Giant Retinal Tears

GIANT R E T I N A L TEARS JACK J. KANSKI, F.R.C.S. London, England

Retinal tears that extend for one or more quadrants around the circumference of the eye, although rare, are important because they are frequently difficult to treat, they are a malady of the young, and patients with spontaneous giant tears frequently suffer from serious bilateral retinal disease. Only a few large series have been re­ ported.1"3 This report is based on 100 cases.

Apart from retinal detachment, the follow­ ing lesions were considered significant; lat­ tice degeneration, retinal breaks, and ac­ quired retinoschisis. Eyes with pigment clumping, pavingstone degeneration, and microcystoid degeneration were considered normal. 8. The methods of treatment, results, com­ plications, and reasons for failure. RESULTS

PATIENTS AND METHODS

Traumatic giant tears—Of the 23 patients (23 eyes) with traumatic giant tears (Tables 1 and 2), 20 developed giant tears after ocu­ lar contusion, two after ocular penetration, and one developed a tear after the removal of an intraocular foreign body. There was a significant male prevalence (73.9%), in keeping with previous data on traumatic retinal detachments in general4 (82.6%). All traumatic giant tears were uni­ lateral, and the upper nasal quadrant was in­ volved in five eyes. Nontrautnatic giant tears—Details of the 71 patients (77 eyes) with nontraumatic gi­ ant tears are summarized in Tables 1 and 2.

We screened the clinical records of 94 pa­ tients (100 eyes) with giant retinal tears who had been examined from 1960 to 1973. To determine the various characteristics of eyes with giant tears, we analyzed the data extracted from the records with respect to the following: 1. The sex and age of patients at the time of presentation. 2. Family history of retinal detachment. 3. Etiology of retinal break. All breaks were classified as either traumatic or nontraumatic ; the former included patients with a history or direct evidence of ocular trauma. Patients with indirect trauma were not in­ cluded in the traumatic group. TABLE 1 4. Extent and location of retinal tears. DATA ON 94 PATIENTS WITH GIANT TEARS 5. Refractive error. Eyes were either myopic ©r nonmyopic. The myopic cases No. of Patients were subdivided into weak myopia (under Data — 10 diopters), severe myopia ( — 10 to Traumatic Nontraumatic Breaks Breaks — 19 diopters), and extreme myopia (—20 diopters or more). A correction of + 1 0 di­ Sex opters or less indicated myopia in aphakic Men 17(73.9%) 49(69.0%) 22 Women 6 eyes. All nonmyopic eyes were grouped to­ gether, irrespective of their refractive error. Age (yrs) 5-68 Range Î-56 6. Associated retinal lesions. 32 Median 17 6(8.4%) — 7. Status of the retina in the fellow eye. Bilateral giant tears From the Retinal Unit, Moorfields Eye Hospital, High Holborn Branch, London WC1, England. Reprint requests to J. J. Kanski, F.R.C.S., 4 Hardwick Green, Clevelands, London W13 8 DN, England.

Bilateral retinal detach­ ment Blind in both eyes Family history of retinal detachment Total no. of patients

846

— —

29(40.8%) 15(21.1%)

—

6(8.4%) 71

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servations1'2 and suggested that a factor other than a retinal weakness was significant in the development of giant tears. Schepens and Freeman 2 believed that the vitreous body played an important role in the pathogenesis of giant tears. They described in detail the vitreous body changes in eyes with giant tears and in their fellow eyes, prior to the development of giant tears. APHAKIA—Six eyes (7.8%) were aphakic; two had undergone repeated con­ genital cataract operations, 30 years previ­ ously. In the other four eyes, the interval between cataract extraction and the develop­ ment of retinal detachment ranged from three months to three years. In one patient, a 360-degree prophylactic equatorial cryopexy prior to lens extraction failed to pre­ vent the development of retinal detachment in the fellow eye. Ashrafzadeh and colleagues6 found that there was no significant difference in the in­ cidence of giant tears between phakic and aphakic eyes. HEREDITY—A family history of retinal detachment was present in seven patients ( 1 0 % ) . Wagner's hereditary vitreoretinal degeneration was present in two brothers with cleft palate who developed bilateral giant tears at an early age. Two eyes were studied prior to the development of retinal detachment. One showed severe, TABLE 2 coarse, fibrillary condensation and syneresis DATA ON 100 EYES WITH GIANT TEARS of the vitreous fluid with only minimal ret­ Eyes with inal changes. The other eye showed marked retinal changes consisting of an extensive Data Traumatic Nontraumatic area of acquired retinoschisis in the temporal Breaks Breaks periphery with large white areas without Aphakic 6(7.8%) pressure, and snowflake degeneration in the Refraction periphery of the nasal retina, extending up Unknown Myopic 7(30.4%) 55(71.4%) to the equator. Only mild fibrillary condensa­ 33 (60%) Weak myopia 7 tion of the vitreous fluid was present. 11 (20%) Severe myopia Hereditary lattice degeneration was pres­ 11 (20%) Extreme myopia Nonmyopic 10(43.5%) 15 (19.5%) ent in two patients with giant tears. One pa­ Retinal breaks tient developed a giant tear in his right eye 180 degrees or more 7 (30.4%) 10(13%) that failed to respond to surgery. A small Peripheral 50 (65%) 20 (87%) 27 (35%) Equatorial 3 (13%) area of lattice degeneration developed in the 77 23 Total no. of eyes upper temporal quadrant of his left eye. A

AGE AND SEX—Our observations—median patient age of 32 years with a 69% male prevalence—agreed with prior reports that giant tears are predominantly a malady of young male subjects. REFRACTIVE ERROR—The reported inci­ dence of myopic eyes with giant tears varied. Schepens and Freeman 2 stated that myopia played no significant role in the causation of giant tears since only one third of their pa­ tients were myopic. Norton and colleagues3 found that 8 3 % of their patients were myopic. There was a high incidence of myopia in this study (71.4%) ; the degree of myopia exceeded —20 diopters in 20% of myopic eyes. In three of four patients in whom the difference in the amount of myopia between the two eyes exceeded —10 diopters, the giant tear developed in the more myopic eye. There was no significant correlation be­ tween the size of the tear and the degree of myopia. The incidence of myopia in eyes with giant tears appeared to be considerably high­ er than the percentage (34.6%) reported by Schepens and Marden 5 in the nontraumatic retinal detachment population. LATTICE DEGENERATION—Lattice degen­ eration was present in six eyes (7.8%) with giant tears, and in 7.8% of fellow eyes. This relatively low incidence confirmed past ob-

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AMERICAN JOURNAL OF OPHTHALMOLOGY TABLE 3 FINDINGS IN 68 FELLOW EYES

Retinal detachment Predisposing lesions Total

No. of Eyes

%

29 10 39

42.6 14.7 57.3

prophylactic encirclement was carried out. Nine months later a new area of lattice de­ generation in the lower temporal quadrant of the left eye was treated by photocoagulation, but within a month a giant tear developed and the retina became detached. Hereditary severe myopia was present in the other three patients. BILATERALITY—Six (8.5%) of the 71 pa­ tients who developed giant tears in both eyes were men and the findings in three have been described. Weak myopia was the only sig­ nificant common ocular finding in the three other patients. The incidence of bilaterality in previous reports was 2.1%, 1 21 %,2 and 3.8%. 3 PATHOLOGIC FINDINGS IN FELLOW EYES—

In the 68 fellow eyes available for examina­ tion retinal detachment was present in 42.6% of the eyes and 14.7% had predisposing le-

Fig. 1 (Kanski). Left, right eye. Postoperative v for 180 degrees. Right, left eye. Postoperative view ferential cryopexy.

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sions (Table 3 ) . The high incidence of path­ ologic findings in fellow eyes in this study has been described previously.1"3'7 Most fel­ low eyes are presently being treated prophylactically bv 360-degree equatorial cryopexy (Fig· 1). ' Ninety-five eyes were treated surgically by members of the Retina Service. Surgical techniques—Preoperative posi­ tioning and head exercises were only used in a few cases. All operations were performed under general anesthesia. A scierai buckling procedure was used in all but nine cases (Table 4) ; retinal incarceration in 19 cases (Table 5) ; intravitreal air injection in nine cases ; and liquid silicone was injected into three eyes (Fig. 2). Success rate—The overall success rate af­ ter a follow-up of not less than six months was 58%, with visual acuity of 6/12 or better in 27.2% of eyes (Table 6). Thirty-one reattachments were achieved (32.6%) at the first operation ; of the 48 eyes that underwent further surgery, 24 were reattached (Table 7). The correlation between the surgical tech­ nique and results can be seen in Table 4. Complications occurred in 22 cases (Table 8).

• of a successfully treated giant tear that extended fellow eye after prophylactic treatment by circum-

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TABLE 4 SURGICAL TECHNIQUE

Success (Attached)

Failure (Detached)

No scierai buckle Photocoagulation Air Liquid silicone Incarceration Subtotal

6 — — — 6

— 1 1 1 3

Scierai buckle Alone Air Liquid silicone Incarceration Incarceration and air Incarceration and liquid silicone Subtotal Total

43 — 1 S — — 49 55 (58%)

20 2 2 6 6 1 37 40 (42%)

Total 6 1 1 1 9 63 2 3 11 6 1 86 95 (100%)

TABLE 5

DISCUSSION

INCARCERATION TECHNIQUE IN 19 CASES

We achieved a relatively high success rate (58%) without complicated operating theater techniques, such as rotating tables, compared with other reattachment rates of 5 7 % / 51%, 2 and 6 3 % . 3

Technique

No. of Eyes

Cryoprobe (Cibis) Hooks Suction (Howard and Gaasterland) Total

2 7 10 19

TABLE 6 VISUAL RESULTS IN SUCCESSFUL CASES

Visual Acuity

No. of Eyes

%

6/12 or better 6/18-6/24 6/36-6/60 CF HM Total

15 13 11 10 6 55

27.2 23.6 20.0 18.2 11.0 100

TABLE 7 NUMBER OF OPERATIONS

No. of Operations

Fig. 2 (Kanski). Postoperative view of a giant tear successfully treated by an encircling buckle and liquid silicone injection.

1 2 3 4 or more Total

Success Failure (Attached) (Detached) 31 17 4 3 55

16 12 8 4 40

Total 47 29 12 7 95

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Fig. 3 (Kanski). Left, Preoperative view of an upper temporal giant tear. Right, Postoperative view of the same eye after successful treatment by a local scierai buckling procedure. In six eyes, in which there was minimal subretinal fluid present, we sealed the retinal tears solely by means of photocoagulation and cryopexy. In 43 eyes with relatively un­ complicated tears, we achieved reattachment by conventional means (Fig. 3). Retinal incarceration was necessary in 19 eyes with large tears with everted posterior flaps ; six of these were situated in the upper part of the eye and the rest were located on the temporal side. We performed retinal in-

TABLE 8 SURGICAL COMPLICATIONS IN 22 EYES

No. of Eyes Operative complications Total vitreous hemorrhage Scierai rupture and vitreous fluid loss Total Postoperative complications Cataract Anterior segment necrosis Maculopathy Diplopia Panophthalmitis Severe uveitis Glaucoma Total

4 1 5 6 4 2 2 1 1 1 17

carceration in one eye without scierai buck­ ling; in the remaining 18 eyes it was per­ formed concomitantly with, or subsequent to, a scierai buckling procedure. We achieved successful incarceration in five eyes (26%). In three eyes, attempts at incarceration re­ sulted in total vitreous hemorrhage. In ten eyes, we attempted to unfold the retinal flap by the Howard and Gaasterland8 technique: using a syringe to aspirate the detached vitreous base they unfolded the posterior flap and incarcerated it into a sclerotomy over the pars plana, without resorting to direct manip­ ulation of the retina. When we attempted this technique, we found it necessary to apply suction to the retina to achieve the desired result in most cases (Fig. 4). Norton and colleagues3 achieved a high success rate (63%) by means of a technique that involved the injection of intravitreal air. They claimed that this technique eliminated the need for retinal incarceration and reduced ocular morbidity. They stressed that in order to achieve good results it was necessary to position the air bubble correctly during in­ jection and immediately afterwards. The uni­ formly poor results seen in the nine patients treated with air in this series can partly be attributed to incorrect positioning.

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851 TABLE 10 PROGNOSTIC CONSIDERATIONS

Fig. 4 (Kanski). Postoperative view of a giant retinal tear treated successfully by an encircling buckle and retinal incarceration (Howard and Gaasterland technique).

Of the 40 cases in which retinal reattachment was not achieved, nine (22.5%) were directly related to surgical complications; in the remaining 31 cases (77.5%), failure was due to inability to unfold the retinal flap (ten cases) ; the development of massive preretinal retraction (13 cases) ; and in eight cases, the exact cause of failure was undetermined (Table 9). The correlation between the reattachment rate and the various prognostic considera­ tions is shown in Table 10. The high success

Type of Retinal Break

% of Sucess

Traumatic Nontraumatic (phakic) Nontraumatic (aphakic) 90 degrees > 9 0 to 180 degrees Over 180 degrees Below horizontal axis Above horizontal axis Peripheral Equatorial Myopia under —10 D Myopia —10 D or over

76.2 50.0 0.0 87.5 48.0 11.0 95.5 42.0 78.0 36.7 50.0 25.0

rate achieved in traumatic cases is probably due to the healthy state of the vitreous body. Of the five traumatic breaks that failed, three were associated with ocular penetration. Breaks situated in the lower half of the eye generally have a better prognosis than those in other locations. Peripheral breaks have a better prognosis than those situated at or posterior to the equator. Only 11% of retinal breaks that extended over 180 degrees were reattached; the largest break that was successfully treated in this series was 230 degrees. There was a significant correlation between the degree of myopia and surgical outcome ; the prognosis was less favorable in eyes in which the degree of myopia exceeded —10 diopters. Aphakia had a detrimental ef­ fect; all six eyes failed to respond to re­ peated surgical intervention.

TABLE 9 CAUSES OF FAILURE IN 40 EYES

No. of Eyes Surgical complications Total vitreous hemorrhage Anterior segment necrosis Infection Total Other causes of failure Failure to unfold posterior flap Massive preretinal retraction Undetermined Total

4 4 1 9(22.5%) 10 13 8 31(77.5%)

SUMMARY

Of 94 patients (100 eyes)with giant ret­ inal tears, 71.4% of eyes with nontraumatic breaks were myopic and severe retinal path­ ologic findings were present in 57.3% of fel­ low eyes. Fifty-five (58%) of 95 treated eyes were successfully reattached ; retinal in­ carceration, attempted in 19 cases, was suc­ cessful in five. Serious surgical complications were responsible for failure in nine cases (22.5%). The worst prognostic factors were extension of the tear for over two quadrants,

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myopia of —10 diopters or more, and the presence of aphakia. REFERENCES

1. Schepens, C. L., Dobbie, J. G., and McMeel, J. W. : Retinal detachments with giant breaks. Preliminary report. Trans. Am. Acad. Ophthalmol. Otolaryngol. 66:471, 1962. 2. Schepens, C. L., and Freeman, H. M. : Cur­ rent management of giant retinal breaks. Trans. Am. Acad. Ophthalmol. Otolaryngol. 71:474, 1967. 3. Norton, E. W. D., Aaberg, T., Fung, W., and Curtin, V. T. : Giant retinal tears. 1. Clinical management with intravitreal air. Am. J. Oph­ thalmol. 68:1011, 1969. 4. Margherio, R. R., and Schepens, C. L. :

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Macular breaks. 1. Diagnosis, etiology, and ob­ servations. Am. J. Ophthalmol. 74:219, 1972. 5. Schepens, C. L., and Marden, D. : Data on the natural history of retinal detachment. Further characterization of certain nontraumatic cases. Am. J. Ophthalmol. 61:213, 1966. 6. Ashrafzadeh, M. T., Schepens, C. L., Elzeneiny, I. I., Maura, R., Morse, P., and Krauschar, M. F. : Aphakic and phakic retinal detach­ ment. 1. Preoperative findings. Arch. Ophthalmol. 89:476,1973. 7. Glasspool, M. G., and Kanski, J. J. : Pro­ phylaxis in giant tears. Trans. Ophthalmol. Soc. U. K. 93:363, 1973. 8. Howard, R. 0., and Gaasterland, D. E. : Giant retinal dialysis and tear. Arch. Ophthalmol. 84:312, 1970.

OPHTHALMIC MINIATURE

Affixing one person's name to two or more disorders has led to con­ fusion; the utilization of multiple names (Hand-Schüller-Christian dis­ ease, Laurence-Biedl-Moon syndrome, Rendu-Osler-Weber disease) has proved both bewildering and cumbersome. . . . In those conditions in which the nature of an underlying disorder was unclear, the eponym was preferred to a descriptive name based upon conjecture. . . . Used as euphemisms, eponyms permitted the free discussion of serious disease in the presence of worried patients and their families. . . . In certain situations there is no really acceptable substitute for the eponym (BenceJones protein, Koplik spots, Kayser-Fleischer ring). Edward A. Gall, The medical eponym. Am. Scientist 48:56, 1960