Retinal detachment: Description
A retinal detachment (ablatio retinae, amotio retinae) is a detachment of the retina, which lines the inside of the eyeball. As the retina consists mainly of sensory cells that register, process and transmit visual information, the detachment usually impairs visual performance.
Retinal detachment is a rather rare disease. Every year, around one in 8,000 people are affected, especially those who are very short-sighted and have glasses with a prescription of six diopters or more. Acute courses are mainly observed in people between the ages of 50 and 70. Retinal detachment also runs in families.
Retinal detachment: symptoms
The disease manifests itself through a number of classic symptoms:
Retinal detachment is generally noticeable through distorted vision. Flashes of light (photopsias) in the affected eye are characteristic. Patients see this mainly in the dark. The effect is caused by tensile forces exerted on the retina from structures inside the eye (e.g. connective tissue cords).
In addition, some sufferers perceive a “rain of soot” (also known as flying gnats) – black dots or flakes that appear to move, i.e. do not always appear to stay in the same place. The cause of the “soot rain” is usually tears or bleeding in the retina.
Such an increasing loss of visual field is an absolute alarm signal for an acute retinal detachment! Signs such as these should never be ignored!
Depending on the cause of the retinal detachment, these symptoms may all be present or may occur individually. Sometimes, however, an amotio retinae is completely symptom-free for a long time. This is mainly the case if the retinal detachment is small and located in the peripheral areas of the retina.
How severe the symptoms of a retinal detachment are depends primarily on where in the retina the damage occurs. If, for example, the area of the retina where the most nerve cells are present (“place of sharpest vision” or macula) is affected, vision is particularly severely impaired.
Retinal detachment: causes and risk factors
The retina is only around 0.1 to 0.5 mm thick and, to put it simply, consists of two overlapping layers: One layer contains the nerve cells (stratum nervosum). The second layer lies underneath towards the back of the eye. It is known as the stratum pigmentosum due to its dark coloration.
The separation of the two layers is problematic because the stratum pigmentosum is responsible for nourishing the stratum nervosum above it. If the connection between the two layers is interrupted, the sensory cells there die after a short time and cause the typical retinal detachment symptoms.
Retinal detachment very often occurs due to diseases of the vitreous body (corpus vitreum) in the eye. The vitreous body fills almost two thirds of the inside of the eye. Its gelatinous substance gives the eyeball its stable shape. At the same time, it presses the retina against the back of the eye and thus prevents the upper retinal layer from detaching from the lower one. The vitreous body therefore plays a very important role in stabilizing the retina.
The most common causes of retinal detachment
There are various causes of fluid entering the gap between the two retinal layers:
Rhegmatogenous (tear-related) retinal detachment
Tears in the retina often occur when the vitreous body is damaged, for example in the case of so-called posterior vitreous detachment. In this case, the vitreous body collapses slightly due to age-related loss of fluid and tears a hole in the retina, to which it adheres with its rear side. This is noticeable through visual disturbances and blurred vision. Especially when looking around quickly, such a visual disturbance moves further than the actual eye movement that was made. This is because the movement of the fluid of the vitreous body is slower than the movement of the head. This can therefore be a sign of retinal detachment.
Another cause of a tear in the retina is blows to the eye (traumatic retinal tear).
Traction-induced retinal detachment
In traction-induced retinal detachment, also known as complicated retinal detachment, the upper retinal layer is literally pulled away by connective tissue strands inside the eye.
Exudative (fluid-related) retinal detachment
Under the lower retinal layer is the so-called choroid. This is a very vascularized layer that supplies the overlying retina with blood. If fluid from the vessels of the choroid penetrates between the two layers of the retina, this results in detachment of the upper retinal layer. The main causes of fluid leakage from the choroidal vessels are inflammation or tumors of the choroid.
Combination traction-rhegmatogenous
In tractional-rhegmatogenous retinal detachment, both a tear in the retina and the traction of connective tissue strands inside the eye are responsible for the retinal detachment. The tear is usually caused by traction, which is often caused by a proliferation of connective tissue. This form often occurs in diabetics.
Risk factors for retinal detachment
Various risk factors increase the likelihood of retinal detachment. These include:
- Surgery on the eye (for example cataracts)
- Repeated inflammation of the eye
- Accidental injuries
Other risk factors are eye diseases such as diabetic retinopathy, Coats’ disease and retinopathy of prematurity. Regular ophthalmologic examinations are recommended for these diseases in order to detect a pathologically altered retina at an early stage.
Retinal detachment: examinations and diagnosis
Ophthalmologists are the specialists for retinal detachment. A clinic with an ophthalmology department is also a suitable place to go. This is especially true if the symptoms develop suddenly and quickly.
Medical history
The first step if a retinal detachment is suspected is a detailed discussion between the doctor and patient to take a medical history. The doctor may ask the following questions, among others:
- Did the symptoms appear suddenly?
- Do you see black dots, lines or flashes of light?
- Do you notice shadows in your field of vision?
- Have you noticed a deterioration in your vision?
- Do you have any known underlying conditions (e.g. diabetes mellitus)?
The symptoms described by the patient often already indicate the presence of a retinal detachment.
Examinations
The first step is to determine visual acuity. This can determine whether vision is reduced.
The most important examination for suspected retinal detachment is an ophthalmoscopy (funduscopy). The ophthalmologist usually uses a so-called slit lamp for this. Beforehand, however, he will drip a medication into your eye to dilate the pupils. This makes it easier to see the retina. The doctor then uses the slit lamp to look at the back of the eye and can thus see the retina directly. In the case of a retinal detachment, blister-like detachments of the retina are usually noticeable. Other abnormalities depending on the cause of amotio retinae are
- rhegmatogenous retinal detachment: a retinal defect may be visible, such as a (horseshoe-shaped) tear or a red-rimmed hole surrounded by blisters.
- Tractional retinal detachment: gray connective tissue strands in front of the retina
- Exudative retinal detachment: bleeding and fatty deposits
Retinal detachment: Treatment
A detached retina is an ophthalmological emergency! So if you notice possible symptoms of retinal detachment, you should see an ophthalmologist as soon as possible. The sooner the retinal detachment is treated, the sooner the detached retina will recover.
No medication is currently available for treatment. Instead, there are a number of procedures that can be used to reattach the upper retinal layer to the lower layer and thus repair the damage. These retinal surgical measures usually require a stay of several days in hospital. Once retinal detachment treatment has been completed, regular check-ups with an ophthalmologist are advisable.
Below you will find more detailed information on the surgical methods for retinal detachment.
Laser or cold probe in the early stages
Laser and cold probe are particularly important as preventive procedures, i.e. to close tears before retinal detachment occurs. Two weeks after the procedure, stable scars have formed and the risk of retinal detachment has been averted. However, it should be borne in mind that in the vast majority of cases, an asymptomatic retinal tear does not lead to retinal detachment.
Treatment methods for extensive retinal detachment
The following procedures are mainly used for large-area retinal detachment:
Single-dent surgery
An effective way of treating large retinal detachments is to dent the eyeball from the outside: pressure is applied to the eyeball from the outside using a surgically applied seal or cerclage, which presses the detached upper retinal layer back onto the lower layer.
Indentation surgery is mainly used in cases where a shrinking vitreous body pulls on the retina. The procedure is usually performed under local anesthesia, takes around 20 to 60 minutes and requires an inpatient stay of around three to seven days, depending on the course of the procedure.
Removal of the vitreous body (vitrectomy)
A newer method of treating retinal detachment is the removal and replacement of the vitreous body. This so-called vitrectomy is usually performed under local anesthesia and takes about 30 to 60 minutes. It requires an inpatient stay of around three to seven days.
During the procedure, three small punctures are made in the eye: one to insert the fine surgical instruments, a second for a light source and a third for irrigation drainage. First, the gel-like vitreous body is aspirated. A special fluid is then introduced into the eye, which displaces the detached upper retinal fluid that has accumulated between the two separate retinal layers. This causes the upper retinal layer to reattach to the lower one.
After the procedure, you are not allowed to read at first, but you do not usually have to stay in bed. Around two to three weeks later, there are usually no more restrictions. If a gas mixture has been used to replace the vitreous fluid, the doctor may give the patient additional recommendations (e.g. no air travel for a while).
Retinal detachment: course of the disease and prognosis
Without treatment, retinal detachment progressively worsens. Blindness practically always occurs. The quicker the diagnosis and treatment, the better the prognosis. However, it also depends on which area of the retina is affected and the specific cause of the retinal detachment.
Complications
Prolonged retinal detachment can lead to a so-called proliferative vitreoretinopathy. This is a reactive proliferation of tissue around the vitreous body, which can lead to severe visual impairment and even blindness.
A further complication of retinal detachment is the infestation of the second eye. For example, if one eye is affected by a rhegmatogenous retinal detachment, there is a 20 percent risk that the retina in the other eye will also detach over time.
Retinal detachment: prevention
Slightly less than half of all retinal detachments can be avoided by taking preventive measures.
Patients at risk should undergo a retinal examination (ophthalmoscopy) once a year from the age of 40. If retinal holes are noticed in healthy eyes, it is possible and sometimes advisable to treat them preventively with a laser or cold application. In the event of a sudden deterioration or (re)appearance of the symptoms of retinal detachment, an ophthalmologist must be consulted immediately.
