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Choroidal Detachment Following Retinal Detachment Surgery Without Drainage of Subretinal Fluid
CHOROIDAL DETACHMENT F O L L O W I N G R E T I N A L DETACHMENT SURGERY W I T H O U T DRAINAGE O F SUBRETINAL FLUID A. H.
CHIGNELL,
F.R.C.S.
London, England
In 1965, Lincoff1 described his technique of modifying the Custodis2 procedure for the treatment of retinal detachments. Lin coff3 later indicated the advantages of his method when combined with cryosurgery and stated that drainage of subretinal fluid was becoming unnecessary increasingly often. The purpose of this paper to to report three cases of extensive choroidal detach ment following treatment of 60 cases of reti nal detachment by external plombage and cryotherapy without drainage of subretinal fluid. Shea4 has indicated that the relation ship between cryosurgery and choroidal de tachment is unkown.
CASE REPORTS
FINDINGS
Symptoms and signs—In two patients, marked blurring of vision heralded the onset of the choroidal detachments on the eighth postoperative day, and in the third case, when choroidal detachments were found on the seventh day there were no symptoms. In all cases the onset of the choroidal detach ments was sudden with rapid accumulation of fluid. Vitreous haze and a few cells in the anterior chamber were found in all cases. In two cases there was marked shallowing of the anterior chamber but no glaucoma. Progression—In one case, resolution took six weeks ; in the second, four weeks ; and in the third, four days. In the case resolving in four weeks re-operation was necessary but had no apparent effect on the choroidal de tachments. In the case resolving in four days, a subsequent re-operation resulted in slight recurrence of the choroidal detach ments which had completely absorbed. From the Retinal Unit, Moorfields Eye Hospital, London, England. This work was supported in part by the Clothesworkers' Company. Reprint requests to A. H. Chignell, Retinal Unit, Moorfields Eye Hospital, City Road, London, E.C.1, England.
Case 1—A 61-year-old man presented with a bal loon detachment in the left upper temporal quadrant due to a single U-shaped tear. This was treated by buckling a S mm radial plomb over full-thickness sciera and cryotherapy without drainage of sub retinal fluid. On the second postoperative day there was proptosis with painful limitation of movement and it was considered that the patient was suffering from mild orbital cellulitis. The anterior chamber was clear and the retina was found to be flat over the plomb but there was some residual subretinal fluid below. There was rapid resolution of the extraocular signs over the next few days when treatment with systemic ampicillin was commenced. On the fourth postoperative day slight vitreous haze was noted and by the seventh postoperative day there had been some increase in the amount of subretinal fluid and choroidal detachments had appeared (Fig. 1). There were some cells in the anterior chamber, but at all times in the postoperative period the intraocu lar pressure remained between IS and 20 mm Hg. The clinical picture remained unchanged for one week. Two weeks later the subretinal fluid and choroidal detachments had completely resolved. When the area of treatment was assessed two months after surgery the lesion was found to be very atrophie with white sciera visible. Only the larger choroidal vessels were intact and pigmentation of the lesion was scattered and irregular.
Fig. 1 (Chignell). Choroidal detachment follow ing external plombage and cryotherapy without drainage of subretinal fluid. Central vitreous haze is present. 860
VOL. 73, NO. 6
CHOROIDAL DETACHMENT
Case 2—A 75-year-old man presented with a bal loon detachment in the upper half of the right eye caused by small U-shaped tears. This was treated at operation by a S mm plomb placed radially and by cryotherapy without drainage of subretinal fluid. Localization of the hole and cryotherapy application was particularly difficult due to marked arcus senilis and peripheral cortical lens opacities. After the plomb had been tied in place the intraocular pressure was measured with the Perkins hand-held applanation tonometer (Chignell5) and was 45 mm Hg. There was no pulsation of the central retinal artery which was filling normally. The intraocular pressure was 20 mm Hg on the first postoperative day and remained between 15-20 mm Hg for the first six days postoperatively. Postoperatively, subretinal fluid absorption was slow so that after one week there was still some subretinal fluid behind the plomb. On the seventh postoperative day large choroidal detachments sud denly appeared (Fig. 2) and some vitreous haze was seen over the plomb and posterior pole. In as sociation with the choroidal detachments there was some shallowing of the anterior chamber and intra ocular pressure reduced to 9 mm Hg. A few cells were found in the anterior chamber. This picture remained unchanged for a further week and there was still some residual subretinal fluid. Two weeks after the first operation the plomb was repositioned as the hole was eccentrically placed on the plomb and no further subretinal fluid absorption had oc curred. At the second operation more cryotherapy was applied and again subretinal fluid was not drained. This operation did not appear to affect the choroidal detachments although there was increased activity in the anterior chamber and thickening of the vitreous haze over the plomb. Over the follow ing two weeks the subretinal fluid absorbed corn-
Fig. 2 (Chignell). Nasal and temporal choroidal detachments following external plombage and cryotherapy without drainage of subretinal fluid.
861
Fig. 3 (Chignell). Large choroidal detachments following external plombage and cryotherapy with out drainage of subretinal fluid. pletely and at the end of that time the nasal of the two main choroidal detachments had considerably lessened. Three weeks later the choroidal detach ments had absorbed. Assessment two months after surgery showed an atrophie retina with scattered and irregular pigmentation and only large choroidal vessels intact. Case 3—A 69-year-old man presented with a large balloon detachment in the right upper tempo ral quadrant due to a single U-shaped tear. This was treated with a 5 mm plomb placed circumferentially and cryotherapy without drainage of subretinal fluid. For the first three postoperative days there was some absorption of subretinal fluid. On the fourth postoperative day large choroidal detachments ap peared (Fig. 3) which were associated with phakodonesis and shallowing of the anterior chamber, but on gonioscopy the angle was found to be narrowly open, and the intraocular pressure was 21 mm Hg. There was only very slight central vitreous haze. Over the next three days the choroidal detachments remained unchanged and there was considerable ab sorption of subretinal fluid. There was complete ab sorption of detachments over the next three days and the patient was discharged. When the patient was seen two weeks later there had been some re-accu mulation of subretinal fluid and the patient was re admitted for readjustment of the plomb which was moved slightly anteriorly and more cryotherapy was applied. Again, subretinal fluid was not drained. Postoperatively the retina flattened satisfactorily but there was slight recurrence of the choroidal de tachments but these quickly reabsorbed. When assessed two months after the second op eration, the lesion was found to be evenly pigmented. There was no excessive whiteness of the area associated with destruction of the choroidal vessel layers.
862
AMERICAN JOURNAL OF OPHTHALMOLOGY COMMENT
Hawkins and Schepens6 found hypotony, age of patient, myopia, and involvement of the vortex veins to be of significance in the production of choroidal detachment follow ing retinal detachment surgery. In 12 of their cases where subretinal fluid was not drained, diathermy was considered to be the causative factor. In our cases, hypotony was not a factor, as drainage of subretinal fluid was not performed and there was no marked lowering of the intraocular pressure in the postoperative period. The three patients were all over the age of 60 years. The effect of the rise in intraocular pressure on the choroidal circulation following tightening of the plomb sutures is unknown. The possibility that there had been in ex cessive application of cyrotherapy leading to choroidal exudation was considered. All these cases had ballooned detachment of the retina, making monitoring of cyrotherapy applica tion at operation difficult. The end-point of cryo-application is taken as subtle choroidal blanching when it is not possible to appose the pigment epithelium to the detached part of the retina with the cryoprobe and in this case if the distinct whiteness of the detached part of the retina is waited for, then the choroid and pigment epithelium will have suf fered an unnecessarily heavy application. The resultant lesion when finally assessed will be pale due to atrophy of choroidal ves sels and the pigmentation of the lesion is very sparse with some clumping on the edge of the lesion.7 In the three cases reported final assessment of the treated area was diffi cult as two cases had reoperations after the appearance of the choroidal detachments and before a reasonable assessment of the treated area could be made. When these two cases were eventually assessed, one had an evenly pigmented pinkish cryotherapy lesion and the second had a severely atrophie lesion with
JUNE, 1972
pigment clumps on the edge of the lesion. The third case which did not have a second operation had a white lesion with scattered pigmentation on the edge of the lesion. The two cases which eventually had atrophie le sions also suffered vitreous haze in the post operative period which supports the possibil ity of over application of cryotherapy. SUMMARY
Choroidal detachment followed treatment of retinal detachment by external plombage and cryotherapy without drainage of subreti nal fluid in three patients. Cryotherapy may have played a part in the production of the choroidal detachments as hypotony was not present, but the relationship is not well de fined. The effect of the variations in the intraocular pressure as a result of surgery on the choroidal circulation is unknown. ACKNOWLEDGMENTS
I thank the Audio-Visual Department of the In stitute of Ophthalmology, London, for preparing the illustrations, and Miss M. Farrell for valuable secretarial assistance. REFERENCES
1. Lincoff, H. A., Baras, I., and McLean, J. M. : Modifications to the Custodis procedure for retinal detachment. Arch. Ophth. 73:160, 1965. 2. Custodis, E. : Bedeutet die Plombenaufnahung auf die Skiera einen Fortschritt in der operativen Behandlung der Netzhautablösung? Ber. Deutsch. Ophth. Ges. 58:102, 1953. 3. Lincoff, H. A., and McLean, J. M. : Cryosurgical treatment of retinal detachment. Am. J. Ophth. 61:1227, 1966. 4. Shea, M. : Complications of cryotherapy in retinal detachment surgery. Canad. J. Ophth. 3:109, 1968. 5. Chignell, A. H. : Use of the Perkins hand-held applanation tonometer in retinal detachment sur gery. Brit. J. Ophth. 55:644, 1971. 6. Hawkins, W. R., and Schepens, G L. : Cho roidal detachment and retinal surgery. A clinical and experimental study. Am. J. Ophth. 62:813, 1966. 7. Chignell, A. H., Revie, I. H. S., and Clemett, R. S. : Complications of retinal cryotherapy. Tr. Ophth. Soc. U.K. 41:635, 1971.
CHIGNELL,
F.R.C.S.
London, England
In 1965, Lincoff1 described his technique of modifying the Custodis2 procedure for the treatment of retinal detachments. Lin coff3 later indicated the advantages of his method when combined with cryosurgery and stated that drainage of subretinal fluid was becoming unnecessary increasingly often. The purpose of this paper to to report three cases of extensive choroidal detach ment following treatment of 60 cases of reti nal detachment by external plombage and cryotherapy without drainage of subretinal fluid. Shea4 has indicated that the relation ship between cryosurgery and choroidal de tachment is unkown.
CASE REPORTS
FINDINGS
Symptoms and signs—In two patients, marked blurring of vision heralded the onset of the choroidal detachments on the eighth postoperative day, and in the third case, when choroidal detachments were found on the seventh day there were no symptoms. In all cases the onset of the choroidal detach ments was sudden with rapid accumulation of fluid. Vitreous haze and a few cells in the anterior chamber were found in all cases. In two cases there was marked shallowing of the anterior chamber but no glaucoma. Progression—In one case, resolution took six weeks ; in the second, four weeks ; and in the third, four days. In the case resolving in four weeks re-operation was necessary but had no apparent effect on the choroidal de tachments. In the case resolving in four days, a subsequent re-operation resulted in slight recurrence of the choroidal detach ments which had completely absorbed. From the Retinal Unit, Moorfields Eye Hospital, London, England. This work was supported in part by the Clothesworkers' Company. Reprint requests to A. H. Chignell, Retinal Unit, Moorfields Eye Hospital, City Road, London, E.C.1, England.
Case 1—A 61-year-old man presented with a bal loon detachment in the left upper temporal quadrant due to a single U-shaped tear. This was treated by buckling a S mm radial plomb over full-thickness sciera and cryotherapy without drainage of sub retinal fluid. On the second postoperative day there was proptosis with painful limitation of movement and it was considered that the patient was suffering from mild orbital cellulitis. The anterior chamber was clear and the retina was found to be flat over the plomb but there was some residual subretinal fluid below. There was rapid resolution of the extraocular signs over the next few days when treatment with systemic ampicillin was commenced. On the fourth postoperative day slight vitreous haze was noted and by the seventh postoperative day there had been some increase in the amount of subretinal fluid and choroidal detachments had appeared (Fig. 1). There were some cells in the anterior chamber, but at all times in the postoperative period the intraocu lar pressure remained between IS and 20 mm Hg. The clinical picture remained unchanged for one week. Two weeks later the subretinal fluid and choroidal detachments had completely resolved. When the area of treatment was assessed two months after surgery the lesion was found to be very atrophie with white sciera visible. Only the larger choroidal vessels were intact and pigmentation of the lesion was scattered and irregular.
Fig. 1 (Chignell). Choroidal detachment follow ing external plombage and cryotherapy without drainage of subretinal fluid. Central vitreous haze is present. 860
VOL. 73, NO. 6
CHOROIDAL DETACHMENT
Case 2—A 75-year-old man presented with a bal loon detachment in the upper half of the right eye caused by small U-shaped tears. This was treated at operation by a S mm plomb placed radially and by cryotherapy without drainage of subretinal fluid. Localization of the hole and cryotherapy application was particularly difficult due to marked arcus senilis and peripheral cortical lens opacities. After the plomb had been tied in place the intraocular pressure was measured with the Perkins hand-held applanation tonometer (Chignell5) and was 45 mm Hg. There was no pulsation of the central retinal artery which was filling normally. The intraocular pressure was 20 mm Hg on the first postoperative day and remained between 15-20 mm Hg for the first six days postoperatively. Postoperatively, subretinal fluid absorption was slow so that after one week there was still some subretinal fluid behind the plomb. On the seventh postoperative day large choroidal detachments sud denly appeared (Fig. 2) and some vitreous haze was seen over the plomb and posterior pole. In as sociation with the choroidal detachments there was some shallowing of the anterior chamber and intra ocular pressure reduced to 9 mm Hg. A few cells were found in the anterior chamber. This picture remained unchanged for a further week and there was still some residual subretinal fluid. Two weeks after the first operation the plomb was repositioned as the hole was eccentrically placed on the plomb and no further subretinal fluid absorption had oc curred. At the second operation more cryotherapy was applied and again subretinal fluid was not drained. This operation did not appear to affect the choroidal detachments although there was increased activity in the anterior chamber and thickening of the vitreous haze over the plomb. Over the follow ing two weeks the subretinal fluid absorbed corn-
Fig. 2 (Chignell). Nasal and temporal choroidal detachments following external plombage and cryotherapy without drainage of subretinal fluid.
861
Fig. 3 (Chignell). Large choroidal detachments following external plombage and cryotherapy with out drainage of subretinal fluid. pletely and at the end of that time the nasal of the two main choroidal detachments had considerably lessened. Three weeks later the choroidal detach ments had absorbed. Assessment two months after surgery showed an atrophie retina with scattered and irregular pigmentation and only large choroidal vessels intact. Case 3—A 69-year-old man presented with a large balloon detachment in the right upper tempo ral quadrant due to a single U-shaped tear. This was treated with a 5 mm plomb placed circumferentially and cryotherapy without drainage of subretinal fluid. For the first three postoperative days there was some absorption of subretinal fluid. On the fourth postoperative day large choroidal detachments ap peared (Fig. 3) which were associated with phakodonesis and shallowing of the anterior chamber, but on gonioscopy the angle was found to be narrowly open, and the intraocular pressure was 21 mm Hg. There was only very slight central vitreous haze. Over the next three days the choroidal detachments remained unchanged and there was considerable ab sorption of subretinal fluid. There was complete ab sorption of detachments over the next three days and the patient was discharged. When the patient was seen two weeks later there had been some re-accu mulation of subretinal fluid and the patient was re admitted for readjustment of the plomb which was moved slightly anteriorly and more cryotherapy was applied. Again, subretinal fluid was not drained. Postoperatively the retina flattened satisfactorily but there was slight recurrence of the choroidal de tachments but these quickly reabsorbed. When assessed two months after the second op eration, the lesion was found to be evenly pigmented. There was no excessive whiteness of the area associated with destruction of the choroidal vessel layers.
862
AMERICAN JOURNAL OF OPHTHALMOLOGY COMMENT
Hawkins and Schepens6 found hypotony, age of patient, myopia, and involvement of the vortex veins to be of significance in the production of choroidal detachment follow ing retinal detachment surgery. In 12 of their cases where subretinal fluid was not drained, diathermy was considered to be the causative factor. In our cases, hypotony was not a factor, as drainage of subretinal fluid was not performed and there was no marked lowering of the intraocular pressure in the postoperative period. The three patients were all over the age of 60 years. The effect of the rise in intraocular pressure on the choroidal circulation following tightening of the plomb sutures is unknown. The possibility that there had been in ex cessive application of cyrotherapy leading to choroidal exudation was considered. All these cases had ballooned detachment of the retina, making monitoring of cyrotherapy applica tion at operation difficult. The end-point of cryo-application is taken as subtle choroidal blanching when it is not possible to appose the pigment epithelium to the detached part of the retina with the cryoprobe and in this case if the distinct whiteness of the detached part of the retina is waited for, then the choroid and pigment epithelium will have suf fered an unnecessarily heavy application. The resultant lesion when finally assessed will be pale due to atrophy of choroidal ves sels and the pigmentation of the lesion is very sparse with some clumping on the edge of the lesion.7 In the three cases reported final assessment of the treated area was diffi cult as two cases had reoperations after the appearance of the choroidal detachments and before a reasonable assessment of the treated area could be made. When these two cases were eventually assessed, one had an evenly pigmented pinkish cryotherapy lesion and the second had a severely atrophie lesion with
JUNE, 1972
pigment clumps on the edge of the lesion. The third case which did not have a second operation had a white lesion with scattered pigmentation on the edge of the lesion. The two cases which eventually had atrophie le sions also suffered vitreous haze in the post operative period which supports the possibil ity of over application of cryotherapy. SUMMARY
Choroidal detachment followed treatment of retinal detachment by external plombage and cryotherapy without drainage of subreti nal fluid in three patients. Cryotherapy may have played a part in the production of the choroidal detachments as hypotony was not present, but the relationship is not well de fined. The effect of the variations in the intraocular pressure as a result of surgery on the choroidal circulation is unknown. ACKNOWLEDGMENTS
I thank the Audio-Visual Department of the In stitute of Ophthalmology, London, for preparing the illustrations, and Miss M. Farrell for valuable secretarial assistance. REFERENCES
1. Lincoff, H. A., Baras, I., and McLean, J. M. : Modifications to the Custodis procedure for retinal detachment. Arch. Ophth. 73:160, 1965. 2. Custodis, E. : Bedeutet die Plombenaufnahung auf die Skiera einen Fortschritt in der operativen Behandlung der Netzhautablösung? Ber. Deutsch. Ophth. Ges. 58:102, 1953. 3. Lincoff, H. A., and McLean, J. M. : Cryosurgical treatment of retinal detachment. Am. J. Ophth. 61:1227, 1966. 4. Shea, M. : Complications of cryotherapy in retinal detachment surgery. Canad. J. Ophth. 3:109, 1968. 5. Chignell, A. H. : Use of the Perkins hand-held applanation tonometer in retinal detachment sur gery. Brit. J. Ophth. 55:644, 1971. 6. Hawkins, W. R., and Schepens, G L. : Cho roidal detachment and retinal surgery. A clinical and experimental study. Am. J. Ophth. 62:813, 1966. 7. Chignell, A. H., Revie, I. H. S., and Clemett, R. S. : Complications of retinal cryotherapy. Tr. Ophth. Soc. U.K. 41:635, 1971.