Wesleyan University Philippines Cabanatuan City College of Nursing and Allied Medical Sciences

Case Study of

Submitted to: Ma am !oan Cauyao "N MAN Clinical #nstructor

Submitted by: $enry "% &agalag 'SN #( 'loc) *

. RETINAL DETACHMENT

A disorder of the eye in which the retina peels away from its underlying layer of support tissue. Initial detachment may be localized, but without rapid treatment the entire retina may detach, leading to vision loss and blindness. It is a medical emergency. The retina is a thin layer of light sensitive tissue on the back wall of the eye. The optical system of the eye focuses light on the retina much like light is focused on the film in a camera. The retina translates that focused image into neural impulses and sends them to the brain via the optic nerve. Occasionally, posterior vitreous detachment, injury or trauma to the eye or head may cause a small tear in the retina. The tear allows vitreous fluid to seep through it under the retina, and peel it away like a bubble in wallpaper.

Eye after retinal detchment &ypes of "etinal +etachment

"hegmatogenous retinal detachment A rhegmatogenous retinal detachment occurs due to a hole, tear, or break in the retina that allows fluid to pass from the vitreous space into the subretinal space between the sensory retina and the retinal pigment epithelium. ,-udative. serous. or secondary retinal detachment An exudative retinal detachment occurs due to inflammation, injury or vascular abnormalities that results in fluid accumulating underneath the retina without the presence of a hole, tear, or break. &ractional retinal detachment A tractional retinal detachment occurs when fibrovascular tissue, caused by an injury, inflammation or neovascularization, pulls the sensory retina from the retinal pigment epithelium.

A substantial number of retinal detachments result from trauma, including blunt blows to the orbit, penetrating trauma, and concussions to the head. A retrospective ndian study of more than !"" cases of rhegmatogenous detachments found that ##$ were due to trauma, and that gradual onset was the norm, with over !"$ presenting more than one month after the inciting injury. Prevalence "ate A physician using a %three&mirror glass% to diagnose retinal detachment

'he risk of retinal detachment in otherwise normal eyes is around ! in #"",""" per year. (etachment is more fre)uent in the middle&aged or elderly population with rates of around *" in #"",""" per year. 'he lifetime risk in normal eyes is about # in +"".

,etinal detachment is more common in those with severe myopia -above !. diopters/, as their eyes are longer and the retina is stretched thin. 'he lifetime risk increases to # in *". 0yopia is associated with .1$ of retinal detachment cases. 2atients suffering from a detachment related to myopia tend to be younger than non&myopic detachment patients. ,etinal detachment can occur more fre)uently after surgery for cataracts. 'he estimated of risk of retinal detachment after cataract surgery is ! to #. per #""" cataract operations.'he risk may be much higher in those who are highly myopic, with a fre)uency of 1$ reported in one study.3oung age at cataract removal further increased risk in this study. 4ong term risk of retinal detachment after extracapsular and phacoemulsification cataract surgery at *, !, and #" years was estimated in one study to be ".+.$, ".11$, and #.*5$, respectively.

Causes of "etinal +etachment ,etinal detachment can occur as a result of6

'rauma Advanced diabetes An inflammatory disorder, such as sarcoidosis or cytomegalovirus retinitis 7agging or shrinkage of the jelly&like vitreous that fills the inside of your eye

t is more likely to develop in people who are nearsighted, or whose relatives had retinal detachments. A hard, solid blow to the eye may also cause the retina to detach. 7evere trauma to the eye, such as a contusion or a penetrating wound, may be the cause, but in the great majority of cases, retinal detachment is the result of internal changes in the vitreous chamber associated with aging, or less fre)uently, with inflammation of the interior of the eye. &he "is) /actors of "etinal +etachment 'he following factors increase your risk of retinal detachment6

Aging 8 retinal detachment is more common in people older than age 9" 2revious retinal detachment in one eye A family history of retinal detachment Extreme nearsightedness -myopia/ 2revious eye surgery, such as cataract removal 2revious severe eye injury or trauma :eak areas on the sides -periphery/ of your retina

PA&$0P$1S#02031

'he development of rhegmatogenous ,( is a conse)uence of both posterior vitreous detachment and the development of one or more breaks in the retina. ;luid can then pass from the vitreous cavity through these retinal breaks into a subretinal space, which extends the detachment once the amount of incoming fluid exceeds the removal capacity of the retinal pigment epithelium -,2E/. (etachment of the posterior vitreous is considered a major & in fact indispensable & factor in the pathogenesis of rhegmatogenous ,(. <owever, no preoperative diagnostic techni)ue can accurately distinguish between a posterior vitreous detachment and a posterior vitreoschisis. 2rogression of the detachment depends on many factors, including6

4ocation of the break6 superior faster than inferior 7ize of the break6 larger faster than smaller Adhesion of the remaining vitreous gel to the retina6 stronger faster than weaker 0ovement of the patient=s head and eyes6 this is also important because lack of such movement, as with bilateral patching, can result in the reattachment of the retina spontaneously, albeit temporarily.

n eyes with tractional ,(, the membranes on either surface of the retina are #/ attached to the retina, and */ elastic. As the membranes contract, the retina detaches from the ,2E. Accumulation of the subretinal fluid is a secondary event> as part of the normal fluid transport from the vitreous to the choroid, the fluid simply fills the space created by the elevated retina. n serous and haemorrhagic ,(, the fluid that accumulates under the neuroretina separates it from the ,2E. Clinical Manifestations of "etinal +etachment ,etinal detachment is painless, but visual symptoms almost always appear before it occurs. :arning signs of retinal detachment include6 'he sudden appearance of many floaters 8 small bits of debris in your field of vision that look like spots, hairs or strings and seem to float before your eyes 7udden flashes of light in one or both eyes A shadow or curtain over a portion of your visual field A sudden blur in your vision ?right flashes of light, especially in peripheral vision 7hadow or blindness in a part of the visual field of one eye

Medical Management

7urgery is the only effective therapy for a retinal tear, hole or detachment. 3our ophthalmologist can tell you about the various risks and benefits of your treatment options. 'ogether you can determine what treatment is best for you. Surgery for retinal detachment: Pneumatic retinope-y% ;or a relatively uncomplicated detachment with the tear located in the upper half of the retina, your ophthalmologist may recommend this outpatient procedure, usually done under local anesthesia. 'he procedure often starts with cryopexy to treat the retinal tear. ,epair of the retinal detachment may re)uire softening the eye by withdrawing a small amount of fluid from the space between the clear dome at the front of your eye -cornea/ and the colored part of your eye -iris/. @ext, your surgeon injects a bubble of expandable gas into the vitreous cavity. Aver the next several days, the gas bubble expands, sealing the retinal tear by pushing against it and the detached area that surrounds the tear. :ith no new fluid passing through the retinal tear, fluid that had previously collected under the retina is absorbed, and the retina is able to reattach itself to the back wall of your eye. 'he gas eventually disappears after several weeks. Scleral buc)ling% 'his is one of the most common surgeries for repairing retinal detachment. t=s usually done in an operating room under local or general anesthesia. f you have an uncomplicated retinal detachment, this surgery may be done on an outpatient basis. (itrectomy% ,emoving portions of the vitreous itself is occasionally necessary when vitreous clouding blocks the surgeon=s view of the detached retina or retinal scarring limits the effectiveness of pneumatic retinopexy or scleral buckling.

Nursing Care Plans *% ,isk for injury rBt the presence of veil or curtain in the field of vision #nterventions 0aintain a safe environment Assist with ambulation and self care activities as needed Ceep side rails raised and bed in low position

0aintain bed in low position with side rails up ,emove environmental barriers to ensure safety

4% (isturbed body image rBt to the slight feeling of heaviness in the eye secondary to the diseaseprocess #nterventions 2rovide hope within parameters of individual situations> do not give false reassurance Assist patient to identify extent of actual change in appearanceBbody functions 7upport and encourage patient> provide care with a positive, friendly attitude Assess central vision with each eye, individually and together Assess factors or aids that improve vision, such as glasses, contact lenses, or bright andBor natural light.

+. Anxiety rBt the presence of floaters or hair in the temporal part of the central vision #nterventions 2rovide accurate, consistent information regarding prognosis of the disease. Avoid arguing about patientDs perceptions of the situation 2rovide open environment in which the patient feels safe to discuss feelings or to refrain from talking (evelop a trusting relationship being honest and non judgemental, providing opportunity for )uestions and answers ntroduce self to patient, and acknowledge visual impairment Eommunicate type and degree of impairment to all involved in patientDs care

9. 7elf& esteem disturbance related to the presence of floaters in the field of visions #nterventions 2romote self& concept without moral judgement 2rovide accurate, consistent information regarding prognosis of the disease. Avoid arguing about patientDs perception of the situation <elp patientDs formulate goals for self and create a manageable plans to reach those goals one at a time. Encourage expressions of fears, negative feelings and grief over body changes Assess factors or aids that improve vision, such as glasses, contact lenses, or bright andBor natural light.

!. ,isk for activity intolerance rBt to the changes in field of vision6 straight lines that suddenly appear curved secondary to retinal detachment #nterventions nstruct patient to change position slowly

nstruct patient to stop activity if changes in field of vision occur 2rovideB recommend assistance with activitiesBambulation as necessary (etermine nature of visual symptoms, onset, and degree of visual loss. Ask patient about specifics such as ability to read, see television, history of fall Assess eye and lid for inflammation, edema, positional defects, and deviation.

Birmingham Ophthalmologists Develop New Retinal Detachment Laser Pevention !""#$ %y& A'( ()*)A*+T

uly

,reviously anyone at high risk of a retinal detachment could do little but wait and hopefully keep on seeing. %ut two %irmingham ophthalmologists have now completed a pilot study on a laser procedure that may become the first reliable retinal detachment preventative procedure for high-risk eyes. .ith rhegmatogenous retinal detachment /**+$ being so effectively repairable, not much attention has been given to preventing it. 0%ut not everyone gets back all their vision after a retinal reattachment, and it1s sometimes a difficult operation,2 said *obert 3orris, 3+, with *etina 4pecialists of Alabama and a clinical associate professor at 5A%. 0If someone has already lost vision due to a retinal detachment in one eye, they don1t want the other shoe to fall. Those second eyes are the ones we1ve performed this procedure on in this first study.2 3orris and his partner 6. +oug .itherspoon, 3+, also with *etina 4pecialists and 5A%, devised their laser prophyla7is as an e7tension of the current repair process for retinal tears. *etinal tears are a primary cause of **+ as the opening allows vitreous cavity fluid to pass behind the retina, floating it away from the eye wall. If not treated 8uickly, this leads to vision loss and even blindness. To repair retinal tears, a laser surrounds the tear with 0burns2 to create a chorioretinal scar that effectively welds the surrounding retina to the eye wall /figure 9$. This treatment is over :; percent effective in preventing progression of that particular retinal tear to retinal detachment. 0%asically, it creates tight adhesion by means of a well-controlled microscopic scar that effectively bonds those tissues together,2 .itherspoon said. 0%ut new tears often occur at other clock hours in the peripheral retina.2 .hen repairing an e7istent retinal detachment, many physicians encircle the retina in some fashion with a laser treatment to help prevent any future tears or retinal detachment /figures !

and <$. It was in this techni8ue that the two ophthalmologists saw even more potential. 0.e took the encircling laser to a purely preventive level by applying it to the second eye where no tears e7isted, only high risk of tears or detachment,2 3orris said. They realized that if encircling worked in eyes with e7istent **+, it might be similarly effective in eyes at high risk from other causes, such as being severely nearsighted with a family history of retinal detachment. 0The new thing we1re doing,2 .itherspoon said, 0is taking the encircling procedure to a second eye as a preventive measure, especially in eyes that have had cataract removal.2 4o they used the encircling techni8ue to create a new 0boundary2 on the retina in eyes that were known to be at risk but not actually damaged. 03ost tears occur in the outer regions of the retina, so we take that area out of play,2 3orris said. 5sing a laser, they burn a ring of minute scars several millimeters wide, just behind the ora serrata, the anterior line of the retina. 0.e1re creating a second line = a second ora = further back from the ora serrata. .e1re calling that the ora secunda,2 3orris said. The ora serrata circumscribes the back two-thirds of the eye orb = in front of the e8uator of the eye = so the laser 0welding2 effectively creates a new retinal boundary. 0All the lasering is done in front of the e8uator of the eye where little vision occurs,2 3orris said. 0The lasering is far out in the peripheral field, but those are the e7act same areas that suffer tears that cause detachment.2

The primary candidates for this new procedure are eyes that harbor multiple risk factors, such as cataract surgery, a family history of detachments, eye trauma, and severe myopia. .ith over 9.<; million cataract surgeries in the 5.4. and about 9 percent suffering retinal detachments, that leaves 9<,;"" eyes at risk of **+. 3orris notes that if a patient has had cataract surgery in both eyes and a retinal detachment in one, there1s a !" percent chance of a **+ in the second eye. 0All these things can add up, and the key is to determine the actual risk for that particular eye,2 .itherspoon said. 0Although laser is noninvasive, you don1t want to be lasering eyes that don1t have a high risk of retinal detachment.2

The two ophthamologists researched this innovative surgery in a study of !>> eyes and accumulated five to ten years of follow-up data. They recently released a paper introducing the concept, and plan to present the hard data this year in more formal medical journals.

The )elen ?eller @oundation for *esearch and (ducation in %irmingham, of which 3orris is president, helped sponsor this discovery. New Approaches Ma!e Retinal Detachment Highl" Treata#le

ScienceDaily (Dec. 1, 2008) = *etinal detachment, a condition that afflicts about 9",""" Americans each year, puts an individual at risk for vision loss or blindness. In a new study in the 'ew (ngland ournal of 3edicine, a leading ophthalmologist at 'ewAork-,resbyterian

)ospitalB.eill 6ornell 3edical 6enter writes, however, that a high probability of reattachment and visual improvement is possible by using one of three currently available surgical techni8ues.

CAlthough no randomized trials have been conducted that show definitively that one procedure is best for every situation, improvements in these surgical techni8ues have led to effective treatments for most patients,C says +r. +onald . +DAmico, ophthalmologist-in-chief at 'ewAork-,resbyterian )ospitalB.eill 6ornell 3edical 6enter, professor and chairman of ophthalmology at .eill 6ornell 3edical 6ollege, and an international leader in vitreoretinal surgery. Although relatively rare, retinal detachment can occur when holes, tears or breaks appear in the light-sensitive retina as a result of trauma or pulling away of the gelatinous mass, known as the vitreous, that fills the back of the eye. *etinal tears occur most often in adults over age >", but may occur much earlier, particularly in those with high myopia. The sudden onset of light flashes and CfloatersC could be the warning signs of an impending retinal detachment, although these symptoms do not always mean that a retinal tear has occurred. 4urgery is the only treatment for a retinal detachment. +r. +DAmico offers his recommendations for treating a ;E-year-old man who e7periences sudden flashes and floaters in one eye, progressive loss of vision and a retinal detachment in the article, C,rimary retinal detachment.C The three surgical options currently in use to treat such a case are& 9. $cleral B%c!ling& A common way to treat a retinal detachment, scleral buckling surgery has been performed with success for several decades. In this procedure, a piece of silicone is sutured onto the outside wall of the eyeball and left in place permanently to create an indentation, or buckle, that restores contact with the detached retina. The individual tears are then closed by a localized scar that is induced with a freezing probe or laser. According to +r. +DAmico, scleral buckling is a relatively involved procedure and re8uires the use of a hospital operating room. It is usually performed on an outpatient basis with local anesthesia with intravenous sedation, and the overall success rate for reattachment is about :" percent. !. Pne%matic Retinope'"& A newer and less invasive procedure than scleral buckling, pneumatic retinope7y is usually done in the retina specialistDs office under local anesthesia. The procedure involves injecting a gas bubble into the vitreous cavity of the eye, then positioning the patientDs head so that the bubble floats to the break in the detached retina. The bubble spans and closes the retinal break, and this allows the natural forces in the eye to reattach the retina. The break is permanently sealed by the application of a freezing probe or laser to create a scar around the break. The gas bubble then resolves over several days, and in successful cases, the retina is left reattached without a trip to the operating room, and with no permanent buckling material applied to the eye. According to +r. +DAmico, pneumatic retinope7y is not suitable for every patient and has a somewhat lower success rate with initial treatment than does scleral buckling or vitrectomy. 'evertheless, he says, because of its minimally invasive attributes, and the fact that an attempted pneumatic does not reduce the ultimate chance for success if additional surgery is re8uired for recurrent detachment, patient and surgeons increasingly select pneumatic retinope7y for suitable primary retinal detachments after a careful discussion of the limitations. <. (itrectom"& In contrast to scleral buckling, vitrectomy is a surgery within the eye in which the vitreous gel is removed. %ecause vitreous traction is the typical cause of the retinal tears in a detachment, this approach has the advantage of directly attacking the underlying cause of the detachment. Fitrectomy surgery -- a few decades old -- is a newer surgery than scleral buckling, and it is continually improving due to innovations in instrumentation and techni8ue. *ecent studies have shown success rates comparable to those of scleral buckling. +r. +DAmico notes that there is a very strong shift toward vitrectomy, and away from buckling, for retinal detachment, particularly by younger surgeons and for patients that have detachment after cataract surgery. Fitrectomy for detachment may be associated with a higher risk of postoperative cataract, and this appears to be its main disadvantage compared

to buckling, which has lower risk of cataract but higher risk of other complications. In cases where bleeding in the vitreous gel is present with the detachment, a vitrectomy approach is clearly preferred to remove the vitreous hemorrhage in order to gain better visualization to find and repair tears or holes in the retina. Fitrectomy, like scleral buckling, is typically done on an outpatient basis with local anesthesia with intravenous sedation. @or the patient described in the vignette who went to his ophthalmologist with classic symptoms of primary retinal detachment, including flashing lights, floaters and progressive loss of vision, +r. +DAmicoDs first recommendation would be to perform a pneumatic retinope7y. CI would select this option for this patient because this specific detachment is well-suited to pneumatic retinope7y by virtue of the retinal breaks being located close together in the superior retina, which is the easiest location to treat with an intraocular gas bubble. @urthermore, the procedure can be done immediately in the doctorDs office at lower cost and with fewer risks of complications, compared to buckling or vitrectomy, and it also compares 8uite favorably with the other procedures with having a E; percent chance of restoring vision to !"B;" or better after this minimally invasive procedure,C +r. +DAmico says. As with any surgery, there are risks associated with each of these techni8ues. @or e7ample, vitrectomy can cause cataract or elevated pressure inside the eye, especially in people with glaucomaG scleral buckling can cause a change in the shape of the eye that may re8uire alteration of the eyeglass prescriptionG and pneumatic retinope7y often re8uires more than one surgery to reattach the retina. CThe benefits of surgery, however, far outweigh the risks,C says +r. +DAmico, who performs all of these procedures. C'o matter which procedure the surgeon chooses, there is a very good chance today that a patientDs retina can be reattached and his or her vision preserved.C