Retinal Surgery: What Patients Need to Know

Retinal surgery addresses a range of conditions that threaten vision. Some of the most common reasons a retina specialist may recommend surgery include the following.

• Retinal detachment: The retina separates from the back wall of the eye, cutting off its blood supply.
• Proliferative diabetic retinopathy: Abnormal blood vessels grow on the retina and can bleed or cause scar tissue.
• Vitreous hemorrhage: Bleeding into the vitreous gel blocks light from reaching the retina.
• Macular hole: A small break forms in the macula, the central part of the retina responsible for sharp vision.
• Epiretinal membrane: A thin layer of scar tissue grows on the surface of the macula, causing distortion.

Certain factors raise the likelihood of developing a retinal condition that may require surgery. Severe nearsightedness (high myopia) is one of the strongest risk factors. The incidence of retinal detachment in highly nearsighted patients is 39 times higher than in people without myopia (Nature Scientific Reports, 2023). Previous eye surgery, especially cataract removal, also increases risk.

Aging plays a role as well. Most people over age 60 experience posterior vitreous detachment, where the vitreous gel separates from the retina. While this is often harmless, it can sometimes cause retinal tears. Diabetes significantly raises the risk of complications that may require surgery. A family history of retinal detachment, eye trauma, and certain genetic conditions such as Stickler syndrome also elevate risk.

Retinal conditions requiring surgical intervention are not rare. The annual incidence of rhegmatogenous retinal detachment in the United States is approximately 19.25 per 100,000 people (PMC, National Library of Medicine, 2022). Nearly 63,000 retinal detachment repair cases were reported in 2018 alone (PMC, National Library of Medicine, 2022). Additional surgeries are performed each year for diabetic eye disease, macular holes, and other conditions.

Pars plana vitrectomy is the most frequently performed retinal surgery. The surgeon makes three tiny incisions in the pars plana, located about 3 to 4 millimeters from the front of the eye. Through these openings, the surgeon inserts a light source, a cutting and suction probe, and an infusion line that maintains the eye's shape with fluid.

Small-gauge vitrectomy using 23-, 25-, or 27-gauge instruments has become the standard. These instruments create incisions between 0.5 and 0.9 millimeters wide. In most cases, the incisions seal on their own without stitches. This contributes to faster healing and greater comfort after surgery.

For certain types of retinal detachment, a scleral buckle may be recommended. A flexible silicone band is sewn around the outside of the eye. It gently indents the wall to support the detached retina. This band stays in place long term but is not visible from the outside.

Pneumatic retinopexy is a less invasive option for some retinal detachments. The retina specialist injects a gas bubble into the eye, which floats against the detached area and holds the retina in place. Cryopexy (a freezing treatment) or laser photocoagulation (thermal laser) is then used to seal the retinal tear. Patients must maintain specific head positions for several days to keep the bubble correctly located.

During vitrectomy, the surgeon may use several additional techniques depending on the condition being treated.

• Endolaser photocoagulation: Laser applied directly to the retina to seal tears or treat abnormal blood vessels.
• Membrane peeling: Delicate removal of epiretinal membranes or internal limiting membrane using microscopic forceps.
• Gas tamponade: Injection of a gas bubble (SF6 or C3F8) to hold the retina in place while it heals.
• Silicone oil tamponade: Used in complex detachments. The oil is typically removed in a later procedure.
• Fluid-air exchange: Replacement of fluid inside the eye with air or gas to flatten the retina.

Anti-VEGF (vascular endothelial growth factor) injections are sometimes used before or during retinal surgery, particularly for diabetic eye disease. These medications block abnormal blood vessel growth and reduce bleeding. Common agents include Eylea (aflibercept), Lucentis (ranibizumab), and Avastin (bevacizumab), which is FDA-approved for cancer but used off-label for eye conditions. A retina specialist may inject one of these before surgery to shrink abnormal vessels and reduce surgical bleeding risk.

Retinal surgery continues to evolve. Robotic-assisted vitreoretinal surgery platforms are being developed to provide even greater precision during delicate maneuvers. Gene therapy for inherited retinal diseases, such as the use of Luxturna (voretigene neparvovec) for RPE65-related conditions, requires precise surgical delivery beneath the retina. These advances are expanding the range of conditions that retinal surgery can address.

Seek immediate care from a retina specialist or go to the emergency room if you experience a sudden onset of many new floaters, flashes of light, a shadow or curtain in your vision, or sudden vision loss in one eye. These symptoms can indicate a retinal detachment or other serious condition that requires prompt treatment. Delays in treatment can lead to severe and lasting vision loss.

Even without symptoms, people with known risk factors should have regular dilated eye exams. If you are highly nearsighted, have diabetes, have a family history of retinal detachment, or have had previous eye surgery, a retina specialist can monitor your eye health. Early detection often means more treatment options and better outcomes.