What does Errol Spence Jr’s boxing future look like after eye surgery?

A week ago, news broke that WBC and IBF welterweight champion Errol Spence Jr would have to withdraw from his pay-per-view showdown with Manny Pacquiao due to a retina injury.

Yordenis Ugas was promoted from the undercard as a substitute, creating an unusually compelling short notice replacement fight. So, the show will go on this Saturday, now with Pacquiao facing Ugas instead of Spence.

In the meantime, Spence went home to Texas for emergency surgery to repair his damaged eye.

Spence and his handlers are saying that recovery is already underway, and he’ll be back in action as soon as possible. But, what might a retina injury mean for a boxer at Spence’s level, both now and in the future?

For a better understanding of Spence’s injury, his treatment options, and what the future may hold, Bad Left Hook spoke to Dr. Brian VanderBeek, a retina surgeon at the Scheie Eye Institute, and Assistant Professor of Ophthalmology in the Perelman School of Medicine at the University of Pennsylvania.

Dr. VanderBeek isn’t involved in Spence’s treatment, but he was able to share his expertise on retina injury, surgical options, and the general prognosis for someone involved in combat sports.

Among the most notable takeaways from our conversation with Dr. VanderBeek? The injury is highly unlikely to be related to Spence’s October 2019 car accident. Spence will face a higher risk of future retinal injury, which could be exacerbated if Spence has one of several other eye or vision problems. And, while Dr. VanderBeek would likely advise an athlete in Spence’s situation to strongly consider retirement, a fighter willing to face the risk could be recovered from surgery and ready to return to the ring again after three to four months.

A transcript of our conversation, edited for length and clarity, follows.

---

BAD LEFT HOOK: Let’s start simple, and please keep in mind that I mean “simple” for someone who went to a directional state school, not an Ivy League professor. Can you describe, ideally in small words or with elementary analogies, where the retina is within the eye and what it does?

DR. BRIAN VANDERBEEK: The retina is a very thin piece of tissue that lines the back wall of the eye. If you think about a hollowed out orange with just the peel intact, and on the inside of the peel was a thin piece of tissue? That would be the retina.

Essentially, if your eye was a camera, the retina would be the film in the camera. Its job is to collect light, turn that light into a signal, and send it to your brain. That’s how you see. For the retina to function properly, it has to stay on the back wall of the eye for it to get the blood, oxygen, and nutrients it needs to function and survive.

Originally, Errol Spence’s injury was described as a tear. Since then, Mike Coppinger with ESPN called it a “detachment/break” based on new information from the Nevada State Athletic Commission. What is the difference between those two injuries? What does it mean to have a tear vs. a detachment or a break?

A retinal “break” is just a broader term for a tear, or another form of break in the retina. Essentially, it is what it sounds like: A break in the retina. Whether that’s a tear, a dialysis, a hole that collected fluid — it’s a discontinuation of the retina. Retinal breaks are the starting points that can lead to a retinal detachment.

A retinal detachment is where the retina comes off the back wall of the eye. It can come off in a limited or small area of the retina. Or, in the worst case scenario, the entire retina can become detached.

A retinal break itself typically does not change your vision. Symptoms of a retinal break or a tear are new or increased floaters, which are those little black spots that float around in your vision, or little flickers of flashing lights which may only last a few seconds.

The reason a break or a tear is a problem is because now there’s a way for fluid to get from in front of the retina, to behind the retina, pushing it off the back wall of the eye. Once enough fluid has built up, we call it a detachment.

Without knowing exactly whether Spence simply had a single retinal break with a very limited detachment, all the way through the worst-case scenario of a total retinal detachment, there are a range of procedures and surgeries that could have been used to fix the condition, depending on what the treating physician saw.

Spence’s tear wasn’t something he noticed or sought treatment for on his own. It was found as part of a pre-fight evaluation by the Nevada State Athletic Commission. How common is it to not realize you have a tear in your retina? Does that tell us anything about the injury, or the post-surgery prognosis?

There’s a lot of variation in how a retinal break can present to a doctor. There are people who don’t realize they have a problem. However, when you ask them “Did you see any floaters?” They say: “Oh yeah, about a week ago I had a bunch of black spots in my vision.” Well, that’s different from someone that was completely asymptomatic and never saw anything.

There are people who have partial retinal detachments and never realize it until diagnosed with an eye exam. In uncommon cases the detachments can stay there for months or years without progressing and never becoming symptomatic. Outside of the floaters, a break is not typically symptomatic in and of itself. Once it’s there, after the brief period of floaters and flashing lights, until it starts becoming a detachment that starts moving towards the center part of your vision? You may not notice it being there for quite a while.

What can you tell us about the recovery period for this sort of injury? How long does it take for a typical patient to resume a normal lifestyle? And, what sort of additional time or precautions are needed for someone competing at the highest level of a combat sport?

Again, depending on the severity of the retinal break or detachment and the type of procedure used to fix the issue, there’s a whole range of recovery periods.

If it’s just a retinal tear or a break, you can fix that in the office with just a laser or a freezing procedure that creates scarring. That scarring usually sets in around 7-10 days, maybe 14. Boxing aside, during that time there’s not a lot of change to your life. We’d ask you obviously not to go get punched in the face during that time. But, for most people in their day-to-day life, they can continue to function relatively normally.

When you get to the level of a detachment, there is an early detachment that can also be fixed in the office with a procedure called a Pneumatic Retinopexy that uses freezing or laser to treat the break and then places a gas bubble in the eye to allow the retina to heal in place.

Once you have a gas bubble in your eye, that’s when things get harder, and changes recovery. A gas bubble will take up about half of your visual field, causing it to be very blurry. Now, the gas will slowly absorb over the course of weeks, and during that time the area of the retina covered by the gas will not see well. With this procedure you’re talking about 4-8 weeks depending on how big of a gas bubble is needed to treat the detachment.

Moving up the ladder in terms of invasiveness of the procedure would be to perform a surgery in the operating room. Then, there’s a couple of different ways to fix the detachment depending on what the surgeon chooses.

To step back for a second, often the reason a retinal break occurs is that traction or pulling on the retina happens. This is done by the vitreous, a gel that fills the center cavity of your eye. It’s that traction or pulling by the vitreous that continues to make problems. If you have a retinal break, the reason it will turn into a detachment is that the vitreous will continue to pull on that area of the retina and cause fluid to get “burped” behind the retina, leading to a detachment.

A central point of surgery then is to relieve that traction, which is primarily done by one of two ways. One is to place a Scleral Buckle, which is a band placed around the outside of the eye that brings the walls of the eye in closer than they would be otherwise, reducing traction within the eye. Healing from a Scleral Buckle is likely to take 3 months.

The other option is to perform a Vitrectomy, where the surgeon will make small slits into the white part of the eye and remove the vitreous gel from the eye, which again is a different way to relieve that traction. However, when a surgeon does this, a much larger gas bubble will be needed, extending the recovery time as compared to a Pneumatic Retinopexy.

The success rate changes for each level of invasiveness across the available procedures. Pneumatic Retinopexy in general has a 70-75% success rate. Scleral Buckle, is about 80-85%. And the Vitrectomy has a 90-95% success rate the first time through. Each one is getting a little more invasive, but you’re getting the benefit of a higher success rate.

Does it tell us anything that Spence was in and out the same day, and posted a picture with a patch on his eye the same day as his procedure?

All of those we discussed are same-day procedures. But, if he had a patch on his eye, that’s more likely that had a full surgery in the operating room. You usually don’t patch the eye for just something done in the office. That means he probably had either Scleral Buckle or a Vitrectomy.

Another common question is: What caused this injury? In Spence’s case, he was in a catastrophic car accident 22 months ago, he fought a 12 round fight against a high-level opponent back in December, and he’s been actively training for what would have been a fight against Manny Pacquiao this weekend. Given what we know about this injury and how it was discovered, are there any conclusions we can draw or possibilities we can likely rule out?

If the standard procedure for a boxer going into a match is to have an eye exam, and he had an eye exam eight months ago because of a previous match? Then it’s reasonable to assume that his eyes were fine at that point, and this was unrelated to the car accident. Had it been related to the accident, it probably would have presented itself when he had the exam for the previous fight.

There’s been concern over the long-term impact on Spence’s career, especially when boxing fans think back to Sugar Ray Leonard briefly retiring mid-career after surgery for a partial retinal detachment. Obviously, medical science and technology have come a long way since the 80s, we’ve seen a lot of issues where treatment was almost certain to be career-ending become practically normalized. Is the advancement in this area anything like Tommy John surgery in baseball, or repairing an ACL or Achilles tendon in basketball?

If Sugar Ray Leonard had a partial detachment in the 80s, it was probably repaired with a Scleral Buckle, because that’s what they were doing then. Vitrectomy has since become the predominate method to fix detachments.

Being a boxer is a little bit of a unique situation. As a physician, I need to balance the patient’s health while also not taking away someone’s career. Unfortunately, my recommendation to him would probably be to stop boxing. However, it is not my place to decide whether a life without boxing is best for the patient. I would make sure we would have a careful discussion of the risks involved with boxing, and would understand if a boxer chose to return to the ring.

As a retina surgeon, this is an interesting situation. How would I treat a boxer who I knew would be returning to the ring? I would probably recommend doing both a Scleral Buckle and a Vitrectomy. This would help to support the retina, while also reducing the risk of future internal traction by removing the vitreous.

In short, my advice would be to quit. Understanding that is not always a reasonable option, I think a boxer could return to full contact in 3-4 months, if he is willing to take that chance.

One thing we haven’t discussed yet was how bad the detachment was, which may impact the decision to return to boxing. Presumably, if the retinal detachment or break was asymptomatic and found on a routine exam, then it was outside the center of vision, which is the most important part for seeing. If the center of vision was impacted by the retinal detachment, then there is likely to be some residual deficiency. This could be minimal, or blinding, depending on how bad the detachment was. This is another consideration to take into account as to whether it is reasonable to start boxing again. If the boxer is now only seeing with one eye, that is a very different situation than someone who has good vision in both eyes.

Whether it’s something that makes you predisposed to that sort of injury, or something related to the treatment and healing process, do we know anything about the probability of a repeat problem given that there’s already been one retinal injury in the eye?

Once you have one detachment, you are at higher risk for having a second. Typically when a tear, break, or detachment occurs, it only involves a limited part of the retina. We often think of the retina like the face of a clock. Typically, a break will only involve one or two clock-hours. Once that area is fixed, it is unlikely to experience another break from that region. However, that leaves a large majority of the retina that is still susceptible.

Also, people who are very nearsighted or myopic are at higher risk for having a retinal break or detachment. Similarly, one in seven people has something called “lattice”, which is a thinning in the peripheral part of the retina. Lattice also increases your risk of having a tear or detachment. I would then have to imagine that being nearsighted and having lattice while also being in a situation where you’re frequently punched in the eye probably increases the risk even more so.

---

Special thanks to Lauren Ingeno at the Perelman School of Medicine for her assistance with this interview.