Vitreo Retina


What is a retinal detachment?

A retinal detachment is an eye condition involving separation of the retina from its attachments to the underlying tissue within the eye. Most retinal detachments are a result of a retinal break, hole, or tear. Retinal detachments of this type are known as rhegmatogenous retinal detachment. These retinal breaks may occur when the vitreous gel pulls loose or separates from its attachment to the retina, usually in the peripheral parts of the retina. The vitreous is a clear gel that fills two-thirds of the inside of the eye and occupies the space in front of the retina. As the vitreous gel pulls loose, it will sometimes exert traction on the retina, and if the retina is weak, the retina will tear. Most retinal breaks are not a result of injury. Retinal tears are sometimes accompanied by bleeding if a retinal blood vessel is included in the tear. Many people develop separation of the vitreous from the retina as they get older. However, only a small percentage of these vitreous separations result in retinal tears. Once the retina has torn, liquid from the vitreous gel can then pass through the tear and accumulate behind the retina. The buildup of fluid behind the retina is what separates (detaches) the retina from the choroid and retinal pigment epithelium (lining tissue) in the back of the eye. As more of the liquid vitreous collects behind the retina, the extent of the retinal detachment can progress and involve the entire retina, leading to a total retinal detachment. A retinal detachment almost always affects only one eye at a time. The second eye, however, must be checked thoroughly for any signs of predisposing factors or existing retinal tears or holes that may lead to detachment in the future.

What is the treatment for retinal detachment?


Retinal holes or tears can be treated with laser therapy or cryotherapy (freezing the retina or cryopexy) to prevent their progression to a full-scale detachment. Many factors determine which holes or tears need to be treated. These factors include the type and location of the defects, whether pulling on the retina (traction) or bleeding is involved, and the presence of any of the other risk factors discussed above. Three types of eye surgery are done for actual retinal detachment: vitrectomy, scleral buckling, and pneumatic retinopexy.

Diabetic retinopathy is the diabetes-related damage occurs to the light-sensitive retina in the back of the eye. As diabetes advances, chronic high blood sugar levels will cause the changes that will damage the small blood vessels in the retina, which makes them to leak the fluid or hemorrhage (bleed). Ultimately, this will leads to vision problems which cannot be rectified or corrected with the eyeglasses or contact lenses.

Diabetic retinopathy generally requires only specific treatment when it reaches to an advanced stage & theres a risk to the vision. The most important part of the treatment is to keep the diabetes under control. In the initial stages of the diabetic retinopathy, controlling diabetes can help to preserve vision.In the more complex stages, when the vision is affected or at risk, keeping the diabetes under the control will help to stop the condition getting more worse.

Treatments for advanced diabetic retinopathy
For diabetic retinopathy that is threatening or affecting your sight, the main treatments are :
Laser treatment

Laser treatment is used to treat the new blood vessels at the back of eyes in the complex stages of diabetic retinopathy. Treatment may help to stabilize the changes in the eyes which caused by the diabetes and prevent vision from getting worse even though it wont generally improve the sight.

♦ It involves shining a laser into the eyes – patient will be given a local anaesthetic drops to numb their eyes; eye drops are used to widen the pupils & special contact lenses are used to hold the eyelids open & focus the laser onto the retina

♦ It usually takes around 20-40 minutes

♦ It is generally carried out on an outpatient basis, that means patient wont need to stay in the hospital overnight

♦ May requires more than one visit to the laser treatment clinic

♦ Isnt generally painful, even though patient may feel like pricking sensation when certain areas of the eye are being treated

Eye injections

♦ In some of the cases in diabetic maculopathy, injections of a medicine known as anti-VEGF can be given directly into the eyes to prevent a new blood vessels forming at back of the eyes.
♦ The main medicines which are used are ranibizumab (Lucentis/Accentrix) & aflibercept (Eylea). These will help prevent the problems from getting worse, and can also improve vision to some extent.

Eye surgery
Surgery will be performed to remove some of the vitreous humour from the eye. This was the transparent, jelly-like substance which fills the space behind the lens of eye.

This surgery, called vitreoretinal surgery, may be needed if:
♦ If there is a extensive scar tissue which likely to cause, or has already causedretinal detachment

People who develop significant age-related macular degeneration (AMD) typically compensate with large-print publications and magnifying lenses for everyday activities. In addition, evidence suggests that certain vitamins and antioxidants -- vitamins C and E, beta-carotene, and zinc -- may help to reduce or delay the risk of severe vision loss. Ask your eye doctor about using nutritional supplements.

Treatment for Dry Macular Degeneration

Dry macular degeneration, the most common form of AMD, cannot be cured at this time, but patients with the condition should continue to remain under an ophthalmologists care to monitor both eyes. If one eye is healthy, screening should still continue.

Treatment for Wet Macular Degeneration

A variety of treatments are available for wet AMD. Successful treatment may not restore normal vision, but it will improve sight and prevent central vision loss from worsening. While laser procedures can destroy the abnormal blood vessels, they also damage neighboring retinal tissue.

Medications , such as Eylea, Lucentis, and Macugen, have become the preferred treatment for acute wet macular degeneration, helping to prevent the growth of leaky blood vessels in your eye. Lucentis is given once every month, although some patients may need treatment only once every three months. Macugen is given every six weeks. Eylea is given once every two months after three once-monthly injections.

Laser photocoagulation destroys leaking blood vessels that have grown under the macula and halts the leakage. Laser therapy is helpful for about 10%-20% of people with wet macular degeneration. Some vision loss may occur, because this treatment creates scar tissue that is perceived as blind spots; however, even more vision would be lost if nothing is done at all. Up to half of the patients who elect for laser therapy may need repeat treatments.

Photodynamic therapy (PDT) uses a different, non-heat-generating laser to treat abnormal blood vessels. Visudyne is injected into the patients arm and flows through the vessels in the eye. Upon exposure to the laser, a chemical reaction occurs that seals off the leaky vessels. Since the dye is light sensitive, you must stay out of the sun or bright light for several days until the dye has passed from your system. Laser photocoagulation must be done before the abnormal blood vessels cause irreversible damage to the retina. More blood vessels could grow later on, so people who undergo this treatment also need to continue with regular follow-up appointments.

Pars plana vitrectomy (PPV or vitrectomy) is today the most common surgery performed for a retinal detachment. Vitrectomy surgery is performed in the hospital under general or local anesthesia. Small openings are made through the sclera to allow positioning of a fiberoptic light, an irrigation system, a cutting source (specialized scissors), and a delicate forceps. The vitreous gel of the eye is removed to reduce or eliminate the pulling forces of the vitreous (traction) on the retina. Laser or cryotherapy (freezing) is used to treat the retinal tears or holes, and the vitreous is replaced with a gas to refill the eye and reposition the retina. The gas eventually is absorbed and is replaced by the eye's own natural fluid. This procedure may require special positioning of the patient's head (such as looking down) in the postoperative period so that the bubble can rise and better seal the break in the retina. If a gas is used that is absorbed very slowly, the patient may have to walk, eat, and sleep with the head facing down for one to four weeks to achieve the desired result. In the past, vitrectomy was reserved only for certain complicated or severe retinal detachments, such as those that are caused by the growth of abnormal blood vessels on the retina or in the vitreous, as occurs in advanced diabetes; retinal detachments associated with giant retinal tears; vitreous hemorrhage (blood in the vitreous cavity that obscures the surgeon's view of the retina); extensive tractional retinal detachments (pulling from scar tissue); membranes (extra tissue) on the retina; or severe infections in the eye (endophthalmitis). In complex cases today, a scleral buckle (see below) is often also performed together with the vitrectomy. In more complicated cases, a silicone oil maybe placed in the vitreous cavity instead of a gas. This oil must be removed at a later date.

A scleral buckle is performed to repair a retinal detachment by reestablishing the anatomic proximity of separated retina from its underlying tissue. An acute retinal detachment is an ophthalmologic emergency that can rapidly progress to irreversible vision loss in the affected eye. The neurosensory retina depends on its underlying layers (the retinal pigment epithelium and choroid) for delivery of oxygen, trophic factors, and nutritional substrates. Therefore, any damage or disruption in the conduit between the layers has great potential to lead to ischemic damage and cell death. The vast majority of detachments are caused by the formation of tears (rhegma) in the retina, which allow the entrance of liquefied vitreous into the subretinal space, leading to subsequent separation of the neurosensory retina from the underlying retinal pigment epithelium. The principle of scleral buckling is based on the need to collapse the anatomic space created between the detached sensory retina and the retinal pigment epithelium. This is done by the inward indentation of the sclera from the exterior, creating a ridge (or buckle) that reduces the fluid underneath the tear and allows for the re-apposition of separated layers, thus reestablishing their physiologic connection. The sclera itself is most commonly indented by placement of a permanent explant or intrascleral implant with sutures, although temporary buckles have been used in variations. The external indentation from the buckle explant reduces the volume of the globe, and in doing so relieves a portion of the vitreous traction contributing to the retinal tear and detachment. Although this procedure involves exposure of the globe and considerable intraorbital manipulation, it is most often performed on an outpatient basis. In addition to the placement of the explant to displace the eye wall inward, it is important that the retinal tears are sealed by the formation of chorioretinal adhesions. This is performed by inducing a chorioretinal scar via cryotherapy, diathermy, or laser energy. In conjunction with the generation of such adhesions, the physical closure of the break by the explant/implant enables the attachment of the retina. The dynamic forces that generated the detachment (vitreoretinal traction and inflow of liquefied vitreous) are thus countered by these maneuvers. Once secured, the normal physiologic and metabolic forces preventing separation may then maintain retinal attachment. Depending on the extent of detachment, the degree of fluid and any associated pathologies, there may also be indications for auxiliary procedures during the placement of the scleral buckle, such as the removal of accumulated subretinal fluid and/or the injection of intravitreal gas. [1] Although modalities such as vitrectomy and pneumatic retinopexy are increasingly used to manage retinal detachments, buckling continues to be an important and useful approach in many clinical scenarios. In addition to the placement of scleral buckles as a primary and solitary procedure, they are often used in combination with pars plana vitrectomy in order to address complicated retinal detachments and provide further support. Given the poor visual outcomes that attend the course of an uncorrected detachment, scleral buckling is most often performed on an emergent to urgent basis, especially in the setting of macula-sparing detachments.

A vitrectomy procedure removes the vitreous humor or gel-like substance in the eye. This approach can address vision problems caused when foreign matter invades this usually pristine area of the eye`s interior. One example of foreign matter is blood, from conditions such as diabetic vitreous hemorrhage.

Scleral buckling surgery is a common way for treating the retinal detachment. It is a method of closing breaks & flattening the retina.

A scleral buckle is a piece of the silicone sponge, rubber, or semi-hard plastic which is placed on the outside of the eye (the sclera, or the white of the eye)by your eye doctor (ophthalmologist). This material is sewn to the eye to keep it in the place. The buckling element is generally left in place permanently.

The element will pushes in, or "buckles" the sclera near the middle of the eye. This buckling effect on the sclera will relieve the pull (traction) on the retina, which will allow the retinal tear to settle oppose to the wall of eye. The buckle effect can cover only the area which is behind the detachment, or it will encircle the eyeball like a ring.

By itself, the buckle won’t prevent a retinal break from opening again. Generally extreme cold (cryopexy) or less commonly, heat (diathermy) or light (laser photocoagulation) is used to scar the retina & hold it in the place till a seal forms in between the retina & the layer under it. This seal will hold the layers of the eye together & keeps fluid from getting in between them.

The surgery will be performed in the operating room, generally on an outpatient basis.
Local or general anesthesia will be performed before the surgery.

Before the operation, your eye doctor will patch both of the eyes & have to stay in the bed to keep the detachment from the spreading. Right before operation, he or she may use the eye drops to dilate your pupils & will trim your eyelashes to keep them way.

A first-time operation will generally lasts 1 - 2 hours. Repeated surgeries or more complex detachments will take too longer.

You will have some pain for some days after the surgery was performed. Your eye may become swollen, red, or tender for some weeks. Your eye doctor will put drops in the eye that will prevent from the infection & keep the pupil from opening wide (dilating) or closing (constricting). You should have to wear a patch over the eye for a day or more.
The eye is often compared to a camera. The front of the eye contains a lens that focuses images inside at the back of the eye. This area, called the retina, is covered with special nerve cells that react to light, like film in a camera. These nerve cells are very close together in the middle of the retina where the eye focuses the images that we see. This small part of the retina is called the macula. Sometimes the nerve cells of the macula become separated from each other and pull away from the back surface of the eye forming a hole.

This is called a macular hole. Sometimes macular holes are the result of an injury or a medical condition that affects the eye, including being very near sighted. In most people, it is due to traction on the center of vision that is more likely to occur as we age.

Macular holes often begin gradually. In the early stage of a macular hole, people may notice a slight distortion or blurriness in their straight-ahead vision. Straight lines or objects can begin to look bent or wavy. Reading and performing other routine tasks with the affected eye become difficult.

The surgical procedure for macular holes is performed under local anesthetic so the patient is awake but does not feel the procedure.

The first part of the operation for macular hole treatment is to remove this gel-like material, which is called the vitreous. The procedure to remove it is called vitrectomy.

The surgeon will make small openings in the eye to insert special instruments that are used to remove the vitreous. The surgeon may also remove any small pieces of tissue ("membranes") or traction near the macular hole using fine forceps. This is done to prevent anything from pulling on the macula preventing the hole from closing.

Finally, the fluid in the eye is exchanged with a sterile gas, which keeps pressure on the macular hole until it heals. Patients will need to maintain a face-down position for 1 to 7 days to keep the gas bubble in place and help close the hole.
Vitrectomy with membrane peel is the most common vitreoretinal surgery. The procedure is typically performed to intervene in the event of epiretinal membrane (ERM) formation or vitreomacular traction syndrome that presents with visually significant symptoms.

An ERM is a semitranslucent, avascular, fibrocellular membrane located along the inner surface of the retina’s internal limiting membrane (ILM). In most instances, ERM formation is seen over or around the macula. Clinically, you may document a loss of foveal reflex, parafoveal light reflection (which looks similar to cellophane), wrinkling of the retinal surface, localized intraretinal hemorrhages or alteration of the parafoveal vasculature (increased tortuosity). Macular edema and/or pseudoholes may also be associated with ERM development.

Some ERM patients are asymptomatic; however, most affected individuals report distorted vision or scotomas that are repeatable on Amsler grid testing. Because some ERMs slowly worsen over time, patients typically experience a gradual reduction in visual acuity.

The first clinical sign of ERM formation tends to be an unnatural macular appearance. Although fluorescein angiography can be used to help diagnose ERM, OCT has become the gold standard; its high-resolution imaging of the vitreoretinal interface detects even the subtlest membrane.

In vitrectomy with membrane peel procedures, the instruments are usually inserted 4mm behind the limbus. The surgery is performed under local anesthesia with very small incision ports that do not require suturing. Visual recovery varies from patient to patient, but can be dramatic the very next day.

Intraocular foreign bodies (IOFBs) are present in up to 40% of traumatic ocular injury cases. Surgical treatment for the removal of an IOFB is perhaps the most difficult procedure, particularly in intense preoperative workup. An IOFB will be further be complicated by the endophthalmitis, retinal detachment & metallosis, warranting prompt IOFB removal. IOFBs should be removed as early as possible and it mode of treatment is surgery.

Surgery involves removing the foreign body and also repairing the ocular structures which were damaged by the trauma in the best possible way. The normal anatomy of the eye may or may not be restored and the final visual outcome will depend upon the extent of damage to the eye. The repair may also involve injecting a special medical grade oil into the eye which is usually removed later by a second surgery a few months later.

If the IOFB or capsule is impacted in the retina or there are other retinal breaks, the doctor will choose to laser to these areas before removing the vitreous and the foreign body.

Endophthalmitis is an inflammation that affects the internal coats of the eye. It is a possible complication of all the intraocular surgeries, especially cataract surgery, with possible loss of the vision & the eye itself. Infectious etiology is the most common cause of endophthalmitis. The other causes may include penetrating trauma & retained intraocular foreign bodies.

There is usually a history of recent intraocular operation or penetrating ocular trauma. In certain cases of endogenous endophthalmitis especially in immunocompromised patients or those with the diabetes the spread of infection can be hematogenous (via the blood-stream).

Endophthalmitis is generally associated with severe pain, loss of vision & redness of the conjunctiva & the underlying episclera.

The patient needs an immediate eye examination by an ophthalmologist if possible a vitreo-retina specialist who will generally decide for the urgent intervention to provide the intravitreal injection of the potent antibiotics & also prepare for an immediate surgery (pars plana vitrectomy) as needed. Evisceration will be necessary if the condition is very severe.

Vitrectomy surgery, will help to manage the endophthalmitis by removing the infecting organisms & their toxins. At the end of surgery appropriate antibiotics are injected into the eye to contain the infection. The aim of treatment is to stop the infection and preserve the eyeball. Vision may or may not recover depending upon the extent of damage caused by the organism.

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Also known as macular pucker or cellophane retinopathy, epiretinal membrane (ERM) involves growth of a membrane across the retina, which interferes with central vision by distorting the central retina. ERM is usually associated with other disorders such as previous retinal detachment, uveitis, retinal tears, branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). People with a clear ERM should receive an epiretinal membrane peeling procedure named membranectomy.

Some disorders occasionally associated with ERMs include previous retinal detachments and related surgery, inflammatory conditions (uveitis), retinal tears, branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO).

You might need a membranectomy if :

♦ An epiretinal membrane clearly is present.
♦ You experience problems such as vision distortions or substantially reduced vision due to ERM.

Your surgeon will help you decide if an epiretinal membrane peeling procedure is appropriate for you. But the decision will depend on the extent of preoperative vision loss and distortions.


The ERM peeling procedure begins with vitrectomy.

The vitreoretinal surgeon then uses an extremely fine forceps, under high magnification, to grasp and gently peel away the membrane from the retina.

Diamond-dusted instruments may be used that helps to remove the membrane. Precision is key, because this procedure may very well be the most delicate operation that's performed on the human eye.

Usually a few tiny sutures are used to close the incisions in the eye; generally these dont require removal later.

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