes too much time, involves potential liability by possibly starting a doctor-patient relationship, and I still can NOT examine you.

On rare occasion, I could be retained to such work.

With regard to fixing the retinal detachment, there are many ways to repair a retinal detachment.

Everyone gets a cataract eventually – with or without retinal detachment surgery.

Retinal detachments can lead to permanent blindness, cataracts do not.

Every effort should be made to repair the retinal detachment without worry to cataract, or even cost. If all things are equal, then, and only then, would I consider cost.

Tags Laser for Retinal Detachment, Retinal detachment, scleral buckle, vitrectomy

Retinal Detachments Surgery

Vitrectomy and Scleral Buckle for Retinal Detachment | Retina Specialist Virginia

Post author By Randall Wong, M.D.
Post date May 8, 2014
6 Comments on Vitrectomy and Scleral Buckle for Retinal Detachment | Retina Specialist Virginia

Vitrectomy combined with scleral buckle is the last way to repair a retinal detachment. This combines two separate methods to repair a retinal detachment. Both vitrectomy and scleral buckle can be used alone to fix a retinal detachment.

Retinal detachments occur because the vitreous has caused a tear in the retina. In addition, the vitreous may also be pulling on the retina to cause it to “tent” or detach.

You Are the Vitreous

Let’s pretend you are in the middle of a room with outstretched arms. The room is the eye and wallpaper is the retina. You are the vitreous. Lastly, imagine long, taut pieces of tape extend from the tips of your fingers with the other ends on the wall paper.

If you lean to the left, you’ll pull and cause a tear in the wallpaper attached to your right hand. If you move to the right, the opposite will happen, you’ll cause a tear to the left.

Scleral Buckle for Retinal Detachment

Whether the scleral buckle goes completely around the eye or is partially installed around the eye does not matter. Whatever element is used to create the “buckling” effect of the eye, the result is to induce slack in the vitreous by reducing the internal diameter of the eye.

In our example, we are moving the walls of the room closer together. This causes the tape to slacken. Now, you can lean left or right without tearing the wallpaper due to the slack. Whatever forces there were pulling on the retina, they have been relieved.

Vitrectomy for Retinal Detachment

Vitrectomy is an intraocular operation where the vitreous is cut away. Remember, it’s the vitreous which causes tears and exerts a pulling force to elevate and detach the retina.

It makes sense to cut away the vitreous which is pulling on the retina. Returning to our example, if we simply cut the tape, leaning left or right would not cause pulling on the wall paper.

This is the value of vitrectomy. It removes the forces of the vitreous pulling on the retina to cause tears and detachment.

After the vitrectomy is completed, it is customary to fill the eye with gas. With proper head positioning, the gas should prevent redetachment by “plugging” the tears causing the retinal detachment. The gas doesn’t really push on the retina to reattach.

What Does this Mean?

The best operation to reattach the retina from a statistical standpoint is to perform a vitrectomy with a scleral buckle. It is the most complicated surgery. With difficult surgery, however, the complications can increase.

This is probably why most surgeons do not always perform both procedures for all retinal detachments. The more difficult the surgery, the more chance of complications.

Over the years, I have developed my algorithms, or practice, for certain types of retinal detachments. In my experience, certain retinal detachments warrant longer and more complicated surgery, but probably yielding better outcomes than if we attempted different procedures.

Maybe this is called experience.

Tags Retinal detachment, vitrectomy