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Physical Activity after Retinal Detachment Surgery
PHYSICAL ACTIVITY A F T E R R E T I N A L D E T A C H M E N T SURGERY J E R A L D A. B O V I N O , M . D . ,
AND D A N I E L F. M A R C U S ,
M.D.
Toledo, Ohio
A prospective, randomized, masked clinical trial to assess the value of limited physical activity after scierai buckling surgery included 108 consecutive patients with rhegmatogenous retinal detachment random ly divided into two groups. The first group was encouraged to resume full physical activity immediately after hospital discharge. In the second group, bending, lifting, straining at stool, driving, sexual activity, lawnmowing, gardening, athletics, and returning to work were strictly forbidden for six weeks. A thorough evaluation of patient compliance was performed after six weeks. Six months after surgery the rates of reoperation and final reattachment percentages of the active and inactive groups showed no statistically significant difference (P>.05). Final visual acuity, measured one year after surgery, also identified no statistically significant difference between the groups (P>.05).
The level of physical activity after reti nal detachment surgery that promotes prompt healing is not known. Instruc tions given to patients about physical activities after such surgery vary widely and are frequently inconsistent. The de cision to restrict a patient's physical activ ity after retinal detachment surgery has significant economic and social ramifica tions. In young working patients, a pro longed job absence may cause serious financial hardship. Sudden limitation of the physical activity of older patients can have adverse psychological and physical effects.1,2 Moreover, many patients in all age groups have indicated that instruc tions to abstain from sexual activity, gar dening, athletics, and driving impose a heavy burden. Although patients fre quently ask when they can safely resume a specific activity after surgery, the surAccepted for publication April 12, 1984. From the St. Vincent Medical Center, Retina Unit, Toledo, Ohio. Reprint requests to Jerald A. Bovino, M.D., St. Vincent Medical Center, Retina Unit, 2213 Cherry St., Toledo, OH 43608.
geon has little data on which to base any recommendations. Because postoperative bedrest and restricted physical activity have been an integral part of successful retinal detachment surgery since Gonin, 3,4 many surgeons persist in advising strictly limited physical activity after sur gery. Others, however, have liberalized their instructions about activity after sur gery without apparent adverse effects. SUBJECTS AND METHODS
We conducted a prospective clinical trial to assess the potential benefits and risks of limited activity after retinal de tachment surgery. We recruited 108 consecutive preoperative patients with rhegmatogenous reti nal detachment at the time they entered the hospital. They were informed that they would be assigned to one of two groups of physical activity, but were not told the possible activity levels before recruitment. After we obtained informed consents we assigned the patients to a full-activity group or a limited-activity group through a table of random num-
©AMERICAN JOURNAL OF OPHTHALMOLOGY 98:171-179, 1984
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bers. The patients in each group had no knowledge of the activity level of the other group. The full-activity group was encouraged to resume all physical activity immediately after leaving the hospital. In the limited-activity group, bending, lift ing, straining at stool, driving, sex, lawnmowing, gardening, athletics, and re turning to work were strictly forbidden until six weeks after surgery. Initial in structions related to postoperative physi cal activity were given by the same regis tered nurse throughout the study. On three occasions, when the registered nurse was not available, patients received instructions about physical activity from an experienced ophthalmic technician. The operating surgeons (J.A.B. and D.F.M.) were not told to which activity group the patients were assigned. All questions that arose during the postoper ative period about physical activity were redirected to the registered nurse, and the patients were not permitted to dis cuss their activity levels with the surgeon at any time during the study. Severe myopia (>5 diopters) was pres ent in nine of 54 patients (16.6%) in the full-activity group and in six of 54 patients (11.1%) in the limited-activity group. A specific history of ocular trauma was elic ited in five of 54 patients (9.3%) in the full-activity group and in two of 54 pa tients (3.7%) in the limited-activity group. Lattice degeneration was identi fied in 12 of 54 patients (24%) in the full-activity group and in seven of 54 patients (13%) in the limited-activity group. Table 1 lists additional preoperative characteristics. All patients had scierai buckling sur gery under general anesthesia. Cryosurgical adhesion was applied to every pa tient in both groups. A silicone episcleral implant with encircling band was used in 50 of 54 patients (94.4%) in the fullactivity group and in 53 of 54 patients (98.1%) in the limited-activity group. A
AUGUST, 1984 TABLE 1
PREOPERATIVE CHARACTERISTICS O F T H E PATIENTS
Characteristics Age (yrs) Mean Range Sex Male Female Status of lens Phakic Aphakic Intraocular lens implant Status of macula Involved Uninvolved
108
Group (No. = 54)
Group (No. = 54)
59 15 to 87
61 12 to 89
26 28
33 21
27 15
23 15
12
16
22 32
18 36
localized episcleral silicone sponge was applied in three of 54 patients (5.6%) in the full-activity group and in one of 54 patients (1.9%) in the limited activity group. Subretinal fluid was drained at the time of surgery in 48 of 54 patients (88.9%) in the full-activity group and in 47 of 54 patients (87%) in the limitedactivity group. Intraocular sulfur hexafluoride gas was used in five of 54 patients (9.3%) in the full-activity group and in eight of 54 patients (14.8%) in the limited-activity group. All patients in both groups were given bathroom privileges on the first postoper ative day. Bedrest and positioning were used as needed in both groups during the hospital stay to facilitate reabsorption of subretinal fluid. The mean length of hos pital stay was 3.6 days (range, three to 15 days) for the full-activity group and 4.4 days (range, three to 15 days) for the limited-activity group. RESULTS
Six weeks after leaving the hospital, each patient was thoroughly questioned by the same registered nurse to deter-
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173
TABLE 2 POSTOPERATIVE ACTIVITIES
Full -Activity Group (No. = 54)
Limited-Activity Group (No. = 54)
Activities
No.
%
No.
%
Bending Lifting Straining at stool Driving Sex Lawnmowing Gardening Athletics* Return to work
42 25 13 27 16 11 11 24 20
77.8 46.3 25.0 50.0 30.0 20.0 20.0 44.0 37.0
11 o 5 11 6 1 0 11 1
20.0 9.0 9.0 20.0 11.0 1.9 0.0 20.0 1.9
'Athletics included weightlifting, jogging, swimming, bicycling, tennis, and golf.
mine his or her degree of compliance with preoperative activity instructions (Table 2). We used the Z test of the equality of two proportions to compare compliance in the two groups. Straining at stool and sex showed a statistically significant difference (P<.05). Bending, lifting, driving, lawnmowing, gardening, athletics, and returning to work also showed a statistically significant differ ence (P<.01). At six months, the visual acuity, the rate of reoperation, and the rate of suc cessful reattachment were recorded. The final visual acuity was remeasured at one year after surgery and compared with the initial visual acuity for both groups (Fig ure). In the full-activity group, six pa tients were lost to follow-up at the oneyear interval and one had died. In the limited-activity group, five patients were lost to follow-up at the one-year interval and one had died. For these 13 patients, the final visual acuity was considered to be the six-month measurement. The visual acuities of the full-activity patients and the limited-activity patients were grouped into four functional levels (Table 3). We used the Z test of the equality of two proportions to compare the preoperative and postoperative visual
acuity functional groupings. There was no statistically significant difference be tween the groups (P>.05). In the full-activity group at six months, 49 of 54 patients (90.7%) had successfully reattached retinas after one operation. In the limited-activity group at six months, 50 of 54 patients (92.6%) had successfully reattached retinas after one operation. Reoperations were performed on three patients in the full-activity group (two scierai buckles and one vitrectomy with scierai buckle). The scierai buckle and the vitrectomy with scierai buckle were successful and the final reattachment rate was 51 of 54 patients (94.4%). Reoperations were performed on two patients in the limited-activity group (one scierai buckle and one vitrectomy with scierai buckle). The retinas were success fully reattached during both revisions for a final reattachment rate of 52 of 54 patients (96.3%). When we used the Z test of the equali ty of two proportions to compare the initial reattachment rate, the reoperation rate, and the final reattachment rate we found no statistically significant differ ences between the groups (P>.05). All but one failure in the two groups were the result of massive periretinal
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AUGUST, 1984
20/20
20/25
NLP
LP
HM
CF
20/400 20/200 20/100 20/70 20/50
20/40
20/30
20/25
20/20
Preoperative Visual Acuity Figure (Bovino and Marcus). Preoperative and postoperative visual acuities of the full-activity and limited-activity groups. Data points above the diagonal line indicate a postoperative visual improvement.
proliferation. The exception was one pa tient in the full-activity group who re fused reoperation after failed surgery de spite no evidence of massive periretinal proliferation. One female patient in the limitedactivity group had a severe pulmonary embolus (documented by electrocardio gram, chest X-ray, and lung scan) despite the postoperative use of elastic stockings. She recovered, however, without perma
nent sequelae. There were no systemic complications in the full-activity group. DISCUSSION
Because retinal detachment surgery in volves the reapproximation of delicate intraocular tissues, surgeons and patients have often worried that exercise could jar the recently attached retina, detaching it and leading to failure of the operation. In an attempt to highlight the preoperative,
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TABLE 3 FUNCTIONAL GROUPING OF PREOPERATIVE AND POSTOPERATIVE VISUAL ACUITIES
Limited Activity Group (No. = 54)
Full-Activity Group (No. = 54) Visual Acuities* Preoperative 20/20 to 20/40 20/50 to 20/200 20/300 to C F . H. M. toL.P. Postoperative 20/20 to 20/40 20/50 to 20/200 20/300 to C F . H.M. toL.P.
No.
%
No.
%
9 13 24 8
16.7 24.1 44.4 14.8
9 12 23 10
16.7 22.2 42.6 18.5
16 26 10 2
29.6 48.2 18.5 3.7
20 19 12 3
37.0 35.2 22.2 5.6
' C F . , counting fingers; H.M., hand movements; L.P., light perception.
surgical, and postoperative factors that can contribute to failure of retinal detach ment surgery, however, Chignell and as sociates 5 mentioned no cases in which the patient's physical activity led to failure. In a review of 1,088 cases of retinal detachment, Rachal and Burton 6 did not mention physical activity in their discus sion of the causes of failure. Tornquist, 7 in a study of reasons for failure necessitating reoperation after retinal detachment sur gery, also failed to mention physical ac tivity. In addition, Clark 8 stated: Any surgeon who blames failure on the post operative conduct of the patient is false to him self as well as the patient. If a retina does not reattach after surgery, it is the result of improp erly placed or inadequate surgery and nothing else. It is true that adequate surgery may be impossible within the limits of the eye's toler ance, but I have never yet seen a failure that was a fault of the patient.
Since the time of Gonin, there has been a slow but steady trend toward more rapid resumption of normal activity after reti nal detachment surgery. Instructions about postoperative physi cal activity from different surgeons and institutions for similar groups of patients, however, have varied widely. Kronfeld 9
advised the postoperative use of pinhole glasses to limit ocular motility and absti nence from physical exercise for three months. Jervey 10 stated that "cure follows good surgery in retinal detachment, re gardless of posture and attempts at fixa tion." H e "began to allow freedom of motion and soon was convinced that rea sonable bodily activity was irrelevant to c u r e . " He also hypothesized that "limita tion of physical activity, by stimulating elements of fear and anger, may actually retard healing and have a detrimental effect on the surgery." He 11 noted three cases in which the usual period of rest after surgery was considerably shortened with no untoward effects and stated that "postoperative care of the patient should be simplified to the great advantage of the patient mentally, physically, and fi nancially." Jervey 12 stated that it was not necessary to follow Gonin's strict postop erative limitations on physical activity, and he reported excellent results in his patients despite rapid resumption of ambulation. In another discussion of postop erative care, Jervey 13 stated "in spite of the practice and teaching of the old mas ters, and many of our present day col leagues, prolonged immobilization in any
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AMERICAN JOURNAL OF OPHTHALMOLOGY
case is of questionable value. Old people in particular lose strength in bed, and immobilization may actually be danger ous." He added, "you are all familiar with the patient who hops all over the place, falls out of bed, and so on and gets a perfectly beautiful result. Prolonged im mobilization in retinal detachment is probably futile and possibly harmful." Norton 14 stated that: Retinal detachment for the most part is cured in the operating room. The chances for success if retinal breaks are closed is 90-95%, regardless of postoperative management. During the first three weeks after operation, the instructions given to patients are as follows: no reading, television permitted from 10 feet away.
He stated that these instructions were intended to cut down eye movement, but added "they may be totally unnecessary." Norton has seen patients "who have vio lated these rules without recurrence." He added, "too often the surgeon blames patients' activity for his own inadequate skills." Havener and Gloeckner 15,16 allowed light work three weeks after surgery and normal activities after six weeks. They suggested that "all of these restrictions are excessively conservative since some patients break all the rules and heal per fectly." Havener 16 stated that "the out come in most patients would not be materially worsened by full normal activ ity as soon as they have recovered from the anesthetic" and added that "clearly the postoperative vomiting and coughing that commonly occur do not dislodge the retina." Pierce 17 advised pinhole glasses and allowed patients to return to work four to eight weeks postoperatively. Colyear 18 believed that the patient should not re turn to full work until three months after retinal detachment surgery but allowed some patients to return to partial activity, depending upon occupation. He allowed
AUGUST, 1984
executives to return to work in two weeks, secretaries to return to work in six to eight weeks, and laborers to return to work in eight to 12 weeks. Chawla 19 al lowed patients to return to normal activi ty after three weeks. Hilton and associates 20 warned patients against stooping over, lifting heavy weights, or bumping the head for three weeks. No sexual intercourse was permit ted during this period. They stated that "it is possible that most patients would have a satisfactory result if the above instructions were not imposed but their routine use seems justified on behalf of the occasional patient in whom it may be important." Chignell 21 stated that "sedentary work can be achieved in two weeks." Strenu ous physical work involving lifting heavy objects or sporting activity such as riding or squash racquets should be avoided for approximately two months. Some sports, such as boxing and high diving, should be abandoned altogether. Worthen 22 stated that 82% of surgeons surveyed suggested avoiding running or jogging after treatment of retinal detach ment, with most recommending absten tion for one to three months. It may be relevant that many surgeons have witnessed reattachment of the reti na many months after apparently failed surgery. Kokolakis, Bravo, and Chignell 23 studied six patients in whom reattach ment of the retina occurred nine to 16 months after retinal detachment surgery that has been considered unsuccessful. In all of these patients the retina became reattached at full levels of physical ac tivity. All of the patients in our series had treatment with cryosurgical adhesion. Lincoff, McLean, and Nano24 believe that bedrest is unnecessary after the second postoperative day. Bloch, O'Connor, and LincofF5 stated that the rapid increase in
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the adhesive strength of both cryosurgical and diathermy lesions justifies current trends toward early mobilization of the retinal detachment patient. They advise full physical activity after the second week. They found that all thermal adhe sions obtain maximum adhesion by 12 days, and that no increase in strength occurred thereafter. Feman and associates 26 found no identi fiable chorioretinal adhesion for eight days after cryotherapy in humans but adhesion was present in an eight-monthold lesion. Laqua and Machemer 27 found normal adhesion between the retina and pigment epithelium four weeks after cry otherapy in monkeys. Lincoff and asso ciates, 28 studying remodeling of the cryosurgical adhesion, found that the two-week cryosurgical lesion correspond ed with maximal adhesion but that signifi cant late remodeling takes place after months and possibly years. Although the chorioretinal adhesion achieves maximum strength during the first eight to 14 days, the relevance of this to physical activity after retinal detach ment surgery is not clear. There is evi dence that an active suction effect of the retinal pigment epithelium may be as important, or more important, than the strength of the chorioretinal adhesion in maintaining attachment of the retina in the postoperative period. 29 Moreover, Chignell and Markham 30 studied retinal detachment surgery without cryotherapy and found an excellent initial rate of retinal reattachment. There was, howev er, a slightly increased late risk of redetachment of the retina in patients with persistent active traction who had lost all of their buckle height. The compliance of the patients in the study with preoperative instructions about permitted physical activity was good. In an attempt to avoid prejudice in management, the treating surgeons were
177
unaware of the activity levels of the indi vidual patients and a registered nurse gave all activity instructions. The rate of patient compliance might have been even higher had the treating physician person ally counselled patients about allowable activity levels. More specific wording of the consent form, with a discussion of the potential benefits and risks of each activi ty level, might have also increased com pliance. Because we believed this might prejudice the patients, however, the form was intentionally brief. Examination of compliance data from the limited-activity group showed that preoperative counselling reduced the level of physical activity but was not entirely effective. Patient compliance in both groups, however, was sufficient to produce statistically significant differenc es in activity levels in all activity catego ries. Examination of the compliance data of the patients in the full-activity group was also informative. The patients who were told they could resume full activity after hospital discharge were more active than the patients in the limited-activity group at all stages during the first six weeks. There was wide variation, howev er, in the rate of resumption of activities. Each patient tended to resume activity consistent with his or her age and lifestyle before surgery. Previously active patients rapidly became active and sedentary pa tients generally remained sedentary. One patient in the limited-activity group had a pulmonary embolus in the postoperative period. This is a well recog nized postoperative complication in pa tients whose physical activity is limited 2 although using elastic stockings and per forming leg exercises can reduce this risk. When we compared the limitedactivity and the full-activity groups, the rates of reoperation, the final reattach ment percentage, and the final visual acuity were not statistically different. Al-
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AMERICAN JOURNAL O F OPHTHALMOLOGY
though prolonged bedrest and severely restricted postoperative physical activity were helpful for Gonin's patients, 3,4 mod ern methods of retinal detachment sur gery incorporating cryosurgical adhesion and permanent scierai buckling elements seem to be effective independent of the activity level of the patient after hospital discharge. We found that the rate of postoperative recovery of strength and the desire of the patient for physical activity vary widely. Patients in the nonrestricted group tended to resume physi cal activity after surgery at a rate selected by the individual. It is unnecessary for the surgeon to rush the patient back to exercise, work, and sex after surgery, but there is little if anything to be gained from an arbitrary list of restrictions. Additionally, if retinal detachment sur gery has been unsuccessful, the surgeon should reassure both the family and the patient that they were not responsible for the failure. Patients whose surgery is unsuccessful frequently blame them selves, attributing the failure to a bout of straining, lifting, or premature sexual ac tivity. The patient's guilt response in this regard should be minimized by a frank discussion of the unlikely relationship of these activities to massive periretinal proliferation. There were no patients in this clinical trial with giant retinal tears. This was, however, a matter of chance, as they were not specifically excluded. Because the mechanical forces on the edge of a giant retinal tear may differ from those of other types of retinal detachment, we do not consider this study to be relevant to patients with giant tears, in whom limita tion of physical activity in the postopera tive period may be helpful. We believe the main mechanical risk to the patient during the postoperative period is that of direct trauma to the globe, and we con tinue to advise patients with all types of
AUGUST,
1984
retinal detachments to wear some protec tive gear during this period. REFERENCES 1. Titchener, J., Zwerling, I., Gottschalk, L., and Levine, M.: Psychosis in surgical patients. Surg. Gynecol. Obstet. 102:59, 1956. 2. Rarker, N. W., Nygaard, K. K., Walters, W., and Priestley, J. T. : A statistical study of postopera tive venous thrombosis and pulmonary embolism. Proc. Mayo Clin. 16:1, 1941. 3. Gonin, J. : Le traitement du décollement retinen. Ann. Ocul. 158:175, 1921. 4. : The evaluation of ideas concerning retinal detachment within the last five years. Br. J. Ophthalmol. 17:726, 1933. 5. Chignell, A. H., Fison, L. G., Davies, E. G., Hartley, R. E., and Gundry, M. F.: Failure in reti nal detachment surgery. Br. J. Ophthalmol. 57:525, 1973. 6. Rachal, W. F . , and Burton, T. C : Changing concepts of failures after retinal detachment surgery. Arch. Ophthalmol. 97:480, 1979. 7. Törnquist, R. : Reoperation. In Rosengren, B. (ed.): Retinal Detachment Surgery. Gothenburg, Elanders, 1966, p. 179. 8. Clark, G. : Factors contributing to the successful treatment of retinal detachment. N.Y. State J. Med. 56:3295, 1956. 9. Kronfeld, P. C : Postoperative care and compli cations. Trans. Am. Acad. Ophthalmol. Otolaryngol. 56:432, 1952. 10. Jervey, J. W. : Postoperative care of retinal detachment. Trans. Am. Ophthalmol. Soc. 55:317, 1957. 11. : Note on postoperative management of retinal detachment. Arch. Ophthalmol. 47:76, 1952. 12. : The postoperative care of retinal de tachment. Am. J. Ophthalmol. 36:25, 1953. 13. : Postoperative care of major eye sur gery. South. Med. J. 45:139, 1952. 14. Norton, E. W. D.: Postoperative manage ment. In Schepens, C. L., and Regan, C. D. J. (eds.): Controversial Aspects of the Management of Retinal Detachment. Boston, Little, Brown, and Co., 1965, pp. 321-326. 15. Havener, W. H., and Gloeckner, S. L.: Atlas of Diagnostic Techniques and Treatment of Retinal Detachment. St. Louis, C. V. Mosby, 1967, pp. 176 and 177. 16. Havener, W. H.: Management of retinal de tachments. Ohio State Med. J. 74:617, 1978. 17. Pierce, L. H. : Pre- and postoperative manage ment of retinal detachment. In McPherson, A. (ed.): New and Controversial Aspects of Retinal Detach ment. New York, Harper and Row, 1968, pp. 455459. 18. Colyear, B. H.: Postoperative management of retinal detachment patients. Trans. Pac. Coast. OtoOphthalmol. Soc. 50:67, 1969.
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19. Chawla, H. B.: Retinal Detachment. The Es sentials of Management. Edinburgh, ChurchillLivingstone, 1974, pp. 37 and 38. 20. Hilton, G. F., Norton, E. W. D., McLean, E. B., and Barnard, E.: Retinal Detachment. A Manual Prepared for Use of Graduates in Medicine, 3rd ed. Rochester, American Academy of Ophthal mology, 1979, pp. 99-102. 21. Chignell, A. H.: Retinal Detachment Sur gery. Berlin, Springer-Verlag, 1980, p. 139. 22. Worthen, D. M.: Retinal detachment and jog ging. Ophthalmic Surg. 11:253, 1980. 23. Kokolakis, S. N., Bravo, L., and Chignell, A. H.: Late retinal reattachment. Br. J. Ophthalmol. 65:142, 1981. 24. Lincoff, H. A., Mclean, J. M., and Nano, H.: Cryosurgical treatment of retinal detachment. Trans. Am. Acad. Ophthalmol. Otolaryngol. 68:412, 1964. 25. Bloch, D., O'Connor, P., and Lincoff, H.: The
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mechanism of the cryosurgical adhesion. III. Statisti cal analysis. Am. J. Ophthalmol. 71:666, 1971. 26. Feman, S. S., Smith, R. S., Ray, G. S., and Long, R. S.: Electron microscopy study of cryogenic chorioretinal adhesions. Am. J. Ophthalmol. 81:823, 1976. 27. Laqua, H., and Machemer, R.: Repair and adhesion mechanisms of the cryotherapy lesion in experimental retinal detachment. Am. .J. Ophthal mol. 81:833, 1976. 28. Lincoff, L., Kreissig, I., Jakobiee, F., and Iwamoto, T. : Remodeling of the cryosurgical adhe sion. Arch. Ophthalmol. 99:1845, 1981. 29. Gonvers, M., and Machemer, R.: A new approach to treating retinal detachment with macular hole. Am. J. Ophthalmol. 94:468, 1982. 30. Chignell, A. H., and Markham, R. H. C.: Retinal detachment surgery without cryotherapy. Br. J. Ophthalmol. 65:371, 1981.
AND D A N I E L F. M A R C U S ,
M.D.
Toledo, Ohio
A prospective, randomized, masked clinical trial to assess the value of limited physical activity after scierai buckling surgery included 108 consecutive patients with rhegmatogenous retinal detachment random ly divided into two groups. The first group was encouraged to resume full physical activity immediately after hospital discharge. In the second group, bending, lifting, straining at stool, driving, sexual activity, lawnmowing, gardening, athletics, and returning to work were strictly forbidden for six weeks. A thorough evaluation of patient compliance was performed after six weeks. Six months after surgery the rates of reoperation and final reattachment percentages of the active and inactive groups showed no statistically significant difference (P>.05). Final visual acuity, measured one year after surgery, also identified no statistically significant difference between the groups (P>.05).
The level of physical activity after reti nal detachment surgery that promotes prompt healing is not known. Instruc tions given to patients about physical activities after such surgery vary widely and are frequently inconsistent. The de cision to restrict a patient's physical activ ity after retinal detachment surgery has significant economic and social ramifica tions. In young working patients, a pro longed job absence may cause serious financial hardship. Sudden limitation of the physical activity of older patients can have adverse psychological and physical effects.1,2 Moreover, many patients in all age groups have indicated that instruc tions to abstain from sexual activity, gar dening, athletics, and driving impose a heavy burden. Although patients fre quently ask when they can safely resume a specific activity after surgery, the surAccepted for publication April 12, 1984. From the St. Vincent Medical Center, Retina Unit, Toledo, Ohio. Reprint requests to Jerald A. Bovino, M.D., St. Vincent Medical Center, Retina Unit, 2213 Cherry St., Toledo, OH 43608.
geon has little data on which to base any recommendations. Because postoperative bedrest and restricted physical activity have been an integral part of successful retinal detachment surgery since Gonin, 3,4 many surgeons persist in advising strictly limited physical activity after sur gery. Others, however, have liberalized their instructions about activity after sur gery without apparent adverse effects. SUBJECTS AND METHODS
We conducted a prospective clinical trial to assess the potential benefits and risks of limited activity after retinal de tachment surgery. We recruited 108 consecutive preoperative patients with rhegmatogenous reti nal detachment at the time they entered the hospital. They were informed that they would be assigned to one of two groups of physical activity, but were not told the possible activity levels before recruitment. After we obtained informed consents we assigned the patients to a full-activity group or a limited-activity group through a table of random num-
©AMERICAN JOURNAL OF OPHTHALMOLOGY 98:171-179, 1984
171
172
AMERICAN JOURNAL OF OPHTHALMOLOGY
bers. The patients in each group had no knowledge of the activity level of the other group. The full-activity group was encouraged to resume all physical activity immediately after leaving the hospital. In the limited-activity group, bending, lift ing, straining at stool, driving, sex, lawnmowing, gardening, athletics, and re turning to work were strictly forbidden until six weeks after surgery. Initial in structions related to postoperative physi cal activity were given by the same regis tered nurse throughout the study. On three occasions, when the registered nurse was not available, patients received instructions about physical activity from an experienced ophthalmic technician. The operating surgeons (J.A.B. and D.F.M.) were not told to which activity group the patients were assigned. All questions that arose during the postoper ative period about physical activity were redirected to the registered nurse, and the patients were not permitted to dis cuss their activity levels with the surgeon at any time during the study. Severe myopia (>5 diopters) was pres ent in nine of 54 patients (16.6%) in the full-activity group and in six of 54 patients (11.1%) in the limited-activity group. A specific history of ocular trauma was elic ited in five of 54 patients (9.3%) in the full-activity group and in two of 54 pa tients (3.7%) in the limited-activity group. Lattice degeneration was identi fied in 12 of 54 patients (24%) in the full-activity group and in seven of 54 patients (13%) in the limited-activity group. Table 1 lists additional preoperative characteristics. All patients had scierai buckling sur gery under general anesthesia. Cryosurgical adhesion was applied to every pa tient in both groups. A silicone episcleral implant with encircling band was used in 50 of 54 patients (94.4%) in the fullactivity group and in 53 of 54 patients (98.1%) in the limited-activity group. A
AUGUST, 1984 TABLE 1
PREOPERATIVE CHARACTERISTICS O F T H E PATIENTS
Characteristics Age (yrs) Mean Range Sex Male Female Status of lens Phakic Aphakic Intraocular lens implant Status of macula Involved Uninvolved
108
Group (No. = 54)
Group (No. = 54)
59 15 to 87
61 12 to 89
26 28
33 21
27 15
23 15
12
16
22 32
18 36
localized episcleral silicone sponge was applied in three of 54 patients (5.6%) in the full-activity group and in one of 54 patients (1.9%) in the limited activity group. Subretinal fluid was drained at the time of surgery in 48 of 54 patients (88.9%) in the full-activity group and in 47 of 54 patients (87%) in the limitedactivity group. Intraocular sulfur hexafluoride gas was used in five of 54 patients (9.3%) in the full-activity group and in eight of 54 patients (14.8%) in the limited-activity group. All patients in both groups were given bathroom privileges on the first postoper ative day. Bedrest and positioning were used as needed in both groups during the hospital stay to facilitate reabsorption of subretinal fluid. The mean length of hos pital stay was 3.6 days (range, three to 15 days) for the full-activity group and 4.4 days (range, three to 15 days) for the limited-activity group. RESULTS
Six weeks after leaving the hospital, each patient was thoroughly questioned by the same registered nurse to deter-
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TABLE 2 POSTOPERATIVE ACTIVITIES
Full -Activity Group (No. = 54)
Limited-Activity Group (No. = 54)
Activities
No.
%
No.
%
Bending Lifting Straining at stool Driving Sex Lawnmowing Gardening Athletics* Return to work
42 25 13 27 16 11 11 24 20
77.8 46.3 25.0 50.0 30.0 20.0 20.0 44.0 37.0
11 o 5 11 6 1 0 11 1
20.0 9.0 9.0 20.0 11.0 1.9 0.0 20.0 1.9
'Athletics included weightlifting, jogging, swimming, bicycling, tennis, and golf.
mine his or her degree of compliance with preoperative activity instructions (Table 2). We used the Z test of the equality of two proportions to compare compliance in the two groups. Straining at stool and sex showed a statistically significant difference (P<.05). Bending, lifting, driving, lawnmowing, gardening, athletics, and returning to work also showed a statistically significant differ ence (P<.01). At six months, the visual acuity, the rate of reoperation, and the rate of suc cessful reattachment were recorded. The final visual acuity was remeasured at one year after surgery and compared with the initial visual acuity for both groups (Fig ure). In the full-activity group, six pa tients were lost to follow-up at the oneyear interval and one had died. In the limited-activity group, five patients were lost to follow-up at the one-year interval and one had died. For these 13 patients, the final visual acuity was considered to be the six-month measurement. The visual acuities of the full-activity patients and the limited-activity patients were grouped into four functional levels (Table 3). We used the Z test of the equality of two proportions to compare the preoperative and postoperative visual
acuity functional groupings. There was no statistically significant difference be tween the groups (P>.05). In the full-activity group at six months, 49 of 54 patients (90.7%) had successfully reattached retinas after one operation. In the limited-activity group at six months, 50 of 54 patients (92.6%) had successfully reattached retinas after one operation. Reoperations were performed on three patients in the full-activity group (two scierai buckles and one vitrectomy with scierai buckle). The scierai buckle and the vitrectomy with scierai buckle were successful and the final reattachment rate was 51 of 54 patients (94.4%). Reoperations were performed on two patients in the limited-activity group (one scierai buckle and one vitrectomy with scierai buckle). The retinas were success fully reattached during both revisions for a final reattachment rate of 52 of 54 patients (96.3%). When we used the Z test of the equali ty of two proportions to compare the initial reattachment rate, the reoperation rate, and the final reattachment rate we found no statistically significant differ ences between the groups (P>.05). All but one failure in the two groups were the result of massive periretinal
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20/20
20/25
NLP
LP
HM
CF
20/400 20/200 20/100 20/70 20/50
20/40
20/30
20/25
20/20
Preoperative Visual Acuity Figure (Bovino and Marcus). Preoperative and postoperative visual acuities of the full-activity and limited-activity groups. Data points above the diagonal line indicate a postoperative visual improvement.
proliferation. The exception was one pa tient in the full-activity group who re fused reoperation after failed surgery de spite no evidence of massive periretinal proliferation. One female patient in the limitedactivity group had a severe pulmonary embolus (documented by electrocardio gram, chest X-ray, and lung scan) despite the postoperative use of elastic stockings. She recovered, however, without perma
nent sequelae. There were no systemic complications in the full-activity group. DISCUSSION
Because retinal detachment surgery in volves the reapproximation of delicate intraocular tissues, surgeons and patients have often worried that exercise could jar the recently attached retina, detaching it and leading to failure of the operation. In an attempt to highlight the preoperative,
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TABLE 3 FUNCTIONAL GROUPING OF PREOPERATIVE AND POSTOPERATIVE VISUAL ACUITIES
Limited Activity Group (No. = 54)
Full-Activity Group (No. = 54) Visual Acuities* Preoperative 20/20 to 20/40 20/50 to 20/200 20/300 to C F . H. M. toL.P. Postoperative 20/20 to 20/40 20/50 to 20/200 20/300 to C F . H.M. toL.P.
No.
%
No.
%
9 13 24 8
16.7 24.1 44.4 14.8
9 12 23 10
16.7 22.2 42.6 18.5
16 26 10 2
29.6 48.2 18.5 3.7
20 19 12 3
37.0 35.2 22.2 5.6
' C F . , counting fingers; H.M., hand movements; L.P., light perception.
surgical, and postoperative factors that can contribute to failure of retinal detach ment surgery, however, Chignell and as sociates 5 mentioned no cases in which the patient's physical activity led to failure. In a review of 1,088 cases of retinal detachment, Rachal and Burton 6 did not mention physical activity in their discus sion of the causes of failure. Tornquist, 7 in a study of reasons for failure necessitating reoperation after retinal detachment sur gery, also failed to mention physical ac tivity. In addition, Clark 8 stated: Any surgeon who blames failure on the post operative conduct of the patient is false to him self as well as the patient. If a retina does not reattach after surgery, it is the result of improp erly placed or inadequate surgery and nothing else. It is true that adequate surgery may be impossible within the limits of the eye's toler ance, but I have never yet seen a failure that was a fault of the patient.
Since the time of Gonin, there has been a slow but steady trend toward more rapid resumption of normal activity after reti nal detachment surgery. Instructions about postoperative physi cal activity from different surgeons and institutions for similar groups of patients, however, have varied widely. Kronfeld 9
advised the postoperative use of pinhole glasses to limit ocular motility and absti nence from physical exercise for three months. Jervey 10 stated that "cure follows good surgery in retinal detachment, re gardless of posture and attempts at fixa tion." H e "began to allow freedom of motion and soon was convinced that rea sonable bodily activity was irrelevant to c u r e . " He also hypothesized that "limita tion of physical activity, by stimulating elements of fear and anger, may actually retard healing and have a detrimental effect on the surgery." He 11 noted three cases in which the usual period of rest after surgery was considerably shortened with no untoward effects and stated that "postoperative care of the patient should be simplified to the great advantage of the patient mentally, physically, and fi nancially." Jervey 12 stated that it was not necessary to follow Gonin's strict postop erative limitations on physical activity, and he reported excellent results in his patients despite rapid resumption of ambulation. In another discussion of postop erative care, Jervey 13 stated "in spite of the practice and teaching of the old mas ters, and many of our present day col leagues, prolonged immobilization in any
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case is of questionable value. Old people in particular lose strength in bed, and immobilization may actually be danger ous." He added, "you are all familiar with the patient who hops all over the place, falls out of bed, and so on and gets a perfectly beautiful result. Prolonged im mobilization in retinal detachment is probably futile and possibly harmful." Norton 14 stated that: Retinal detachment for the most part is cured in the operating room. The chances for success if retinal breaks are closed is 90-95%, regardless of postoperative management. During the first three weeks after operation, the instructions given to patients are as follows: no reading, television permitted from 10 feet away.
He stated that these instructions were intended to cut down eye movement, but added "they may be totally unnecessary." Norton has seen patients "who have vio lated these rules without recurrence." He added, "too often the surgeon blames patients' activity for his own inadequate skills." Havener and Gloeckner 15,16 allowed light work three weeks after surgery and normal activities after six weeks. They suggested that "all of these restrictions are excessively conservative since some patients break all the rules and heal per fectly." Havener 16 stated that "the out come in most patients would not be materially worsened by full normal activ ity as soon as they have recovered from the anesthetic" and added that "clearly the postoperative vomiting and coughing that commonly occur do not dislodge the retina." Pierce 17 advised pinhole glasses and allowed patients to return to work four to eight weeks postoperatively. Colyear 18 believed that the patient should not re turn to full work until three months after retinal detachment surgery but allowed some patients to return to partial activity, depending upon occupation. He allowed
AUGUST, 1984
executives to return to work in two weeks, secretaries to return to work in six to eight weeks, and laborers to return to work in eight to 12 weeks. Chawla 19 al lowed patients to return to normal activi ty after three weeks. Hilton and associates 20 warned patients against stooping over, lifting heavy weights, or bumping the head for three weeks. No sexual intercourse was permit ted during this period. They stated that "it is possible that most patients would have a satisfactory result if the above instructions were not imposed but their routine use seems justified on behalf of the occasional patient in whom it may be important." Chignell 21 stated that "sedentary work can be achieved in two weeks." Strenu ous physical work involving lifting heavy objects or sporting activity such as riding or squash racquets should be avoided for approximately two months. Some sports, such as boxing and high diving, should be abandoned altogether. Worthen 22 stated that 82% of surgeons surveyed suggested avoiding running or jogging after treatment of retinal detach ment, with most recommending absten tion for one to three months. It may be relevant that many surgeons have witnessed reattachment of the reti na many months after apparently failed surgery. Kokolakis, Bravo, and Chignell 23 studied six patients in whom reattach ment of the retina occurred nine to 16 months after retinal detachment surgery that has been considered unsuccessful. In all of these patients the retina became reattached at full levels of physical ac tivity. All of the patients in our series had treatment with cryosurgical adhesion. Lincoff, McLean, and Nano24 believe that bedrest is unnecessary after the second postoperative day. Bloch, O'Connor, and LincofF5 stated that the rapid increase in
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the adhesive strength of both cryosurgical and diathermy lesions justifies current trends toward early mobilization of the retinal detachment patient. They advise full physical activity after the second week. They found that all thermal adhe sions obtain maximum adhesion by 12 days, and that no increase in strength occurred thereafter. Feman and associates 26 found no identi fiable chorioretinal adhesion for eight days after cryotherapy in humans but adhesion was present in an eight-monthold lesion. Laqua and Machemer 27 found normal adhesion between the retina and pigment epithelium four weeks after cry otherapy in monkeys. Lincoff and asso ciates, 28 studying remodeling of the cryosurgical adhesion, found that the two-week cryosurgical lesion correspond ed with maximal adhesion but that signifi cant late remodeling takes place after months and possibly years. Although the chorioretinal adhesion achieves maximum strength during the first eight to 14 days, the relevance of this to physical activity after retinal detach ment surgery is not clear. There is evi dence that an active suction effect of the retinal pigment epithelium may be as important, or more important, than the strength of the chorioretinal adhesion in maintaining attachment of the retina in the postoperative period. 29 Moreover, Chignell and Markham 30 studied retinal detachment surgery without cryotherapy and found an excellent initial rate of retinal reattachment. There was, howev er, a slightly increased late risk of redetachment of the retina in patients with persistent active traction who had lost all of their buckle height. The compliance of the patients in the study with preoperative instructions about permitted physical activity was good. In an attempt to avoid prejudice in management, the treating surgeons were
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unaware of the activity levels of the indi vidual patients and a registered nurse gave all activity instructions. The rate of patient compliance might have been even higher had the treating physician person ally counselled patients about allowable activity levels. More specific wording of the consent form, with a discussion of the potential benefits and risks of each activi ty level, might have also increased com pliance. Because we believed this might prejudice the patients, however, the form was intentionally brief. Examination of compliance data from the limited-activity group showed that preoperative counselling reduced the level of physical activity but was not entirely effective. Patient compliance in both groups, however, was sufficient to produce statistically significant differenc es in activity levels in all activity catego ries. Examination of the compliance data of the patients in the full-activity group was also informative. The patients who were told they could resume full activity after hospital discharge were more active than the patients in the limited-activity group at all stages during the first six weeks. There was wide variation, howev er, in the rate of resumption of activities. Each patient tended to resume activity consistent with his or her age and lifestyle before surgery. Previously active patients rapidly became active and sedentary pa tients generally remained sedentary. One patient in the limited-activity group had a pulmonary embolus in the postoperative period. This is a well recog nized postoperative complication in pa tients whose physical activity is limited 2 although using elastic stockings and per forming leg exercises can reduce this risk. When we compared the limitedactivity and the full-activity groups, the rates of reoperation, the final reattach ment percentage, and the final visual acuity were not statistically different. Al-
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though prolonged bedrest and severely restricted postoperative physical activity were helpful for Gonin's patients, 3,4 mod ern methods of retinal detachment sur gery incorporating cryosurgical adhesion and permanent scierai buckling elements seem to be effective independent of the activity level of the patient after hospital discharge. We found that the rate of postoperative recovery of strength and the desire of the patient for physical activity vary widely. Patients in the nonrestricted group tended to resume physi cal activity after surgery at a rate selected by the individual. It is unnecessary for the surgeon to rush the patient back to exercise, work, and sex after surgery, but there is little if anything to be gained from an arbitrary list of restrictions. Additionally, if retinal detachment sur gery has been unsuccessful, the surgeon should reassure both the family and the patient that they were not responsible for the failure. Patients whose surgery is unsuccessful frequently blame them selves, attributing the failure to a bout of straining, lifting, or premature sexual ac tivity. The patient's guilt response in this regard should be minimized by a frank discussion of the unlikely relationship of these activities to massive periretinal proliferation. There were no patients in this clinical trial with giant retinal tears. This was, however, a matter of chance, as they were not specifically excluded. Because the mechanical forces on the edge of a giant retinal tear may differ from those of other types of retinal detachment, we do not consider this study to be relevant to patients with giant tears, in whom limita tion of physical activity in the postopera tive period may be helpful. We believe the main mechanical risk to the patient during the postoperative period is that of direct trauma to the globe, and we con tinue to advise patients with all types of
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1984
retinal detachments to wear some protec tive gear during this period. REFERENCES 1. Titchener, J., Zwerling, I., Gottschalk, L., and Levine, M.: Psychosis in surgical patients. Surg. Gynecol. Obstet. 102:59, 1956. 2. Rarker, N. W., Nygaard, K. K., Walters, W., and Priestley, J. T. : A statistical study of postopera tive venous thrombosis and pulmonary embolism. Proc. Mayo Clin. 16:1, 1941. 3. Gonin, J. : Le traitement du décollement retinen. Ann. Ocul. 158:175, 1921. 4. : The evaluation of ideas concerning retinal detachment within the last five years. Br. J. Ophthalmol. 17:726, 1933. 5. Chignell, A. H., Fison, L. G., Davies, E. G., Hartley, R. E., and Gundry, M. F.: Failure in reti nal detachment surgery. Br. J. Ophthalmol. 57:525, 1973. 6. Rachal, W. F . , and Burton, T. C : Changing concepts of failures after retinal detachment surgery. Arch. Ophthalmol. 97:480, 1979. 7. Törnquist, R. : Reoperation. In Rosengren, B. (ed.): Retinal Detachment Surgery. Gothenburg, Elanders, 1966, p. 179. 8. Clark, G. : Factors contributing to the successful treatment of retinal detachment. N.Y. State J. Med. 56:3295, 1956. 9. Kronfeld, P. C : Postoperative care and compli cations. Trans. Am. Acad. Ophthalmol. Otolaryngol. 56:432, 1952. 10. Jervey, J. W. : Postoperative care of retinal detachment. Trans. Am. Ophthalmol. Soc. 55:317, 1957. 11. : Note on postoperative management of retinal detachment. Arch. Ophthalmol. 47:76, 1952. 12. : The postoperative care of retinal de tachment. Am. J. Ophthalmol. 36:25, 1953. 13. : Postoperative care of major eye sur gery. South. Med. J. 45:139, 1952. 14. Norton, E. W. D.: Postoperative manage ment. In Schepens, C. L., and Regan, C. D. J. (eds.): Controversial Aspects of the Management of Retinal Detachment. Boston, Little, Brown, and Co., 1965, pp. 321-326. 15. Havener, W. H., and Gloeckner, S. L.: Atlas of Diagnostic Techniques and Treatment of Retinal Detachment. St. Louis, C. V. Mosby, 1967, pp. 176 and 177. 16. Havener, W. H.: Management of retinal de tachments. Ohio State Med. J. 74:617, 1978. 17. Pierce, L. H. : Pre- and postoperative manage ment of retinal detachment. In McPherson, A. (ed.): New and Controversial Aspects of Retinal Detach ment. New York, Harper and Row, 1968, pp. 455459. 18. Colyear, B. H.: Postoperative management of retinal detachment patients. Trans. Pac. Coast. OtoOphthalmol. Soc. 50:67, 1969.
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19. Chawla, H. B.: Retinal Detachment. The Es sentials of Management. Edinburgh, ChurchillLivingstone, 1974, pp. 37 and 38. 20. Hilton, G. F., Norton, E. W. D., McLean, E. B., and Barnard, E.: Retinal Detachment. A Manual Prepared for Use of Graduates in Medicine, 3rd ed. Rochester, American Academy of Ophthal mology, 1979, pp. 99-102. 21. Chignell, A. H.: Retinal Detachment Sur gery. Berlin, Springer-Verlag, 1980, p. 139. 22. Worthen, D. M.: Retinal detachment and jog ging. Ophthalmic Surg. 11:253, 1980. 23. Kokolakis, S. N., Bravo, L., and Chignell, A. H.: Late retinal reattachment. Br. J. Ophthalmol. 65:142, 1981. 24. Lincoff, H. A., Mclean, J. M., and Nano, H.: Cryosurgical treatment of retinal detachment. Trans. Am. Acad. Ophthalmol. Otolaryngol. 68:412, 1964. 25. Bloch, D., O'Connor, P., and Lincoff, H.: The
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mechanism of the cryosurgical adhesion. III. Statisti cal analysis. Am. J. Ophthalmol. 71:666, 1971. 26. Feman, S. S., Smith, R. S., Ray, G. S., and Long, R. S.: Electron microscopy study of cryogenic chorioretinal adhesions. Am. J. Ophthalmol. 81:823, 1976. 27. Laqua, H., and Machemer, R.: Repair and adhesion mechanisms of the cryotherapy lesion in experimental retinal detachment. Am. .J. Ophthal mol. 81:833, 1976. 28. Lincoff, L., Kreissig, I., Jakobiee, F., and Iwamoto, T. : Remodeling of the cryosurgical adhe sion. Arch. Ophthalmol. 99:1845, 1981. 29. Gonvers, M., and Machemer, R.: A new approach to treating retinal detachment with macular hole. Am. J. Ophthalmol. 94:468, 1982. 30. Chignell, A. H., and Markham, R. H. C.: Retinal detachment surgery without cryotherapy. Br. J. Ophthalmol. 65:371, 1981.