Retinal detachment is a sudden and unexpected condition that can happen to anyone. The retina , which is the thin nerve layer at the back of your eye, separates from the rest of the eye due to a hole in the retinal layer. People who are short-sighted (myopic) are at higher risk of retinal detachment.
Happy new year! I hope you have had a good break over the Christmas and New Year holidays and are ready to face 2013. I am quite excited as there will be a couple of new medicines for retinal diseases that will soon be available in Malaysia for my patients. Both drugs have to be injected into the eyeball as an intravitreal injection.
Eyelea (Aflibercept) blocks VEGF
Eyelea is a new type of Anti-VEGF drug that binds to VEGF molecules in the eye. VEGF is one of the factors involved in common eyes diseases like AMD, diabetic retinopathy, and retinal vein occlusion. Drugs that can reduce VEGF in the eye like Avastin and Lucentis are now widely used to treat these retinal diseases. The main problem is that we have to inject the current drugs into the eyeball every month as current medicines only last about one month in the eye and the disease recurs. Eyelea is unique in that it can stay in the eye for more than two months. This means that patients will need less frequent injections. I am looking forward to Eyelea being approved in Malaysia as I have many patients that require monthly injections and it becomes a big burden for them to come to clinic every month for their injection. So, rather then needing an injection every month for your retina disease, you will probably only need an injection every 2 months if you choose to have Eyelea.
Jetrea (Ocriplasmin) is an enzyme that helps the vitreous to detach from the retina
In our eyes, the vitreous jelly is attached to the retina inside the eye. Sometimes if the vitreous is too tightly attached to the macula, this can lead to conditions like macula hole which is normally treated with vitrectomy surgery. During vitrectomy surgery, retina surgeons aim to release the vitreous from the retina and this can be sometimes very difficult. Studies have shown that Jetrea can help release the vitreous from the retina if injected before vitrectomy surgery. In some cases, the macula hole was actually closed with the injection of Jetrea alone and the patient did not require surgery! This is very exciting. This new drug may also be used for cases of diabetic retinopathy requiring vitrectomy surgery as detaching the vitreous from the retina is often required for such cases. Children with retina diseases like retinopathy of prematurity (ROP) or retina detachment, may also benefit from having an injection of Jetrea prior to vitrectomy surgery. In children, the vitreous jelly is very stuck to the retina and it is extremely difficult to separate the vitreous from the retina with surgery. This new drug is a breakthrough and earned a publication in the prestigious New England Journal of Medicine for the discovery.
Have a happy and healthy year ahead!
Kuala Lumpur, Malaysia
Almost all of us will experience seeing spots or lines in our vision at some point of our life. This is commonly known as “floaters”. This is sometimes an early sign of retinal detachment and you should seek medical advice. Floaters happen because the vitreous gel in our eye shrinks and detaches from the retina. The vitreous gel is normally attached to our retina. When this gel detaches, this results in a “posterior vitreous detachment” or PVD. Rarely, this can cause a hole in the retina.
Retinal holes can be treated with laser
If there are holes in your retina, this needs to be treated urgently to prevent retinal detachment from occurring. We usually use a laser beam to seal the hole. If retinal detachment has occurred, this will require urgent vitrectomy surgery.
Floaters can be very annoying and affect your quality of life
I have many patients who are bothered by these floaters. Floaters can be of various shapes and sizes. They can appear like black spots, wavy lines, spider webs, or tadpoles moving around. These floaters usually appear in our middle age but it can happen in younger people who are myopic. The good news is that these floaters will get better with time as the gel in our eye gradually becomes more liquified. This means the floaters will move out of view. The bad news is that it can take a long time for the floaters to disappear – up to many months.
There are no eye drops or medications you can take for floaters. Some doctors offer laser treatment to make the floaters disappear using a YAG laser. I am not very keen on this as the laser can potentially damage your retina and cause retinal holes. If there are many things in the eye that are blocking your vision and causing visual problems, then vitrectomy surgery may the best option to permanently remove them. Modern vitrectomy surgery is now done without sutures and is very safe.
Have a great week !
Vitrectomy is the most common operation done for retinal detachment. I usually inject a gas bubble like SF6 into the eye at the end of the operation. This gas bubble helps prevent the retina from coming off again and stays in the eye for 2 weeks. It will dissolve by itself naturally. When you have a gas bubble in the eye, you cannot fly in an airplane as the bubble can expand at high altitude and cause permanent damage to your eyesight.
You can travel by air with silicone oil in your eye
Recently, I had a few patients that had retinal detachment who needed to travel by airplane soon after surgery for work purposes. For these cases, instead of injecting gas into the eye, I injected a substance called silicone oil. Unlike gas, oil will not expand in the eye at high altitude. The main disadvantage of silicone oil in your eye is that you will require a second operation in 3 months time to remove the oil. Retinal specialists do not recommend leaving the oil in your eye permanently as your eye can develop glaucoma and cataract. With oil in the eye, you can usually have some vision immediately after the operation. With gas in the eye, your vision will be very blurred until the gas bubble dissolves.
What is silicone oil?
It is a highly purified medical grade substance that floats and can stay in the eye for a long time without damaging the retina or other structures in the eye. There are several types available with different viscosities. There used to be many complications associated with silicone oil use in the past but this was due to impurities in the oil. With more modern silicone oils now, these complications are less. Among the complications are glaucoma, cataract, and, inflammation in the eye. All these can usually be treated by removal of the oil. There is a small risk of the retina redetaching after the oil is removed.
I am now on the way home from Shanghai after a regional eye meeting on cataract surgery. It will be nice to be back in Malaysia to see my friends and family. Have a great week ahead, my dear readers.
All patients with diabetes should have their retina examined once a year to look for signs of retinopathy. Early laser treatment can prevent progression of retinopathy and prevent loss of vision.
Vitrectomy Eye Surgery for Diabetes
Unfortunately, many patients with diabetes are unaware of this and only seek help when the have lost their eye sight. I have come across many young patients with severe diabetic retinopathy in both eyes that cannot be treated with laser.
This is because there is blood in the eye that prevents the laser beam from entering the eye or there is retinal detachment present. The only option left to try to save the eye sight is to carry out vitrectomy surgery.
Surgery for diabetic retinopathy is very challenging. This is because the retina of these patients are already damaged and have poor potential for vision. I often give an injection of Avastin (an anti-VEGF drug) into the eyeball of the patients 1 week before their operation.
This wonder drug causes rapid shrinking of any new blood vessels in the eye and reduces the chance of bleeding during surgery.
Advantages of Small Gauge Vitrectomy Surgery
I feel that the best approach for diabetic vitrectomy is to use the latest modern sutureless small gauge vitrectomy machines. Although the cost is slightly more expensive, it really makes my life as a surgeon easier.
It is also more comfortable for the patient post op as there are no sutures in the eye and recovery is quicker. Surgery aims to remove all blood in the eye and any scar tissue. This is easier said than done!
Very often, the scar tissue is very tightly stuck to the retina and you can easily cause damage to the retina. It is like trying to peel away two wet pieces of tissue paper that are stuck together. Surgery can often take more than 1 hour.
Surgery to Prevent or Repair Retinal Detachment
Once all scar tissue is removed, I often try to flatten the retina by putting air into the eye ball. I then perform extensive laser treatment to try to stick the retina down.
Sometimes, despite all my best efforts and the retina is reattached, the patient fails to see any improvement in vision. This is probably due to the fact that the eye has been deprived of oxygen and nutrients for too long.
It is of course much better to prevent severe diabetic retinopathy from occurring in the first place. A well organized local screening program for all diabetics is key to this as well as good control of the diabetes, lipids and blood pressure.
I just returned from the Asia Pacific Academy of Ophthalmology Annual Meeting in Busan, Korea. I was invited to give several talks and co-chaired a session on “Pathological Myopia”. Patients with pathological myopia often get retinal problems like macular hole, retinal detachment and macular degeneration. The incidence of pathological myopia is increasing world wide due to the influence of our modern environment. Children who have parents who are myopic and do not do enough outdoor activities are at increased risk of becoming myopic.
Most of the retinal problems from myopia occur because the eyeball continues to grow longer as we get older. This results in our spectacle prescription becoming higher and higher. The retina becomes stretched on the inside and retinal holes can easily occur. This can result in retinal detachment which requires urgent surgery to save the eye sight. Myopic macula holes are also more common and vitrectomy surgery with peeling of the internal limiting membrane and gas tamponade is essential to close the hole and preserve vision.
One of the topics we discussed at the meeting was whether retinal specialists could predict which myopic patient are at greater risk of developing macular holes and needed early vitrectomy surgery. The use of the OCT machine to scan the layers of the retina is very important in the management of myopic patients. We can identify early splitting (schisis) of the different layers of the retina with the OCT. Patients with “outer lamellar schisis” and “foveal detachment” on OCT were found to develop macular holes much quicker. These patients require closer monitoring and probably early surgery would help prevent visual loss.
We also discussed the use of Anti-VEGF agents in the treatment of myopic macular degeneration (MMD). Patients with this condition do not appear to require as many injections as patients with AMD. Photodynamic therapy (PDT) is also less effective for MMD. There is a new clinical trial in Asia looking at the use of a new drug called VEGF Trap Eye (eyelea) for MMD and I am looking forward to the results of the trial.
Busan is the 2nd largest city in South Korea and the weather in April was lovely. The cherry blossoms were out in full bloom and I have the chance to take a walk in the local park to enjoy the weather and scenery of Busan. The food was also very nice, in particular, the Korean BBQs. I also met up with many local and overseas colleagues at this meeting. I will update this blog with more insights that I gained from this useful meeting.
While surgery for retinal detachment is very successful, there may be a few rare complications that can occur. Among the complications that can occur are recurrence of retinal detachment, scar tissue forming on the macula (epiretinal membrane), high eye pressure, and infection.
Macular Hole is Uncommon Complication
One of my patients recently developed a macular hole soon after a successful retinal detachment operation. This is the second time that I have come across this complication. The macular hole was not observed during the procedure and was only noticed 2 weeks after surgery. It turns out that this rare complication occurs in less than 0.5% of eyes after vitrectomy surgery (as reported by my Korean colleagues in a recent scientific article).
Many Diseases Affect the Macula
The macula is the most sensitive part of our retina. It has the highest concentration of nerve cells and is responsible for our ability to see sharp details and colour. It is very easily damaged by various diseases like AMD and diabetic retinopathy. As it is the thinnest part of the retina, holes can also occur there. Macular holes are caused by the vitreous gel pulling on the macula. Scar tissue around the macula can also cause holes to occur.
Surgical Repair for Macular Holes
Macular holes can only be treated with surgery. An essential surgical step is to peel off the innermost layer of the retina called the ILM. This is a very difficult surgical procedure but is essential to ensure the complete closure of the hole. By peeling away the ILM, the retina tissue at the macula is less stretched and can come together to close the hole. I also put a gas bubble in the eye at the end of surgery and instruct my patients to sleep with their face facing down for one night after surgery.
The gas bubble will help close the macular hole. Many surgeons have different posturing regimes after macular hole surgery and I don’t think that you need to sleep face down for more than 1 night and I tell my patients to just avoid sleeping on their back for 1 week after surgery. This ensures that the gas bubble is always in contact with the macula.
My patient had a second operation to fix the macular hole and to mine and her relief, the hole has closed up and she can see well again!
One of my recent patients with retinal detachment (aka “RD”) had LASIK for myopia 5 years previously. He wondered whether his LASIK surgery had caused his problem. I reassured him that this was likely related to his pre-existing myopia (near sightedness). People who are myopic are 4 times more likely to develop a detachment than people who do not need to wear glasses or contact lenses.
Why Nearsightedness (Myopia) is a Risk for Retinal Detachment
The myopic eyeball is longer than normal and this causes stretching of the retina layer inside the eye which can lead to holes in the retina. The vitreous jelly in the eye also detaches from the retina in myopic people at a much earlier age (a process called posterior vitreous detachment, PVD). PVD can also cause holes in the retina which can lead to retinal detachment.
LASIK Does NOT Change Risk
Some people believe that after they have had LASIK surgery, their myopia is ‘cured’ and they are no longer at risk of retinal detachment. This is not true as LASIK only treats the front of the eye, the cornea. It reshapes the cornea to focus the light rays directly onto the retina so that you do not need to wear glasses again. However, the eyeball size remains longer than normal and the retina is still at risk of future “RD.”
All LASIK surgeons thoroughly check the retina of their patients before surgery to ensure that there are no holes or other signs of retinal disease present. If there are suspicious areas in the retina, these patients are normally referred to a retinal specialist for their opinion. Laser treatment can be done to retinal holes to prevent retinal detachment.
LASIK Probably NOT a Risk for Retinal Detachment
As LASIK surgery is now so commonly done for young myopic people, it is not surprising that some of these people develop retinal detachment years later. It is tempting to link LASIK and a detachment together but most studies have not shown an association. These people would have got a retinal detachment anyway, whether or not they had LASIK surgery in the past. This is due to their eye which has always been myopic.
For more information about myopia, please check out this article I wrote recently in my medical column in the Star newspaper.
My favorite chef had a retinal detachment.
One of my indulgences is fine dining. When I used to work in the UK, I would save up to have a meal with my wife once every few months at a Michelin starred restaurant. One of our favorite restaurants is Le Gavrouche in London whose chef Michel Roux Jr. is a culinary genius.
Imagine my surprise to discover that he had a retinal detachment in the past!
In the article, Michel asks if there was anything that he did to have caused this potentially blinding condition like running on hard pavements or knocking his head on something.
Myopia is Risk Factor for Retinal Detachment
While trauma can rarely cause a detachment, Michel’s detachment was most likely due to his preexisting myopia. He also had a family history which increased his risk. I am glad he was treated in Moorfields Eye Hospital, where I have had the privilege of working in the past.
It is absolutely crucial that retinal detachment be treated only by trained retinal surgeons as the first operation is the most crucial in determining how well the eye can see after surgery. Thankfully, he made a good recovery from surgery and is still cooking for the public.
Common Symptoms Include Flashes and Floaters
Retinal detachment is a disease that progresses very rapidly when it occurs. Usually, there are symptoms of floaters and flashing lights to alert the patient.
If there is a retinal hole present, early treatment with laser or cryotherapy can prevent detachment. I always examine the other eye of the patient as there are often undetected holes there that require treatment.
I recently diagnosed an early retinal detachment in the good eye of a myopic patient referred to me for problems in his other eye. He had surgery the same day and has managed to retain his vision.
In patients with conditions that have a high risk of developing retinal detachment like Stickler syndrome, I usually perform laser or cryotherapy treatment on the entire periphery of the retina of both eyes even though there is no retinal hole present.
This is controversial as some retinal specialists do not believe that this can prevent a detachment from occurring and that the laser scars themselves may cause retinal detachment when the vitreous jelly detaches later on and pulls on the scars.
Any patient who is myopic needs to get their retina checked if they have any symptoms of retina detachment. Myopic patients are 4 times more likely to get a retinal detachment.
Laser Treatment Can Reduce Chance of Detachment
I often treat with laser suspicious areas in the peripheral retina called lattice degeneration. This is not a retinal hole but an area of weakness in the retina that can develop retinal holes more easily that other places in the retina.
Laser treatment helps the retina stick on harder and may prevent holes from developing there.
Finally, there is no diet, supplements or eye exercises that can prevent retinal detachment. If you suffer from myopia or have a family history, you need to seek expert advice urgently if you have any of the symptoms of retinal detachment. Rest assured that modern eye surgery is very successful and 90% of patients have their retinal detachment fixed with just one operation.