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Pseudophakic retinal detachment in high axial myopia
Pseudophakic retinal detachment in high axial myopia Felix K. Jacobi, MD, Volker Hessemer, MD
ABSTRACT Purpose: To investigate the effect of extracapsular cataract surgery with intraocular lens (IOL) implantation and neodymium:YAG (Nd:YAG) laser posterior capsulotomy on the rate of retinal detachment (RD) in myopic eyes with an axial length of 27 mm or more. Setting: Department of Ophthalmology, University of Giessen, Germany. Methods: This retrospective, nonrandomized study comprised the records of 386 consecutive surgical procedures in 275 patients performed between December 1985 and December 1993. In May 1994, all patients were asked by a mailed questionnaire whether they had had an RD in either eye or laser treatment for posterior capsule opacification. Responses from 190 patients concerning 253 surgical procedures were evaluated. Results: The pseudophakic RD rate was 0.8% (two cases). One patient developed aphakic RD after IOL explantation. One expulsive choroidal hemorrhage occurred during secondary IOL implantation. Four eyes (1.6%) had vitreous loss, and 74 eyes (29.2%) had an Nd:YAG capsulotomy. Mean axial length was 29.2 mm ± 1.71 (SO), mean follow-up was 3.8 ± 2 years, and mean age at surgery was 69.8 ± 12 years. Conclusion: Pseudophakia with no other risk factor posed little additional risk for RD in eyes with high axial myopia; however, Nd:YAG laser posterior capsulotomy was a risk factor for pseudophakic RD. Complicated surgery, such as a secondary procedure or vitreous loss, and young age were major causative factors. J Cataract Refract Surg 1997; 23: 1095-1102
n
etinal detachment (RD) is the most common Rserious complication associated with cataract surgery in eyes with axial myopia.! Its incidence and risk factors have been investigated in numerous studies. 2- 7 Intraocular lens (IOL) implantation in eyes with From the Department ofOphthalmology, University ofGiessen, Giessen, Germany. Presented at the Symposium on Cataract, JOL and Refractive Surgery, San Diego, California, USA, April 1995. Reprint requests to Felix K Jacobi, MD, Department of Ophthalmology, University ofGiessen, Friedrichstrasse 18, 35385 Giessen, Germany.
high axial myopia has been recommended. 8-!4 Under the assumption that pseudophakia offers better optical rehabilitation and structural support to the eye, IOLs have been routinely implanted in eyes with high myopia since IOL implantation was initiated at the Department of Ophthalmology, University of Giessen. In the present study, we evaluated the long-term incidence of RD in a large series of highly myopic patients after planned extracapsular cataract extraction (ECCE) and IOL implantation. This problem is of special interest with respect to clear lens extraction for refractive purposes. 15-17
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RETINAL DETACHMENT IN HIGH MYOPIA
Patients and Methods This retrospective, nonrandomized study comprised the records of 386 consecutive surgical procedures (275 patients) performed between December 1985 and December 1993. In May 1994, all patients were asked by a mailed questionnaire whether they had had an RD in either eye or laser treatment for posterior capsule opacification (PCO). Inclusion criteria included a minimum axial length of 27.0 mm. Axial length biometry was determined by A-scan ultrasonography using the Hochfrequenz Echograph nOOA (Kretztechnik) until the end of 1990 and the Ultrasonic Biometer (Allergan Humphrey) thereafter. Intraocular lens power was calculated using the Binkhorst II formula. During the period evaluated, 22 10L models from six manufacturers were implanted. The preferred surgical technique was the envelope method of intercapsular nucleus extraction (pressurecounterpressure) with 10L implantation in the capsular bag. Sodium hyaluronate (Healon®) was routinely used as a surgical adjunct. One 41-year-old man with congenital glaucoma and high myopia had intracapsular cataract extraction and 10L implantation by scleral fixation after spontaneous lens subluxation. Secondary 10L implantation was performed in five eyes: two received a sulcus-fixated 10L, two a scleral-fixated 10L, and one an anterior chamber 10L. A 52-year-old woman was referred to our department for a quadruple procedure in both eyes (penetrating keratoplasty, anterior chamber 10L explantation, cataract extraction, and posterior chamber 10L implantation) because of bullous keratopathy and cataract formation after phakic anterior chamber 10L implantation for refractive purposes.
followed for fewer than 2 years and 16 (8.4%) for less than 1 year. Mean age was 69.8 ± 12 years on August 1, 1994, and 66 ± 11.8 years at the time of surgery. Sex and age distribution are shown in Figure 1. Mean axial length was 29.2 ± 1.71 mm (range 27.01 to 37.50 mm) (Figure 2). Mean calculated postoperative refraction was - 3.54 ± 2.00 diopters (D) (range -0.32 to -13.30 D). Mean 10L power was +9.30 ± 4.10 D (range -2.00 to +23.00 D) (Figure 3). Surgery was performed by 17 surgeons; 6 did 203 (80.2%) of the procedures. Two respondents reported an RD that had been treated elsewhere: One developed an RD 3.5 years after surgery and 1.5 years after neodymium:YAG (Nd:YAG) laser posterior capsulotomy and one, an aphakic RD 3 years after 10L explantation performed because of a lens subluxation that occurred 3 days after the primary
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Results The questionnaire response rate was 77.8% (214 of 275 cases). In 24 cases, relatives reported the patient had died, and 61 patients (22.2%) were lost to followup for unknown reasons. Returned questionnaires from the remaining 190 patients concerning 253 surgical procedures (65.5%, 63 bilateral cases) were evaluated. Mean follow-up was 3.8 years ± 2 (SD) (range 7 months to 8 years, 7 months). Sixty-two patients (32.6%) were 1096
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Figure 1. (Jacobi) Sex and age distribution (fSJ = women; • = men).
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RETINAL DETACHMENT IN HIGH MYOPIA
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procedure. At the time of IOL explantation, a large posterior capsular defect with no vitreous loss was noted. Retinal surgery was reported to have been successful in both cases. A third patient had an RD 8 days after uneventful surgery. The RD was located in the superior retina with a tear in the superonasal quadrant and peripheral degenerations temporally. Visual acuity after retinal surgery performed at our department was 20/400 as compared to 20/200 before cataract surgery. None of these three patients had had an RD in the fellow eye, nor did any receive prophylactic laser photocoagulation or cryotherapy for peripheral vitreoretinal lesions. Table 1 summarizes the clinical characteristics of the patients with RD. One patient developed an expulsive choroidal hemorrhage during secondary anterior chamber IOL implantation. Vitreoretinal surgery was unsuccessful, and final visual acuity was hand motion (20/35 preopera-
tively). One patient with a secondary sulcus-fixated IOL had IOL explantation for bullous keratopathy resulting from traumatic IOL subluxation 3 years after surgery. Vitreous pressure during surgery was present in 52 cases (20.6%). In four (1.6%), surgery was complicated by inadvertent posterior capsule rupture with subsequent vitreous prolapse requiring vitrectomy. An Nd:YAG laser posterior capsulotomy had been performed in 74 eyes (29.2%). Primary open-angle glaucoma was present in 26 eyes (10.3%). In five of these eyes (1.9%), a filtering procedure had been performed before cataract surgery. Peripheral retinal lesions and atrophic retinal holes had been present in 61 (24.1%) and 22 (8.7%) cases, respectively. Twenty-eight eyes (11.1%) received prophylactic laser photocoagulation or cryotherapy for peripheral retinal lesions before surgery.
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RETINAL DETACHMENT IN HIGH MYOPIA
Table 1. Characteristics of patients with RD. Age at
Axial
Time to
RD
Length
Detach-
Type
Status of
of IOL
Capsule
(Years)
Sex
(mm)
ment
54
M
27.24
3 years, 7 months
Posterior Post YAG chamber capsulotomy
41
M
31.71
2 years, 3 months'
None
Intact
60
F
27.66
8 days
Posterior chamber
Intact
'Aphakia after IOL explantation
In the evaluated series of 253 surgical procedures, an RD was observed before cataract surgery in 11 patients in the operated eye and in 3 patients in the phakic fellow eye (5.5%). No patient had bilateral RD. The incidence of preoperative phakic RD in the total population of eyes with an axial length of 27.0 mm or more having surgery between 1985 and 1993 was 25 of 386 eyes (6.5%). Mean age of patients with phakic RD at the time of RD was 46.5 :±: 13.2 years, and mean axial length was 29.15 :±: 2.43 mm. Axial lengths in the fellow eyes (8 cases) were not documented.
capsule openings, a history ofRD, and other contributing factors. A comparative analysis of data in the literature is difficult because of differences in such factors as reporting, surgical techniques, patient population, and follow-up. One difficulty with retrospective studies is the lack of long-term follow-up of a large percentage of patients. It is the usual practice at our department that cataract patients are referred only for surgery, while follow-up examinations are performed by a general ophthalmologist. We addressed the questionnaire to the patient rather than to the general ophthalmologist to elicit more responses. One might contest the reliability of the inquiry in that elderly patients might not understand the meaning of retinal detachment and laser surgery for PCO (termed "after-cataract" on questionnaire). However, only one patient noted on the questionnaire that he did not understand what was meant by after-cataract, and four patients had their ophthalmologist complete the form. We know from epidemiologic studies that medical data are likely to be reported accurately by respondents when the medical condition represents a significant life event or is itself serious or distinctive with clear diag-
Discussion High myopia has been defined as ametropia based on abnormal refractive power,18-20 or axiallength. 3,21-23 The latter definition is more relevant to cataract surgery because of the association between axial length and myopic pathology.23 In our study, we choose an axial length of 27.0 mm or more as indicative of high myopia. 3 The incidence of postoperative pseudophakic RD in the series was 0.8% (2 of 253 cases), which is low compared with reports in the literature (Table 2). In the general population, the probability of pseudophakic RD after modern extracapsular cataract surgery has been reported to be between 0 and 1%.4,6,8,24,25 The risk increases to 2 to 7% in eyes with axial myopia (25.0 mm or greater).9,21.22,24-26 The incidence rates of7.5 and 7% reported in the studies by Amstrong and Lichtenstein21 and Lindstrom and coauthors,22 respectively, overestimate the risk of pseudophakic RD after uneventful cataract surgery. They evaluated the RD rate in small senes that included complicated cases with posterior 1098
Table 2. Incidence of pseudophakic retinal detachment in eyes with high axial myopia.
RD Incidence
Axial Length
Study
%
(Eyes)
(mm)
Follow-up
Armstrong & Lichtenstein 21
7.5
(3/40)
~24.0
22 months'
Buratt0 8
1.9
(1/156)
~26.5
36 months'
Davison 2'
3.4
(8/233)
~25.0
71 weeks'
3.6
(16/443)
~25.0
~3
Lindstrom & coauthors 22
7.0
(5/71)
~25.0
23 months'
Percival & Setty 9
1.9
(7/367)
~25.0
1-3 years
Smith et al.
6.3
(15/239)
25.0 to <26.5
~12
months months
Kraft & Sanders
26
25
years
4.8
(5/105)
~26.5
~12
Wollensak & coauthors33
1.7
(7/407)
~25.0
~2
Present study
0.8
(2/253)
~27.0
3.8 years'
'Mean
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RETINAL DETACHMENT IN HIGH MYOPIA
nostic criteria and when the condition affects the person's everyday activities. 27-29 The occurrence of RD and laser surgery for PCO satisfies these criteria, and we assume that patients accurately reported whether they had an RD and laser surgery for PCO. On the other hand, we must consider that many elderly people are careless about routine consultations and that they may consider a loss of sight normal in view of their advanced age, even had it been restored after the cataract surgery.30 However, we do not expect this to have a great influence on the pseudophakic RD rate as it is more likely to occur in younger myopic patients. 6,10,31 The RD rate in our series may be underestimated because 61 patients (32.6%) were lost to follow-up for unknown reasons and 8.4% had a follow-up of less than 1 year. More men than women develop RD,22,24,32,33 which may account for the low RD rate in our series as the number of men was amply outweighed by the number of women (ratio 1:2.8 ) compared with other series in the literature (1:1.7 and 1:1.6 from Percival and Setty9 and Davison,24 respectively). Davison24 found an RD rate three times greater in men than in women. The low number of RDs in our study may be further attributed to the low incidence of inadvertent vitreous loss at the time of surgery 0.6%). Vitreous loss is the main intraoperative complication predisposing to RD.6,34-37 Kroll and coauthors38 noted that the incidence of vitreous loss was more frequently associated with myopia, but we found this not to be true. The rate of inadvertent vitreous loss in cataract surgery between 1988 and 1993 was 6 of 367 cases (1.635%) with an axial length of 27.0 mm or greater and 164 of 10,074 cases (1.628%) with an axial length ofless than 27 mm (unpublished data). Our results are in accordance with those of a large study by Schinz,32 who investigated the RD incidence after cataract surgery in 383 male eyes and 342 female eyes (402 eyes with ECCE and 10L). The overall incidence was 1.3%, but with only one RD in 108 eyes (0.9%) with an axial length of 27 mm or greater. In surgical studies, Gross and Pearce 12 and Lamrani and coauthors39 reported low RD rates (0.8 and 0%, respectively); however, mean follow-up was only 1 year. According to Percival and Setty,960% of RDs occur within the first postoperative year. In analysis of our serious complications, we found surgical trauma causative in at least two cases. The
occurrence of an expulsive choroidal hemorrhage in a 72-year-old woman with hypertension is a dramatic complication. In the literature, an incidence of 0.05 to 0.2% is reported. 40 ,41 There is an association with high myopia and systemic vascular disease. 42 Because the RD occurred so soon after surgery (8 days in one case), it was considered a complication of surgery. Since there was no complication reported during surgery, one may speculate in such cases that a subclinical and asymptomatic form of RD was present and became manifest only shortly after surgery.43 In this patient, who had a detachment in the superior retina, peripheral degeneration with an atrophic hole in the temporal retina was only recognized after the cataract operation. The appearance of aphakic RD 3 years after cataract surgery and secondary 10L explantation because of 10L subluxation may be attributed to the aphakic condition and a posterior capsule defect. The importance of the posterior capsule in protecting the eye against RD has been demonstrated in many studies.6.44-49 It is believed that the posterior capsule acts as a barrier against vitreous movement toward the anterior chamber, reducing the loss of hyaluronic acid and incidence of posterior vitreous detachment. 8 Kraff and Sanders26 reported a higher pseudophakic RD incidence in eyes with high myopia after primary knife discission (6.2%) than in eyes with a closed capsule (2.0%). Dardenne and coauthorsSO found that the RD rate in high myopia increased 10 times (from 0.5 to 5.4%) after Nd:YAG posterior capsulotomy. The literature further suggests that the posterior capsule opening rather than direct physical trauma from Nd:YAG laser irridation is the primary factor contributing to RD.S 1,S2 Among our patients, 29% had received an Nd:YAG capsulotomy for PCO. The reported incidence is 20 to 50% of patients within 3 years after surgery.S3-SS In our series, one case of RD occurred 1.5 years after Nd:YAG capsulotomy, which does not suggest a direct relationship. Most published series report a mean latency of 6 months from Nd:YAG capsulotomy to RD; according to Rickman-Barger and coauthors,47 85% occur within the first year. Besides surgical trauma and pseudophakia, high myopia is a major factor in the pathogenesis of pseudophakic RD. Myopia predisposes to RD because of an increased incidence of lattice degeneration, 56 a higher rate of posterior vitreous detachment,S7 and a
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thin retina that is prone to developing retinal breaks. 58 According to Burton,59 lattice degeneration is a greater predisposing factor in myopia than in emmetropia. Studies further indicate that lattice degeneration is more frequent in moderate than in high myopia. Celorio and Pruett60 found the highest prevalence (41%) in eyes with axial lengths between 26.0 and 27.0 mm and the lowest prevalence (7%) with axial lengths greater than 32.0 mm. Smith et al. 25 reported higher rates of RD after ECCE and IOL implantation in eyes with axial lengths less than 26.5 mm (6.3%) than in those with axial lengths greater than 26.5 mm (4.8%). Our study supports these findings and lends further credence to the theory that RD after cataract surgery may be more frequent in moderate than in high myopIa. Finally, one must consider the influence of age on the incidence of pseudophakic RD. In a large study population, Bohringer61 found that the lifetime risk for phakic RD in high myopia (10.00 D or greater) is 4.2% to the age of 60 years and 6.7% to the age of 80 years. This is comparable to the incidence of 5.5% of phakic RD in the evaluated series at a mean age at cataract surgery of 66 years. It is well recognized that RD in myopia develops at an earlier age than in emmetropia. 2,6,25,31 In our total population of eyes with an axial length of 27.0 mm or greater operated on between 1985 and 1993, the mean age of patients with phakic RD at the time of RD was 46.5 years. Spitznas and GraefP'2 have shown that only 31 % of RDs in myopic eyes occur after the age of 60 years compared with 63% in emmetropic eyes. In our series, 187 patients (73.9%) were 60 years or older at the time of surgery. Thus, we believe that the risk of pseudophakic RD in highly myopic patients may be largely dependent on the age at surgery. In the study by Lindstrom and coauthors,22 three of five (60%) male patients with RD were younger than 40 years, while mean age in the entire male population was 57 years. Barraquer and coauthors l6 reported an RD incidence of 7.3% after clear lens extraction in aphakic eyes. They found 58% of the RDs occurred in patients younger than 30 years of age, while only 31 % of patients younger than 30 years did not have RD. From our study, we conclude that RD after cataract surgery in high myopia occurs at an acceptably low level in the absence of risk factors. Complicated surgery 1100
such as a secondary procedure or vitreous loss in a young man is the greatest predisposing condition for pseudophakic RD in high myopia. Therefore, a diligent surgical technique in high myopia is of paramount importance, and clear lens extraction for refractive purpose in high-risk patients is to be considered with caution.
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1102
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retina. Trans Am Acad Ophthalmol Otolaryngol 1965; 69:1065-1081 Jaffe NS. The Vitreous in Clinical Ophthalmology. St Louis, MO, CV Mosby, 1969; 83-98 Hyams Sw, Neumann E, Friedman Z. Myopia-Aphakia. II. Vitreous and peripheral retina. Br J Ophthalmol 1975; 59:483-485 Burton TC. The influence of refractive error and lattice degeneration on the incidence of retinal detachment. Trans Am Ophthalmol Soc 1989; 87:143-157 Celorio JM, Pruett RC. Prevalence of lattice degeneration and its relation to axial length in severe myopia. Am J Ophthalmol 1991; 111:20-23 Bohringer HR Statistisches zur Haufigkeit und Risiko der Netzhautablosung. Ophthalmologica 1956; 131 :331-334 Spitznas M, GraeffY. Netzhautablosung und Refraktion. Dtsch Med Wochenschr 1970; 95:1205-1209
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ABSTRACT Purpose: To investigate the effect of extracapsular cataract surgery with intraocular lens (IOL) implantation and neodymium:YAG (Nd:YAG) laser posterior capsulotomy on the rate of retinal detachment (RD) in myopic eyes with an axial length of 27 mm or more. Setting: Department of Ophthalmology, University of Giessen, Germany. Methods: This retrospective, nonrandomized study comprised the records of 386 consecutive surgical procedures in 275 patients performed between December 1985 and December 1993. In May 1994, all patients were asked by a mailed questionnaire whether they had had an RD in either eye or laser treatment for posterior capsule opacification. Responses from 190 patients concerning 253 surgical procedures were evaluated. Results: The pseudophakic RD rate was 0.8% (two cases). One patient developed aphakic RD after IOL explantation. One expulsive choroidal hemorrhage occurred during secondary IOL implantation. Four eyes (1.6%) had vitreous loss, and 74 eyes (29.2%) had an Nd:YAG capsulotomy. Mean axial length was 29.2 mm ± 1.71 (SO), mean follow-up was 3.8 ± 2 years, and mean age at surgery was 69.8 ± 12 years. Conclusion: Pseudophakia with no other risk factor posed little additional risk for RD in eyes with high axial myopia; however, Nd:YAG laser posterior capsulotomy was a risk factor for pseudophakic RD. Complicated surgery, such as a secondary procedure or vitreous loss, and young age were major causative factors. J Cataract Refract Surg 1997; 23: 1095-1102
n
etinal detachment (RD) is the most common Rserious complication associated with cataract surgery in eyes with axial myopia.! Its incidence and risk factors have been investigated in numerous studies. 2- 7 Intraocular lens (IOL) implantation in eyes with From the Department ofOphthalmology, University ofGiessen, Giessen, Germany. Presented at the Symposium on Cataract, JOL and Refractive Surgery, San Diego, California, USA, April 1995. Reprint requests to Felix K Jacobi, MD, Department of Ophthalmology, University ofGiessen, Friedrichstrasse 18, 35385 Giessen, Germany.
high axial myopia has been recommended. 8-!4 Under the assumption that pseudophakia offers better optical rehabilitation and structural support to the eye, IOLs have been routinely implanted in eyes with high myopia since IOL implantation was initiated at the Department of Ophthalmology, University of Giessen. In the present study, we evaluated the long-term incidence of RD in a large series of highly myopic patients after planned extracapsular cataract extraction (ECCE) and IOL implantation. This problem is of special interest with respect to clear lens extraction for refractive purposes. 15-17
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RETINAL DETACHMENT IN HIGH MYOPIA
Patients and Methods This retrospective, nonrandomized study comprised the records of 386 consecutive surgical procedures (275 patients) performed between December 1985 and December 1993. In May 1994, all patients were asked by a mailed questionnaire whether they had had an RD in either eye or laser treatment for posterior capsule opacification (PCO). Inclusion criteria included a minimum axial length of 27.0 mm. Axial length biometry was determined by A-scan ultrasonography using the Hochfrequenz Echograph nOOA (Kretztechnik) until the end of 1990 and the Ultrasonic Biometer (Allergan Humphrey) thereafter. Intraocular lens power was calculated using the Binkhorst II formula. During the period evaluated, 22 10L models from six manufacturers were implanted. The preferred surgical technique was the envelope method of intercapsular nucleus extraction (pressurecounterpressure) with 10L implantation in the capsular bag. Sodium hyaluronate (Healon®) was routinely used as a surgical adjunct. One 41-year-old man with congenital glaucoma and high myopia had intracapsular cataract extraction and 10L implantation by scleral fixation after spontaneous lens subluxation. Secondary 10L implantation was performed in five eyes: two received a sulcus-fixated 10L, two a scleral-fixated 10L, and one an anterior chamber 10L. A 52-year-old woman was referred to our department for a quadruple procedure in both eyes (penetrating keratoplasty, anterior chamber 10L explantation, cataract extraction, and posterior chamber 10L implantation) because of bullous keratopathy and cataract formation after phakic anterior chamber 10L implantation for refractive purposes.
followed for fewer than 2 years and 16 (8.4%) for less than 1 year. Mean age was 69.8 ± 12 years on August 1, 1994, and 66 ± 11.8 years at the time of surgery. Sex and age distribution are shown in Figure 1. Mean axial length was 29.2 ± 1.71 mm (range 27.01 to 37.50 mm) (Figure 2). Mean calculated postoperative refraction was - 3.54 ± 2.00 diopters (D) (range -0.32 to -13.30 D). Mean 10L power was +9.30 ± 4.10 D (range -2.00 to +23.00 D) (Figure 3). Surgery was performed by 17 surgeons; 6 did 203 (80.2%) of the procedures. Two respondents reported an RD that had been treated elsewhere: One developed an RD 3.5 years after surgery and 1.5 years after neodymium:YAG (Nd:YAG) laser posterior capsulotomy and one, an aphakic RD 3 years after 10L explantation performed because of a lens subluxation that occurred 3 days after the primary
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Results The questionnaire response rate was 77.8% (214 of 275 cases). In 24 cases, relatives reported the patient had died, and 61 patients (22.2%) were lost to followup for unknown reasons. Returned questionnaires from the remaining 190 patients concerning 253 surgical procedures (65.5%, 63 bilateral cases) were evaluated. Mean follow-up was 3.8 years ± 2 (SD) (range 7 months to 8 years, 7 months). Sixty-two patients (32.6%) were 1096
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Figure 1. (Jacobi) Sex and age distribution (fSJ = women; • = men).
J CATARACT REFRACT SURG-VOL 23. SEPTEMBER 1997
RETINAL DETACHMENT IN HIGH MYOPIA
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procedure. At the time of IOL explantation, a large posterior capsular defect with no vitreous loss was noted. Retinal surgery was reported to have been successful in both cases. A third patient had an RD 8 days after uneventful surgery. The RD was located in the superior retina with a tear in the superonasal quadrant and peripheral degenerations temporally. Visual acuity after retinal surgery performed at our department was 20/400 as compared to 20/200 before cataract surgery. None of these three patients had had an RD in the fellow eye, nor did any receive prophylactic laser photocoagulation or cryotherapy for peripheral vitreoretinal lesions. Table 1 summarizes the clinical characteristics of the patients with RD. One patient developed an expulsive choroidal hemorrhage during secondary anterior chamber IOL implantation. Vitreoretinal surgery was unsuccessful, and final visual acuity was hand motion (20/35 preopera-
tively). One patient with a secondary sulcus-fixated IOL had IOL explantation for bullous keratopathy resulting from traumatic IOL subluxation 3 years after surgery. Vitreous pressure during surgery was present in 52 cases (20.6%). In four (1.6%), surgery was complicated by inadvertent posterior capsule rupture with subsequent vitreous prolapse requiring vitrectomy. An Nd:YAG laser posterior capsulotomy had been performed in 74 eyes (29.2%). Primary open-angle glaucoma was present in 26 eyes (10.3%). In five of these eyes (1.9%), a filtering procedure had been performed before cataract surgery. Peripheral retinal lesions and atrophic retinal holes had been present in 61 (24.1%) and 22 (8.7%) cases, respectively. Twenty-eight eyes (11.1%) received prophylactic laser photocoagulation or cryotherapy for peripheral retinal lesions before surgery.
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RETINAL DETACHMENT IN HIGH MYOPIA
Table 1. Characteristics of patients with RD. Age at
Axial
Time to
RD
Length
Detach-
Type
Status of
of IOL
Capsule
(Years)
Sex
(mm)
ment
54
M
27.24
3 years, 7 months
Posterior Post YAG chamber capsulotomy
41
M
31.71
2 years, 3 months'
None
Intact
60
F
27.66
8 days
Posterior chamber
Intact
'Aphakia after IOL explantation
In the evaluated series of 253 surgical procedures, an RD was observed before cataract surgery in 11 patients in the operated eye and in 3 patients in the phakic fellow eye (5.5%). No patient had bilateral RD. The incidence of preoperative phakic RD in the total population of eyes with an axial length of 27.0 mm or more having surgery between 1985 and 1993 was 25 of 386 eyes (6.5%). Mean age of patients with phakic RD at the time of RD was 46.5 :±: 13.2 years, and mean axial length was 29.15 :±: 2.43 mm. Axial lengths in the fellow eyes (8 cases) were not documented.
capsule openings, a history ofRD, and other contributing factors. A comparative analysis of data in the literature is difficult because of differences in such factors as reporting, surgical techniques, patient population, and follow-up. One difficulty with retrospective studies is the lack of long-term follow-up of a large percentage of patients. It is the usual practice at our department that cataract patients are referred only for surgery, while follow-up examinations are performed by a general ophthalmologist. We addressed the questionnaire to the patient rather than to the general ophthalmologist to elicit more responses. One might contest the reliability of the inquiry in that elderly patients might not understand the meaning of retinal detachment and laser surgery for PCO (termed "after-cataract" on questionnaire). However, only one patient noted on the questionnaire that he did not understand what was meant by after-cataract, and four patients had their ophthalmologist complete the form. We know from epidemiologic studies that medical data are likely to be reported accurately by respondents when the medical condition represents a significant life event or is itself serious or distinctive with clear diag-
Discussion High myopia has been defined as ametropia based on abnormal refractive power,18-20 or axiallength. 3,21-23 The latter definition is more relevant to cataract surgery because of the association between axial length and myopic pathology.23 In our study, we choose an axial length of 27.0 mm or more as indicative of high myopia. 3 The incidence of postoperative pseudophakic RD in the series was 0.8% (2 of 253 cases), which is low compared with reports in the literature (Table 2). In the general population, the probability of pseudophakic RD after modern extracapsular cataract surgery has been reported to be between 0 and 1%.4,6,8,24,25 The risk increases to 2 to 7% in eyes with axial myopia (25.0 mm or greater).9,21.22,24-26 The incidence rates of7.5 and 7% reported in the studies by Amstrong and Lichtenstein21 and Lindstrom and coauthors,22 respectively, overestimate the risk of pseudophakic RD after uneventful cataract surgery. They evaluated the RD rate in small senes that included complicated cases with posterior 1098
Table 2. Incidence of pseudophakic retinal detachment in eyes with high axial myopia.
RD Incidence
Axial Length
Study
%
(Eyes)
(mm)
Follow-up
Armstrong & Lichtenstein 21
7.5
(3/40)
~24.0
22 months'
Buratt0 8
1.9
(1/156)
~26.5
36 months'
Davison 2'
3.4
(8/233)
~25.0
71 weeks'
3.6
(16/443)
~25.0
~3
Lindstrom & coauthors 22
7.0
(5/71)
~25.0
23 months'
Percival & Setty 9
1.9
(7/367)
~25.0
1-3 years
Smith et al.
6.3
(15/239)
25.0 to <26.5
~12
months months
Kraft & Sanders
26
25
years
4.8
(5/105)
~26.5
~12
Wollensak & coauthors33
1.7
(7/407)
~25.0
~2
Present study
0.8
(2/253)
~27.0
3.8 years'
'Mean
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RETINAL DETACHMENT IN HIGH MYOPIA
nostic criteria and when the condition affects the person's everyday activities. 27-29 The occurrence of RD and laser surgery for PCO satisfies these criteria, and we assume that patients accurately reported whether they had an RD and laser surgery for PCO. On the other hand, we must consider that many elderly people are careless about routine consultations and that they may consider a loss of sight normal in view of their advanced age, even had it been restored after the cataract surgery.30 However, we do not expect this to have a great influence on the pseudophakic RD rate as it is more likely to occur in younger myopic patients. 6,10,31 The RD rate in our series may be underestimated because 61 patients (32.6%) were lost to follow-up for unknown reasons and 8.4% had a follow-up of less than 1 year. More men than women develop RD,22,24,32,33 which may account for the low RD rate in our series as the number of men was amply outweighed by the number of women (ratio 1:2.8 ) compared with other series in the literature (1:1.7 and 1:1.6 from Percival and Setty9 and Davison,24 respectively). Davison24 found an RD rate three times greater in men than in women. The low number of RDs in our study may be further attributed to the low incidence of inadvertent vitreous loss at the time of surgery 0.6%). Vitreous loss is the main intraoperative complication predisposing to RD.6,34-37 Kroll and coauthors38 noted that the incidence of vitreous loss was more frequently associated with myopia, but we found this not to be true. The rate of inadvertent vitreous loss in cataract surgery between 1988 and 1993 was 6 of 367 cases (1.635%) with an axial length of 27.0 mm or greater and 164 of 10,074 cases (1.628%) with an axial length ofless than 27 mm (unpublished data). Our results are in accordance with those of a large study by Schinz,32 who investigated the RD incidence after cataract surgery in 383 male eyes and 342 female eyes (402 eyes with ECCE and 10L). The overall incidence was 1.3%, but with only one RD in 108 eyes (0.9%) with an axial length of 27 mm or greater. In surgical studies, Gross and Pearce 12 and Lamrani and coauthors39 reported low RD rates (0.8 and 0%, respectively); however, mean follow-up was only 1 year. According to Percival and Setty,960% of RDs occur within the first postoperative year. In analysis of our serious complications, we found surgical trauma causative in at least two cases. The
occurrence of an expulsive choroidal hemorrhage in a 72-year-old woman with hypertension is a dramatic complication. In the literature, an incidence of 0.05 to 0.2% is reported. 40 ,41 There is an association with high myopia and systemic vascular disease. 42 Because the RD occurred so soon after surgery (8 days in one case), it was considered a complication of surgery. Since there was no complication reported during surgery, one may speculate in such cases that a subclinical and asymptomatic form of RD was present and became manifest only shortly after surgery.43 In this patient, who had a detachment in the superior retina, peripheral degeneration with an atrophic hole in the temporal retina was only recognized after the cataract operation. The appearance of aphakic RD 3 years after cataract surgery and secondary 10L explantation because of 10L subluxation may be attributed to the aphakic condition and a posterior capsule defect. The importance of the posterior capsule in protecting the eye against RD has been demonstrated in many studies.6.44-49 It is believed that the posterior capsule acts as a barrier against vitreous movement toward the anterior chamber, reducing the loss of hyaluronic acid and incidence of posterior vitreous detachment. 8 Kraff and Sanders26 reported a higher pseudophakic RD incidence in eyes with high myopia after primary knife discission (6.2%) than in eyes with a closed capsule (2.0%). Dardenne and coauthorsSO found that the RD rate in high myopia increased 10 times (from 0.5 to 5.4%) after Nd:YAG posterior capsulotomy. The literature further suggests that the posterior capsule opening rather than direct physical trauma from Nd:YAG laser irridation is the primary factor contributing to RD.S 1,S2 Among our patients, 29% had received an Nd:YAG capsulotomy for PCO. The reported incidence is 20 to 50% of patients within 3 years after surgery.S3-SS In our series, one case of RD occurred 1.5 years after Nd:YAG capsulotomy, which does not suggest a direct relationship. Most published series report a mean latency of 6 months from Nd:YAG capsulotomy to RD; according to Rickman-Barger and coauthors,47 85% occur within the first year. Besides surgical trauma and pseudophakia, high myopia is a major factor in the pathogenesis of pseudophakic RD. Myopia predisposes to RD because of an increased incidence of lattice degeneration, 56 a higher rate of posterior vitreous detachment,S7 and a
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RETINAL DETACHMENT IN HIGH MYOPIA
thin retina that is prone to developing retinal breaks. 58 According to Burton,59 lattice degeneration is a greater predisposing factor in myopia than in emmetropia. Studies further indicate that lattice degeneration is more frequent in moderate than in high myopia. Celorio and Pruett60 found the highest prevalence (41%) in eyes with axial lengths between 26.0 and 27.0 mm and the lowest prevalence (7%) with axial lengths greater than 32.0 mm. Smith et al. 25 reported higher rates of RD after ECCE and IOL implantation in eyes with axial lengths less than 26.5 mm (6.3%) than in those with axial lengths greater than 26.5 mm (4.8%). Our study supports these findings and lends further credence to the theory that RD after cataract surgery may be more frequent in moderate than in high myopIa. Finally, one must consider the influence of age on the incidence of pseudophakic RD. In a large study population, Bohringer61 found that the lifetime risk for phakic RD in high myopia (10.00 D or greater) is 4.2% to the age of 60 years and 6.7% to the age of 80 years. This is comparable to the incidence of 5.5% of phakic RD in the evaluated series at a mean age at cataract surgery of 66 years. It is well recognized that RD in myopia develops at an earlier age than in emmetropia. 2,6,25,31 In our total population of eyes with an axial length of 27.0 mm or greater operated on between 1985 and 1993, the mean age of patients with phakic RD at the time of RD was 46.5 years. Spitznas and GraefP'2 have shown that only 31 % of RDs in myopic eyes occur after the age of 60 years compared with 63% in emmetropic eyes. In our series, 187 patients (73.9%) were 60 years or older at the time of surgery. Thus, we believe that the risk of pseudophakic RD in highly myopic patients may be largely dependent on the age at surgery. In the study by Lindstrom and coauthors,22 three of five (60%) male patients with RD were younger than 40 years, while mean age in the entire male population was 57 years. Barraquer and coauthors l6 reported an RD incidence of 7.3% after clear lens extraction in aphakic eyes. They found 58% of the RDs occurred in patients younger than 30 years of age, while only 31 % of patients younger than 30 years did not have RD. From our study, we conclude that RD after cataract surgery in high myopia occurs at an acceptably low level in the absence of risk factors. Complicated surgery 1100
such as a secondary procedure or vitreous loss in a young man is the greatest predisposing condition for pseudophakic RD in high myopia. Therefore, a diligent surgical technique in high myopia is of paramount importance, and clear lens extraction for refractive purpose in high-risk patients is to be considered with caution.
References 1. Jaffe NS. Cataract Surgery and Its Complications, 4th ed. St Louis, MO, CV Mosby, 1984; 637-649 2. Hyams Sw, Bialik M, Neumann E. Myopia-aphakia. 1. Prevalence of retinal detachment. Br J Ophthalmol 1975; 59:480-482 3. Praeger OL. Five years' follow-up in surgical management of cataracts in high myopia treated with the Kelman phacoemulsification technique. Ophthalmology 1979; 86:2024-2033 4. Clayman HM, Jaffe NS, Light OS, et al. Intraocular lenses, axial length, and retinal detachment. Am J Ophthalmol 1981; 92:778-780 5. Percival SPB, Anand V, Oas SK. Prevalence of aphakic retinal detachment. Br J Ophthalmol 1983; 67:43-45 6. Coonan P, Fung WE, Webster RG Jr, et al. The incidence of retinal detachment following extracapsular cataract extraction; a ten-year study. Ophthalmology 1985; 92:1096-1101 7. Heider W, Sallner T. Netzhautablasung nach extrakapsuther Kataraktextraktion bei myopen Augen. Fortschr Ophthalmol 1985; 82:347-348 8. Buratto L. Cataract surgery in high myopia. Eur J Implant Refract Surg 1991; 3:271-278 9. Percival SPB, Setty SS. Sight-threatening pathology related to high myopia after posterior chamber lens implantation: a prospective study. Eur J Implant Refract Surg 1993; 5:95-98 10. Smith SG, Lindstrom RL. Intraocular Lens Complications and Their Management. Thorofare, NJ, Slack Inc, 1988; 157-166 11. Ochi T, Gon A, Kora Y, et al. Intraocular lens implantation and high myopia. J Cataract Refract Surg 1988; 14:403-408 12. Gross KA, Pearce JL. Modern cataract surgery in a highly myopic population. Br J Ophthalmol 1987; 71: 215-219 13. Livernois R, Sinskey RM. Low power intraocular lenses. Am Intra-Ocular Implant Soc J 1983; 9:321-323 14. Menezo JL, Cisneros A, Harto M. Extracapsular cataract extraction and implantation of a low power lens for high myopia. J Cataract Refract Surg 1988; 14:409-412 15. Lyle WA, George GJc. Clear lens extraction for the correction of high refractive error. J Cataract Refract Surg 1994; 20:273-276
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1102
57. 58.
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