A retinal detachment (RD) is a serious eye condition where the thin, light-sensitive layer of tissue at the back of the eye separates from the underlying support tissue. This separation causes the retina to lose the blood and nutrient supply necessary for it to function correctly. Since the retina converts light into signals sent to the brain, its detachment causes a sudden disruption of vision. A detached retina is a medical emergency requiring prompt surgical intervention to prevent permanent vision loss.
Less Invasive Repair: Pneumatic Retinopexy
Pneumatic retinopexy (PR) is a minimally invasive technique often performed in an eye doctor’s office, used primarily for certain types of retinal detachments. This procedure is generally reserved for smaller tears located in the upper part of the retina. The technique involves injecting a small, expanding gas bubble into the center of the eye, known as the vitreous cavity.
The injected gas bubble (such as sulfur hexafluoride or perfluoropropane) acts as a temporary internal splint. Because the gas bubble is lighter than the fluid in the eye, it floats upward and pushes the detached retinal tissue back against the inner wall of the eye. This reattachment allows the fluid accumulated beneath the retina to be reabsorbed by the eye’s tissues.
To ensure the gas bubble correctly pushes the retina back, the patient must maintain specific head positioning for several days following the procedure. This strict positioning keeps the bubble floating directly over the retinal tear, effectively sealing the break. Once the retina is successfully reattached by the bubble, a freezing treatment called cryopexy or laser photocoagulation is applied to create a permanent scar around the tear.
This permanent scarring secures the retina to the underlying tissue layer, preventing fluid from passing through the tear and causing a re-detachment. Cryopexy is often performed just before the gas injection, while laser treatment may be applied after the gas bubble has flattened the retina. The gas bubble naturally dissipates and is replaced by the eye’s own fluid over one to two weeks, depending on the type of gas used.
Primary Operating Room Procedures
For more complex or extensive retinal detachments, two primary surgical procedures are performed in an operating room: scleral buckling and vitrectomy. These techniques are effective and are chosen when pneumatic retinopexy is not suitable due to the tear’s size, location, or complexity. Surgeons may combine both procedures during the same operation to maximize the chance of successful reattachment.
Scleral Buckling
Scleral buckling is an external procedure that involves placing a flexible silicone band, or “buckle,” around the eye’s outer white layer, called the sclera. The buckle is positioned permanently beneath the eye muscles, similar to a belt wrapped around the eyeball. This band is tightened slightly to create a gentle inward indentation on the wall of the eye.
This inward pressure from the buckle supports the retina from the outside, pushing the eye wall closer to the detached retina and helping to flatten it. Before the buckle is secured, a freezing probe may be used to apply cryotherapy to the retinal tear, causing a scar to form that seals the break permanently.
The scleral buckle remains a permanent fixture and is not visible, as it is positioned underneath the conjunctiva and eye muscles. This procedure is often favored for younger patients or for detachments involving tears in the lower portion of the eye. Scleral buckling can be performed alone or in conjunction with other techniques, such as draining the fluid from under the retina.
Vitrectomy
A vitrectomy is an internal surgical procedure where the surgeon removes the vitreous gel, the clear, jelly-like substance that fills the center of the eye. This is performed using micro-surgical instruments inserted through three tiny incisions in the sclera. Removing the vitreous gel relieves any pulling or traction it may be exerting on the retina, which is a common cause of detachment.
With the vitreous removed, the surgeon can access the retina directly to remove any scar tissue and flatten the retina back into its proper position. The surgeon then uses a laser or cryotherapy to seal the retinal tears. Specialized instruments are used to illuminate the inside of the eye and delicately perform these internal repairs.
After the repair is complete, the removed vitreous gel is replaced with a substitute to hold the retina in place while it heals. This substitute can be sterile saline solution, an expanding gas bubble, or silicone oil. Gas and silicone oil act as an internal “tamponade,” pressing the retina against the eye wall and providing support for several weeks or months.
When gas is used, it is gradually absorbed by the body and naturally replaced by the eye’s own aqueous humor. Silicone oil is typically reserved for more complicated or recurrent detachments, requiring a second surgery several months later to remove it. The choice of substitute depends on the specific characteristics of the detachment and the surgeon’s preference.
Post-Surgical Recovery and Visual Prognosis
Recovery from retinal detachment surgery requires rest and strict adherence to post-operative instructions to maximize successful reattachment. Patients are advised to avoid strenuous activities, heavy lifting, and bending over, which can increase pressure in the eye. Eye drops are prescribed for several weeks to prevent infection and manage inflammation.
If a gas bubble or silicone oil was placed during surgery, mandatory head positioning is a non-negotiable part of the recovery. The patient must maintain a specific position (often face-down or on their side) for several days or weeks, allowing the bubble to float correctly and press against the repair site. Failure to maintain this position can cause the retina to detach again.
A gas bubble also imposes an absolute restriction on changes in altitude; air travel must be avoided until the bubble is fully absorbed. Flying or traveling to high altitudes causes the gas bubble to expand rapidly due to pressure changes, which can lead to a severe increase in intraocular pressure. The bubble may take up to eight weeks to disappear, depending on the gas mixture.
The final visual prognosis depends heavily on whether the central vision area, the macula, was detached before the operation and for how long. If the macula remained attached, the chances of achieving a final visual acuity of 20/40 or better are significantly higher. If the macula was detached, however, visual recovery is often incomplete because the photoreceptor cells are highly sensitive to the lack of oxygen and nutrients. Vision recovery is a gradual process that can take many months, sometimes improving for up to a year or more after reattachment. Even with successful reattachment, complications like scar tissue formation can limit the final visual outcome.