The retina is an important part of our eye as it houses all the photoreceptors or light-sensitive cells that are responsible for absorbing light that enters our eyes and transmitting this information to our brain for interpretation. Without these cells, we would be unable to see under any circumstance. As the retina is irreplaceable, any damage to it can lead to irreversible visual loss.
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What are retinal tears?
Retinal tears are breaks in the retina, which is the thin inner lining of our eye. This happens due to pre-existing retinal weakness or degenerative changes which come about due to age. Retinal tears are dangerous as they are precursors to retinal detachment, which is when the retina falls off the back wall of the eye. If not treated quickly, a retinal detachment can result in permanent vision loss.
Who gets retinal tears?
You are more susceptible to retinal tears if you have:
- High Myopia (Spectacle prescriptions ≥500 degrees)
- Family History of Retinal tears/detachment
- Older Age (>40 years)
- Previous Eye Trauma
- Previous Eye Surgery
- Certain Eye Conditions such as Peripheral Retinal Degeneration
Our retina is not completely elastic, like a piece of rubber or dough, if you excessively stretch it, it will become extremely thin and delicate, tearing easily. Therefore, people with high myopia are more susceptible to retinal tears because they have elongated eyeballs and their retina is thinned and stretched-out, which likely lead to areas of retinal weakness.
People with a strong family history of retinal tears are also predisposed genetically. Increased age is also a risk factor for retinal tears because aging causes degenerative changes within the eye. Any form of trauma to the eye can also cause retinal tears to occur.
How do retinal tears start?
The vitreous gel is a jelly-like substance inside the eyeball which is responsible for shock absorption, keeping the retina connected to the walls of the eye. The vitreous attaches itself to the retina at various points, namely, the optic nerve (the bridge between the brain and the eye), ora serrata (outermost edge of the retina), along the peripheral blood vessels and the macula (location responsible for clear central vision). When we age, our vitreous gel gradually degenerates, liquefies and sags. This brings about the process of posterior vitreous detachment, in which the vitreous inadvertently pulls away from the tightly adhered retina. Most of the time, when the vitreous detaches or separates from the retina, the vitreous is able to separate cleanly from the retina. Only in 10% of the time, as the vitreous separates, it pulls along some retina to cause a tear. Sudden jerky head movements from trauma or high impact sport can also contribute to retinal tears as well.
What happens if retinal tears are left untreated?
Our greatest fear for leaving a retinal tear unchecked is a retinal detachment. 30-50% of untreated eyes may progress to retinal detachment approximately 4-8 weeks after the onset of symptoms. A common analogy I like to give to my patients is to imagine the retina as an important wallpaper of our eye. If there is a hole (equivalent to a retinal tear) in the wallpaper, given enough time, the hole may widen and if it is sufficiently large or fluid starts to trickle inside beneath the wallpaper, segments of the wallpaper begin to lift off and may fall off (retinal detachment).
In our eye, as the vitreous degenerates, it liquefies, and this fluid can enter the layers of the retina through the tear, which can eventually cause the retina to separate and detach.
Similarly, even if we were to patch the hole of the damaged wallpaper, there will be a visible mark indicating that it has been damaged before. Unfortunately, there is no way to replace the retina at the moment. The retina consists of important cells that rely on the inner walls of the eye for survival, if the retina remains detached for too long, these retinal cells will start to die off. When these cells die, the chances of the retina returning back to its normal state is very low. As a result, even if surgery is done to return and fix the retina back onto the eye, the damage can be irreversible and hence may lead to permanent vision loss. Therefore, timing is crucial, once a retinal detachment is detected, urgent surgery is required for a better visual outcome.
What are the symptoms of a retinal tear?
Occasionally, retinal tears may cause bleeding and dispersion of pigment if the detachment site was adhered to some blood vessel, which leads to the patient suddenly seeing a shower of floaters (≥10) in the eye. The tugging of the retina also may bring about flashes of light which appear as a camera flashlight in the absence of one. These flashes can occur at any time, regardless of the environment and often last only for a few seconds. Having said that, approximately 8% of the general population may present with asymptomatic retinal breaks and are only discovered during a routine eye examination. That is why it is so important to have an annual eye check to detect silent retinal breaks.
How are retinal tears detected?
Conventionally, a dilated fundus examination is conducted and the practitioner will examine the retina using a combination of a specialized lens and a special microscope to have a look inside the eye. A light is shone into your eye during this process and you’ll be asked to look in different gazes to allow the practitioner to examine the periphery. The downside to this technique is that it is very difficult to take pictures to show the patient what the practitioner is seeing.
In my clinic, with the use of a specialized camera, we are able to take ultra-widefield photographs of your retina, allowing us to see far into the periphery to detect the presence of any retinal tears or weakness. By combining the conventional dilated fundus examination and the wide field photographs, I am able to show you what I am looking at and discuss with you what our next move is.
Typically, even if no retinal tear is discovered on the first visit of a symptomatic patient (someone who is seeing a shower of floaters) I will review the same patient again in 1-2 months within the acute posterior detachment event. This is to ensure that the retina is stable and no tears have developed as retinal tears can develop during this window period.
How do we treat retinal tears?
In the event of a retinal tear, we need to seal the tear immediately to prevent it from progressing to a retinal detachment. We seal the tear by using an in-office retinal laser treatment which is a quick and painless procedure with no downtime and takes about 15 minutes to complete. By using a laser, the lasered spots on the retina around the tear will eventually form scar tissue which acts as a barrier to prevent retina detachments. Retinal laser, in the hands of a competent retinal specialist, is a very safe procedure with no side effects and is the treatment of choice for retinal tears to prevent the blinding complication of retinal detachment.
What can I expect on the day of the laser treatment?
When you arrive for your appointment, eye drops will be instilled into your eye to dilate your pupil. Once your pupils have been sufficiently dilated, a numbing eye drop will be used to anaesthetize the front of your eye so that you do not feel any discomfort. A special contact lens will be used on your eye to keep your eye in the right position. You will then see some bright lights and hear some clicking sounds from the laser as I use the laser to laser around the tear to seal it. However, there will be no pain sensation. You might be asked to look in different directions depending on the location and number of tears detected. Once all the laser is done, my assistant will help to rinse and clean your eye.
After the procedure, your near vision will still be blurry due to the dilating drops which need a few hours to wear off. You will still be able to see some floaters as this laser does not remove any existing floaters within the eye. After the procedure, you will be free to resume your daily activities. I will then review in 1 to 2 months to check that no new retinal breaks have developed.
What are the risks for this treatment?
Thanks to technological advancements, the lasers used today are very safe. There is almost no risk of any eye infections from this procedure as no incisions were made to the eye. It is extremely safe and most of my patients have undergone this procedure without any complications. There is a very small chance that even after the laser, new retinal tears or a retinal detachment can occur from other areas of the eye that were not lasered.
How can we prevent retinal tears?
If you have a strong family history of retinal tears and/or have high myopia, it will be wise to get your eyes checked on a regular basis. If you have high myopia, it is advised to avoid high impact sports or activities such as boxing, muay thai, bungee jumping, roller coaster rides, etc.
References:
- Coffee, R. E., Westfall, A. C., Davis, G. H., Mieler, W. F., & Holz, E. R. (2007). Symptomatic posterior vitreous detachment and the incidence of DELAYED Retinal Breaks: Case series and meta-analysis. American Journal of Ophthalmology, 144(3). https://doi.org/10.1016/j.ajo.2007.05.002
- Crim, N., Esposito, E., Monti, R., Correa, L. J., Serra, H. M., & Urrets-Zavalia, J. A. (2017). Myopia as a risk factor for subsequent retinal tears in the course of a symptomatic posterior vitreous detachment. BMC Ophthalmology, 17(1). https://doi.org/10.1186/s12886-017-0629-6
- Ghazi, N. G., & Green, W. R. (2002). Pathology and pathogenesis of retinal detachment. Eye, 16(4), 411–421. https://doi.org/10.1038/sj.eye.6700197
- Gishti, O., Nieuwenhof, R., Verhoekx, J., & Overdam, K. (2019). Symptoms related to posterior vitreous detachment and the risk of developing retinal tears: A systematic review. Acta Ophthalmologica, 97(4), 347–352. https://doi.org/10.1111/aos.14012
- Lankry, P., Loewenstein, A., & Moisseiev, E. (2020). Outcomes following Laser RETINOPEXY for Retinal Tears: A comparative study Between trainees and specialists. Ophthalmologica, 243(5), 355–359. https://doi.org/10.1159/000507483
- Uhr, J. H., Obeid, A., Wibbelsman, T. D., Wu, C. M., Levin, H. J., Garrigan, H., Spirn, M. J., Chiang, A., Sivalingam, A., & Hsu, J. (2020). Delayed retinal breaks and DETACHMENTS after acute Posterior vitreous detachment. Ophthalmology, 127(4), 516–522. https://doi.org/10.1016/j.ophtha.2019.10.020