Retinal tear

The retina is the seeing part of the eye located on the inner side of your eyeball. Most of the eyeball contains a gel called the vitreous. With age this gel starts to liquefy and contract. As it contracts it should separate from the retina in a process called a vitreous detachment or posterior vitreous detachment (PVD). However, there can be areas of firmer attachment between the vitreous and the retina. When the vitreous pulls on these areas, it can lead to the appearance of a retinal tear or hole.

Some retinal tears and holes are of little consequence. Sometimes during a routine exam, we find an old round hole over which there is no vitreous traction present. These holes are not worrisome for an EyeMD and should not cause you any worry either. If there is residual traction between the vitreous and the edge of the retinal tear, this give us more pause for thought and you will probably be told that a treatment is necessary.

This is particularly true if the tear is recent or new. The reason for our concern is that new tears with vitreous traction often evolve to a retinal detachment. While a tear on its own will not cause a loss of vision, a retinal detachment can.

Detachments also require more elaborate surgery, while the treatment of a retinal tear is usually straightforward and can be done in the ophthalmologist’s office.

What do you see? What are the symptoms?

New retinal tears usually occur when the vitreous collapses. You are likely to see new shadows or floaters in your vision which suddenly appear. Some people notice multiple small spots or a decrease in vision. This is due to a small amount of bleeding into the eye (self limited), which occurs when a small retinal vessel breaks and bleeds as the retinal tear develops.

In some cases, patients mention seeing bright lights circulating in the eye or even light flashes or light fireworks inside the eye. These are mainly seen when the lights in a room are turned off at night. The light flashes or photopsias are rarely seen during the daytime.

If you experience any of these symptoms, particularly if you are a high myope (nearsighted) or you were a high myope prior to refractive surgery, had previous ocular trauma, or had cataract surgery in the past, you should be seen by an EyeMD (ophthalmologist) within several days to rule out a retinal tear.

If you start seeing a shadow appear over part of your peripheral vision, you should get to an EyeMD much earlier, as this could be a sign of a retinal detachment. Progressive detachments of the retina are an emergency, which needs to be repaired promptly.

What are the eye exams that will be done during an office visit?

Your EyeMD (ophthalmologist) will go over your ocular history. He/she will want to know when the symptoms appeared and if they have gotten worse or better since then. He will do a thorough exam of both eyes, checking your vision, eye pressure, and (following dilatation of your pupil) carefully examine the inside of your eyes.

A careful exam of the retina, particularly the peripheral retina will be carried out to find the location of the tear, or make sure that none is missed. This may involve pushing slightly on the ocular globe through your eyelid (as you might do using a finger). This allows your EyeMD to see more clearly the areas where tears may form or be present.

If he/she finds a tear, he/she will propose a treatment based on its location and characteristics. Occasionally, a retinal detachment might be found instead of a tear. In these cases the location of the tear, the presence of vitreous traction and the proximity to the macula (center of vision) will be carefully determined to judge the urgency of a surgical intervention.

What can be done?

As we mentioned earlier, not all tears require treatment. Old round holes can be left untreated. New holes or tears, or those that are causing symptoms (as described above) are usually treated to prevent them from causing a retinal detachment.

The aim of the treatment is to produce a permanent seal around the tear or hole between the retina and the pigment epithelial layer under the retina. The creation of this seal counteracts the vitreoretinal traction in the affected area prevents the elevation of the retina, the accumulation of fluid underneath and finally, the beginning of a retinal detachment. Placing a laser barrier around the tear treats in this way most holes and tears.

This sealing requires from an “irritation” of the pigment epithelium either with heat (laser) or by cold (freezing).

Treatments with laser are quick and generally non-invasive. Although several dozen to a few hundred-laser spots will be required to complete the treatment, these treatments can normally be performed in one session lasting up to 30 minutes using a contact lens and a slit lamp, or a laser indirect ophthalmoscope (LIO). The use of a LIO allows the patient to be treated while lying on a couch, a much more pleasant experience for most patients but it also allows the EyeMD to see more clearly the peripheral retinal structures something that facilitates your treatment.

The laser light is very bright. You will not see much for some time after completing the treatment but after several minutes to an hour your vision will be back. You probably experienced something similar passing from bright sunlight to a darkened room. Your eye needs time to adapt to the lower light level.

An alternative approach to treat retinal tears, particularly those that are very peripheral is to use a contact (diode) laser or to use cryotherapy (freezing). In both cases, a probe is placed on the sclera (the white part of the eye) adjacent to the tear and the treatment will be applied through the eyewall.

In very rare circumstances will a surgical procedure be required to treat a retina tear.