Deepak Vijay

New Treatments and Improvements for Retinal Detachments

A significant portion of the population experiences a retinal detachment (RD) at some

point in their life. In fact, they can occur without any prior indication of such a condition. There

are numerous treatments available, most of which involve surgery, but they are continually

improving to this day. One of the main causes of RD is when retinal tears allow vitreous fluid to

flow through under the retina and pull on it (American Society of Retina Specialists, 2016).

Retinal lattice degeneration (which thins the retina) and posterior vitreous detachment (PVD) can

result in retinal tears. RD can disrupt eyesight via the appearance of floaters, bright flashes of

light, and even vision loss. Some treatments include utilizing a scleral buckle, laser treatment,

cryotherapy, stem cell therapy, and having a vitrectomy (removing the vitreous fluid in the eye)

using intraocular gas or silicone oil. However, improvements could be made to increase the

success rates and decrease the negative postoperative effects such as a recurrent retinal

detachment. I would like to research this topic because one of my parents has several retinal tears

caused by PVD. Since this issue can often run in the family, I am inclined to educate myself on

the improvements of treatments and methods to prevent retinal detachments caused by retinal

tears. Although, almost everybody should feel a need to learn more about this because of the

prominence of retinal detachments and the fact that it could occur to almost anybody (American

Society of Retina Specialists, 2016).

Having a vitrectomy, the removal of the vitreous fluid in the middle of the eye, helps a

doctor provide treatment for RD because it makes it easier to access the retina (WebMD, 2015).

After the vitrectomy, a doctor often uses intraocular gas or silicone oil to heal the eye after
surgery. However, these methods have its drawbacks as well; they are not a perfect solution as

they can cause another RD. Thus, various vitreous gel substitutes have been tested to reduce the

likelihood of recurrent retinal detachments (WebMD, 2015).

A certain pilot study aims to decrease retinal detachment chances through the injection of

bevacizumab (Tousi, Hasanpour, & Soheilian, 2016). The researchers used 27 random patients

with retinal detachments about to undergo pars plana deep vitrectomies, in which 12 of them

received intravitreal bevacizumab (IVB). IVB is an agent suspected to improve anti-VEGF

treatments for intraocular proliferative issues, such as retinal detachment. After three months,

27.3% of the patients that received IVB experienced a recurrent retinal detachment compared to

50% of the patients in the control group. After six months, 30% of the patients that received IVB

had a recurrent retinal detachment compared to 37.5% of the patients in the control group. While

these results may indicate a very slight improvement of postoperative effects for the patients who

received IVB, the results are not conclusive, and more large scale studies are necessary to

demonstrate accurate results. Since this is only one study, a slight correlation of retinal

detachment decrease due to IVB injection does not mean causation. If several consistent, large

scale studies are conducted, it may indicate causation (Tousi et al., 2016).

Another study seeks to test the efficacy of a certain hydrogel, as opposed to silicone oil,

to be used as vitreous substitute, often utilized to stabilize the retina after a complicated

vitrectomy in retinal detachment cases (Schnichels et al., 2017). Eight chinchilla bastard rabbits

each were used to test the silicone oil, a more viscous hydrogel, and a less viscous hydrogel.

Several tests, including an intraocular pressure measurements (IOP), optical coherence

tomography (OCT), and electroretinogram (ERG), were used to measure and examine the eyes
of the rabbits. Seven out of eight of the rabbits that received silicone oil experienced a recurrent

retinal detachment, compared to the three out of sixteen rabbits that received a hydrogel. ​Within

those rabbits who received a more viscous hydrogel, no retinal detachments occurred.​ Since the

thiol-modified crosslinked hyaluronate hydrogels were much more efficacious than the silicone

oil, the hydrogel could be used as a novel vitreous substitute after retinal detachment

vitrectomies, improving the postoperative effects of the surgery. However, larger experiments

should be conducted to validate the accuracy of these results, especially since only twenty-four

rabbits were used. Once larger studies are conducted with similarly consistent results, it may

suggest that the correspondence of data is more than just an association by chance, meaning that

the hydrogel may actually be more effective than the silicone oil (Schnichels et al., 2017).

Another article used two mouse models of retinal degeneration (rd1 and rd10) to show

that when adult stem cells, from bone marrow, (lineage-negative hematopoietic stem cells or Lin​–

HSCs) with endothelial precursors stabilize and help recover retinal blood vessels, the nerves

within the retina are also improved (Otani et al., 2004). The results include a significant

upregulation of transcription factors and small heat shock proteins, which suggest that these stem

cells may help slow the progression of retinal degeneration. While this stem cell implantation

may help reduce the chances of a retinal detachment, considering that retinal degeneration can

cause RD, more conclusive studies need to be conducted. The primary need for this is to truly

isolate the two variables (the stem cell therapy and reduction in retinal degeneration) and ensure

that the results are not just due to chance (Otani et al., 2004).

Based on this research, I would recommend patients with a retinal detachment to undergo

a vitrectomy and receive a more viscous thiol-modified crosslinked hyaluronate formulation

because it has a superiorly higher efficacy than the silicone oil. Compared to the IVB, I would

still recommend the hydrogel because the IVB injection did not provide substantially decreased

rates of retinal detachments. Even with the stem cell treatment method, my recommendation

resides with the hydrogel because of how strong the results showed the success of the

hyaluronate formulation. However, in all of these research studies, the experiments were small

scale, and thus it is difficult to conclude that any of these treatments or improved treatments are

as successful as the results indicate. Furthermore, since these studies were conducted with

different species (humans, rabbits, and mice), comparing them may not reflect accurately. While

every experiment cannot be expected to be exactly the same in regards to the number of subjects

used, what the subjects were, the environment the subjects were in, etc., inconsistencies between

experiments still make it challenging to compare data in order to formulate a conclusive verdict.

There exists three main treatments (or treatment improvements) discussed in this paper.

First, retinal detachment treatments can be improved by using a certain hydrogel instead of

silicone oil in vitrectomies. Second, IVB injections can reduce the likelihood of recurrent RD,

just like the hydrogel. Third, stem cell therapy, though relatively new, opens an entire field of

research. Overall, I learned a lot about the intricacies of retinal detachment treatments we

usually just know there are some treatments, but not too much about the details and

improvements that can be made to the treatments themselves. This may be very useful for me as

an educated potential patient because one of my parents had many retinal tears and is at risk for a

retinal detachment.

Since the results of the research studies I explored are small scale rather than large scale

(which are needed to make definite conclusions), I have a few questions. How can more official
tests be conducted faster to get new research into actual practice sooner? How many more tests

need to be done (and in what scale and manner) to prove causation (compared to mere

correlation)? The answers to these questions may educate me more on the conclusive research

process and help me understand what it tangibly takes to prove that an association is accurate and

caused by a variable.

Furthermore, I would recommend patients to read up on new treatments and

modifications being done to them due to the fact that retinal detachments can be quite a hassle,

especially recurrent ones. Keeping up to date with these treatments may also serve as extremely

beneficial because novel improvements are currently underway and healthcare is always

improving. The self-education of patients is quite important in order to understand some

concepts and options for themselves. If or when I become a doctor, I would recommend my

patients to get treatments that reduce the likelihood of recurrent retinal detachments as much as

possible and that are proven to have superior efficacy compared to other options. One concept

not discussed is the comfort of such treatments. How utilizing a hydrogel compared to

intraocular gas or silicone oil impacts the comfort and serenity the patient experiences is

noteworthy. After all, it is a factor patients should consider before undergoing any treatment.

This demonstrates another flaw with using animals as test subjects it is difficult to gauge their

pain or comfort levels since they cannot communicate with us.

Nonetheless, I am significantly more interested in ophthalmology now. Becoming an eye

doctor was never really on my list of potential careers, but I can now see myself with such an

occupation, especially since this research has fueled a passion for eye research. The eyes are so

small, yet so complex; the fact that these treatments are only a few of many and they are just
regarding the retina is astounding. There is so much more to such a small organ, and I am more

ecstatic than ever to explore the details of various portions of the eye in the future. It is surprising

to grow fondness towards a career I never had my eye out for, but I am glad that this research has

not only educated me, but inspired me.

 References

American Society of Retina Specialists. (2016). Retinal tears. Retrieved from

http://www.asrs.org/patients/retinal-diseases/26/retinal-tears

Otani, A., Dorrell, M. I., Kinder, K., Moreno, S. K., Nusinowitz, S., Banin, E., … Friedlander,

M. (2004). Rescue of retinal degeneration by intravitreally injected adult bone

marrow–derived lineage-negative hematopoietic stem cells.​ Journal of Clinical

Investigation​, 114(6), 765-774. doi:10.1172/JCI200421686

Schnichels, S., Schneider, N., Hohenadl, C., Hurst, J., Schatz, A., Januschowski, K. & Spitzer,

M. S. (2017). Efficacy of two different thiol-modified crosslinked hyaluronate

formulations as vitreous replacement compared to silicone oil in a model of retinal

detachment. ​PLoS One, 12(3)​. doi:10.1371/journal.pone.0172895

Tousi, A., Hasanpour, H. & Soheilian, M. (2016). Intravitreal injection of bevacizumab in

primary vitrectomy to decrease the rate of retinal detachment: A randomized pilot study.

Journal of Ophthalmic & Vision Research, 11(3)​, 271-276.

doi:10.4103/2008-322X.188390

WebMD. (2015). Vitrectomy. Retrieved from https://www.webmd.com/eye-health/vitrectomy