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The retina is the nerve tissue that lines the inside back wall of your eye. Light travels through the pupil and lens and is focused on the retina, where it is converted into a neural impulse and transmitted to the brain. If there is a break in the retina, fluid can track underneath the retina and separate it from the eye wall. Depending on the location and degree of retinal detachment, there can be very serious vision loss.

Symptoms

The three 3 F’s are the most common symptoms of a retinal detachment:

  • Flashes: Flashing lights that are usually seen in peripheral (side) vision.

  • Floaters: Hundreds of dark spots that persist in the center of vision.

  • Field cut: Curtain or shadow that usually starts in peripheral vision that may move to involve the center of vision.

Causes

Retinal detachments can be broadly divided into three categories depending on the cause of the detachment:

Rhegmatogenous retinal detachments: Rhegmatogenous means “arising from a rupture,” so these detachments are due to a break in the retina that allows fluid to collect underneath the retina. A retinal tear can develop when the vitreous (the gel-like substance that fills the back cavity of the eye) separates from the retina as part of the normal aging process.

The risk factors associated with this type of retinal detachment:

  • Lattice degeneration – thinning of the retina.

  • High myopia (nearsighted) - can result in thinning of the retina.

  • History of a previous retinal break or detachment in the other eye.

  • Trauma.

  • Family history of retinal detachment.

Tractional retinal detachments: These are caused by scar tissue that grows on the surface of the retina and contraction of the scar tissue pulls the retina off the back of the eye. The most common cause of scar tissue formation is due to uncontrolled diabetes.

Exudative retinal detachments: These types of detachments form when fluid accumulates underneath the retina. This is due to inflammation inside the eye that results in leaking blood vessels. The visual changes can vary depending on your head position because the fluid will shift as you move your head. There is no associated retinal hole or break in this type detachment. Of the three types of retinal detachments, exudative is the least common.

Diagnostic tests

  • A dilated eye exam is needed to examine the retina and the periphery. This may entail a scleral depression exam where gentle pressure is applied to the eye to examine the peripheral retina.

  • A scan of the retina (optical coherence tomography) may be performed to detect any subtle fluid that may accumulate under the retina.

  • If there is significant blood or a clear view of the retina is not possible then an ultrasound of the eye may be performed.

Treatment

The goal of treatment is to re-attach the retina to the eye wall and treat the retinal tears or holes.

In general, there are four treatment options:

  • Laser: A small retinal detachment can be walled off with a barrier laser to prevent further spread of the fluid and the retinal detachment.

  • Pneumatic Retinopexy: This is an office-based procedure that requires injecting a gas bubble inside the eye. After this procedure, you need to position your head in a certain direction for the gas bubble to reposition the retina back along the inside wall of the eye. A freezing or laser procedure is performed around the retinal break. This procedure has about 70% to 80% success rate but not everyone is a good candidate for a pneumatic retinopexy.

  • Scleral buckle: This is a surgery that needs to be performed in the operating room. This procedure involves placing a silicone band around the outside of the eye to bring the eye wall closer to the retina. The retinal tear is then treated with a freezing procedure. Vitrectomy: In this surgery, the vitreous inside the eye is removed and the fluid underneath the retina is drained. The retinal tear is then treated with either a laser or freezing procedure. At the completion of the surgery, a gas bubble fills the eye to hold the retina in place. The gas bubble will slowly dissipate over several weeks. Sometimes a scleral buckle is combined with a vitrectomy surgery.

Prognosis

Final vision after retinal detachment repair is usually dependent on whether the macula (central part of the retina that you use for fine vision) is involved. If the macula is detached, then there is usually some decrease in final vision after reattachment. Therefore, a good predictor is initial presenting vision. We recommend that patients with symptoms of retinal detachments (flashes, floaters, or field cuts) have a dilated eye exam. The sooner the diagnosis is made, the better the treatment outcome.

 

Article contributed by Dr. Jane Pan

This blog provides general information and discussion about eye health and related subjects. The words and other content provided in this blog, and in any linked materials, are not intended and should not be construed as medical advice. If the reader or any other person has a medical concern, he or she should consult with an appropriately licensed physician. The content of this blog cannot be reproduced or duplicated without the express written consent of Eye IQ.

There are several different variations of Glaucoma, but in this article we will mainly focus on Primary Open Angle Glaucoma. This means that there is no specific underlying cause for the Glaucoma like inflammation, trauma or a severe cataract. It also means that the drainage angle where fluid is drained from the inside of the eye into the bloodstream is not narrow or closed.

Closed or Narrow Angle Glaucoma, which will be discussed in another article, is treated differently from Open Angle Glaucoma

In the U.S., Primary Open Angle Glaucoma (POAG) is by far the most common type of Glaucoma we treat.

Glaucoma is a disease where the Optic Nerve in the back of the eye deteriorates over time, and that deterioration has a relationship to the Intraocular Pressure (IOP).  Most - but not all - people diagnosed with Glaucoma have an elevated IOP.  Some people have fairly normal IOP’s but show the characteristic deterioration in the Optic Nerve. Regardless of whether or not the pressure was high initially, our primary treatment is to lower the IOP. We usually are looking to try to get the IOP down by about 25% from the pre-treatment levels.

The two mainstays of initial treatment for POAG in the U.S. are medications or laser treatments. There are other places in the world where Glaucoma is initially treated with surgery. However, while surgery can often lower the pressure to a greater degree than either medications or laser treatments, it comes with a higher rate of complications. Most U.S. eye doctors elect to go with the more conservative approach and utilize either medications - most often in the form of eye drops - or a laser treatment.

Drops

There are several different classes of medications used to treat Glaucoma.

The most common class used are the Prostaglandin Analogues or PGA’s.  The PGA’s available in the U.S. are Xalatan (latanaprost), Travatan (travapost), Lumigan (bimatoprost) and Zioptan (tafluprost).

PGA’s are most doctors’ first line of treatment because they generally lower the IOP better than the other classes; they are reasonably well tolerated by most people; and they are dosed just once a day, while most of the other drugs available have to be used multiple times a day.

The other classes of drugs include beta-blockers that are used once or twice a day; carbonic anhydrase inhibitors (CAI’s ), which come in either a drop or pill form and are used either twice or three times a day; alpha agonists that are used either twice or three times a day; and miotics, which are used three or four times a day. All of these other medications are typically used as either second-line or adjunctive treatment when the PGA’s are not successful in keeping the pressure down as single agents.

There are also several combination drops available in the U.S. that combine two of the second-line agents (Cosopt, Combigan, and Symbrinza).

Laser

The second option as initial treatment is a laser procedure.

The two most common laser treatments for Open Angle Glaucoma are Argon Laser Trabeculoplasty (ALT) or Selective Laser Trabeculoplasty (SLT).  These treatments try and get an area inside the eye called the Trabecular Meshwork - where fluid is drained from the inside of the eye into the venous system - to drain more efficiently.

These treatments tend to lower the pressure to about the same degree as the PGA’s do with over 80% of patients achieving a significant decrease in their eye pressure that lasts at least a year.  Both laser treatments can be repeated if the pressure begins to rise again in the future but the SLT works slightly better as a repeat procedure compared to the ALT.

Article contributed by Dr. Brian Wnorowski, M.D.

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