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Retinal Detachment Following Cyclocryothermy
R E T I N A L DETACHMENT F O L L O W I N G CYCLOCRYOTHERMY PETER G. BURCH, M.D.
AI m PETER H. MORSE,
M.D.
Baltimore, Maryland
In an effort to decrease aqueous humor secretion in cases of glaucoma resistant to medical therapy, numerous surgical proce dures have been devised to cause partial de struction of the ciliary body. These proce dures include cyclotomy, sclerocyclotomy with thermocautery, cyclectomy, cyclodiathermy, angiodiathermy and cycloelectrolysis.1 Of these techniques, cyclodiathermy has emerged the most popular, although its use by most surgeons is limited to hemorrhagic glaucoma and to glaucoma uncontrollable by other types of surgery. Numerous complica tions of cyclodiathermy have been noted in the literature, including scleral necrosis, in traocular hemorrhage, cyclitis, sympathetic ophthalmia, endophthalmitis and phthisis bulbi. These complications, coupled with the frequent failure of cyclodiathermy to perma nently reduce intraocular tension to a normal level, have encouraged attempts to find other surgical means of decreasing aqueous secre tion. In 1950, the use of ciliary body freezing in animals and man was first described.1 The recent availability of more sophisticated cryosurgical instruments has led to further ex perimental and clinical studies on the effec tiveness of this method in reducing intraocu lar tension.2"4 While some success has been reported, most clinicians have been disap pointed in the efficacy of this technique to cause a permanent decrease in aqueous pro duction. The most commonly noted compli cation of cyclocryothermy is iridocyclitis, which may last for several weeks. Choroidal hemorrhage and hyphema have also been noted.3 Phthisis bulbi has been produced by cyclocryothermy in experimental animals, From the Wilmer Ophthalmological Institute, the Johns Hopkins University School of Medicine and Hospital. Reprint requests to 4858 Battery Lane, Bethesda, Maryland20014 (Dr. Burch).
when temperatures of —100 C to —120 C were used.4 This report draws attention to a pre viously unreported complication of cyclo cryothermy. A rhegmatogenous retinal de tachment developed in an infant following ciliary body freezing for congenital glau coma. CASE REPORT
W. W., a white male infant, was noted to have cloudy corneas, photophobia, and ele vated intraocular pressure bilaterally two days after birth. He was referred to the Wilmer Ophthalmological Institute and on February 20, 1967, at age seven days, was examined under ether anesthesia. At that time, his corneal diameters measured 11 mm vertical by 12 mm horizontal on the right, and 10 mm vertical by 11.75 mm horizontal on the left. Schip'tz tension was 32 mm Hg in the right eye and 29 mm Hg in the left. The left pupil was dilated with a subconjunctival mydriatic solution, and 60% glaucomatous cupping of the disc, associated with vessel na salization, was noted; the far periphery of the retina was normal. An uncomplicated goniotomy was performed in the right eye from the 3:30- to the 5:30-o'clock positions. On February 24, 1967, Schip'tz tension under ether anesthesia was 18.9 mm Hg in the right eye and 24.4 mm Hg in the left. An at tempt to perform a goniotomy in the left eye was unsuccessful because of corneal haze and loss of the anterior chamber after the goniotomy knife had entered the chamber. It was then elected to perform a cyclocryo thermy on the left eye. Utilizing a Frigitronics cryosurgical unit set at — 65 C to — 70 C, a one-minute application was placed in each of the four quadrants 4.5 mm posterior to the corneoscleral limbus. On March 30, 1967, examination under ether anesthesia revealed no change in cor-
VOL. 65, NO. 6
917
RETINAL DETACHMENT
Fig. 1 (Burch and Morse). Fundus drawing of retinal detachment. Retina is detached from the 4- to the 8:4S-o'clock positions, with a dialysis from the 5 :4S- to the 7:30o'clock positions.
neal diameters, but Schip'tz tension measured 28 mm Hg in both eyes. Therefore, a goniotomy was performed in the left eye from the 8- to the 10-o'clock positions with a goniopuncture at the 10-o'clock meridian. Be cause of corneal haze in the right eye, a cyclocryothermy was performed in this eye, using six applications from the 6- to the 12o'clock positions of 45 seconds each, with the temperature set at —75 C and the probe 2 mm posterior to the corneoscleral limbus. On May 3, 1967, the patient was again examined under ether anesthesia. Corneal di ameters were unchanged and intraocular pressure measured 18.9 mm Hg in the right eye and 17.3 mm Hg in the left. Both fundi appeared normal except for 50%-60% cup ping of the optic discs in both eyes. On June 14, 1967, examination under Fluothane anesthesia revealed Schijftz ten sions of 20.6 mm Hg in the right eye and 14.6 mm Hg in the left. The right fundus was normal except for 75% glaucomatous cupping of the optic disc. Examination of the left fundus revealed a retinal detachment from the 4- to the 8:45-o'clock positions, not involving the macula (fig. 1). Large pig-
mented scars corresponding to the previous cryosurgical applications were seen at the 1:30-, 3:30-, 6:30- and 9-o'clock positions, in volving the pars plana and peripheral retina. A large retinal dialysis extending from the 5:45- to the 7:30-o'clock positions was visual ized, corresponding in extent to the cry osurgical scar in this quadrant. Two demar cation lines were noted, one just posterior to the dialysis and another along the 4-o'clock edge of the detachment. On June 16, 1967, the patient underwent a procedure for retinal detachment in the left eye, consisting of a 6-mm-wide scleral groove from the 5- to the 8:30-o'clock posi tions with cryothermy in the bed of the groove, surface diathermy from the 4- to the 5-o'clock positions, and a No. 20 silicone im plant in the groove. No encircling band was placed and no sclerotomy was performed. On reexamination under anesthesia 11 days later, the retina was completely flat. COMMENT
The histopathology of clinically adequate cryosurgical lesions of the ciliary body and retina has been determined in experimental
918
AMERICAN JOURNAL OF OPHTHALMOLOGY
animals.1'2'4 Cryosurgical applications over the ciliary body immediately produce edema and detachment of the epithelium as well as edema, congestion, and hemorrhages of the ciliary body stroma. These changes persist for several days and are then followed by progressive atrophy of the epithelium and ir regular pigmentation and atrophy of the cili ary body stroma. Cryosurgical applications over the retina ultimately result in thinning, atrophy, and disorganization of the neuroretina; disorganization or absence of the pig ment epithelium with formation of chorioretinal adhesions; and atrophy of the smaller choroidal vessels with preservation of the larger ones. Retinal breaks previously have been re ported to occur within scars produced by ex cessive diathermy in operations for retinal detachment.5 The retinal detachment in the case described above was the result of a reti nal dialysis which occurred within a large chorioretinal scar produced by cyclocryo thermy. Presumably, excessive freezing pro duced a lesion extending across the ora serrata into the peripheral retina, and subse quent atrophic changes in the retina resulted in its disinsertion. There was no evidence of vitreous traction, such as vitreous strands, fixed retinal folds, or rolling of the edge of the dialysis. The pathogenesis of the detach ment in this case differs from that described following penetrating cyclodiathermy, in which ingrowth of fibrous tissue through the penetration sites results in small round reti nal breaks.8 The presence of two sets of demarcation lines would suggest a long-standing detach ment. The retinal dialysis, resulting from a degenerative process within a chorioretinal scar, presumably occurred during the first one or two months following cyclocryo thermy. Although no retinal detachment was observed during the examination on May 3, 1967, it is certainly possible that a small pe ripheral detachment was present at that time. It would seem reasonable that cyclo-
JUNE, 1968
cryothermy should be performed with cau tion. Lengthy applications, or applications over the posterior portion of the ciliary body, increase the possibility that the cry osurgical lesion will extend posteriorly across the ora serrata into the peripheral ret ina. Use of cyclocryothermy in infants in creases this hazard, due to the smaller width of the ciliary body. Cyclocryothermy for glaucoma requires colder temperatures and longer applications than does cryothermy in retinal detachment surgery, because of the relatively large distance between the sclera and the secreting epithelium of the ciliary body. In addition, a lower temperature is re quired to produce the tissue necrosis needed for cyclocryothermy than is required to pro duce the inflammatory reaction necessary in surgery for retinal detachment. Since more extensive freezing is necessary during cyclo cryothermy for glaucoma, patients should re ceive careful examinations of the retinal pe riphery following this procedure. SUMMARY
A case of rhegmatogenous retinal detach ment is described in an infant who had been treated with cyclocryothermy for congenital glaucoma. The detachment resulted from a retinal dialysis which occurred within a chorioretinal scar produced by the freezing. U. S. Naval Hospital (20014) REFERENCES
1. Bietti, G.: Surgical intervention on the ciliary body. JAMA, 142 :889, 1950. 2. Polack, F. M. and de Roetth, A., Jr.: Effect of freezing on the ciliary body (cyclocryotherapy). In vest. Ophth. 3 :164, 1964. 3. de Roetth, A., Jr.: Cryosurgery for the treat ment of glaucoma. Am. J. Ophth. 61:443, 1966. 4. McLean, J. M. and Lincoff, H. A.: Cryosur gery of the ciliary body. Tr. Am. Ophth. Soc. 62:385, 1964. 5. Schepens, C. L., Dobbie, J. G. and McMeel, J. W.: Retinal detachments with giant breaks: Pre liminary report. Tr. Am. Acad. Ophth. Otolaryn. 66:471, 1962. 6. Galainena, M. L.: Retinal detachment after penetrating cyclodiathermy. EENT Monthly, 46: 722, 1967.
AI m PETER H. MORSE,
M.D.
Baltimore, Maryland
In an effort to decrease aqueous humor secretion in cases of glaucoma resistant to medical therapy, numerous surgical proce dures have been devised to cause partial de struction of the ciliary body. These proce dures include cyclotomy, sclerocyclotomy with thermocautery, cyclectomy, cyclodiathermy, angiodiathermy and cycloelectrolysis.1 Of these techniques, cyclodiathermy has emerged the most popular, although its use by most surgeons is limited to hemorrhagic glaucoma and to glaucoma uncontrollable by other types of surgery. Numerous complica tions of cyclodiathermy have been noted in the literature, including scleral necrosis, in traocular hemorrhage, cyclitis, sympathetic ophthalmia, endophthalmitis and phthisis bulbi. These complications, coupled with the frequent failure of cyclodiathermy to perma nently reduce intraocular tension to a normal level, have encouraged attempts to find other surgical means of decreasing aqueous secre tion. In 1950, the use of ciliary body freezing in animals and man was first described.1 The recent availability of more sophisticated cryosurgical instruments has led to further ex perimental and clinical studies on the effec tiveness of this method in reducing intraocu lar tension.2"4 While some success has been reported, most clinicians have been disap pointed in the efficacy of this technique to cause a permanent decrease in aqueous pro duction. The most commonly noted compli cation of cyclocryothermy is iridocyclitis, which may last for several weeks. Choroidal hemorrhage and hyphema have also been noted.3 Phthisis bulbi has been produced by cyclocryothermy in experimental animals, From the Wilmer Ophthalmological Institute, the Johns Hopkins University School of Medicine and Hospital. Reprint requests to 4858 Battery Lane, Bethesda, Maryland20014 (Dr. Burch).
when temperatures of —100 C to —120 C were used.4 This report draws attention to a pre viously unreported complication of cyclo cryothermy. A rhegmatogenous retinal de tachment developed in an infant following ciliary body freezing for congenital glau coma. CASE REPORT
W. W., a white male infant, was noted to have cloudy corneas, photophobia, and ele vated intraocular pressure bilaterally two days after birth. He was referred to the Wilmer Ophthalmological Institute and on February 20, 1967, at age seven days, was examined under ether anesthesia. At that time, his corneal diameters measured 11 mm vertical by 12 mm horizontal on the right, and 10 mm vertical by 11.75 mm horizontal on the left. Schip'tz tension was 32 mm Hg in the right eye and 29 mm Hg in the left. The left pupil was dilated with a subconjunctival mydriatic solution, and 60% glaucomatous cupping of the disc, associated with vessel na salization, was noted; the far periphery of the retina was normal. An uncomplicated goniotomy was performed in the right eye from the 3:30- to the 5:30-o'clock positions. On February 24, 1967, Schip'tz tension under ether anesthesia was 18.9 mm Hg in the right eye and 24.4 mm Hg in the left. An at tempt to perform a goniotomy in the left eye was unsuccessful because of corneal haze and loss of the anterior chamber after the goniotomy knife had entered the chamber. It was then elected to perform a cyclocryo thermy on the left eye. Utilizing a Frigitronics cryosurgical unit set at — 65 C to — 70 C, a one-minute application was placed in each of the four quadrants 4.5 mm posterior to the corneoscleral limbus. On March 30, 1967, examination under ether anesthesia revealed no change in cor-
VOL. 65, NO. 6
917
RETINAL DETACHMENT
Fig. 1 (Burch and Morse). Fundus drawing of retinal detachment. Retina is detached from the 4- to the 8:4S-o'clock positions, with a dialysis from the 5 :4S- to the 7:30o'clock positions.
neal diameters, but Schip'tz tension measured 28 mm Hg in both eyes. Therefore, a goniotomy was performed in the left eye from the 8- to the 10-o'clock positions with a goniopuncture at the 10-o'clock meridian. Be cause of corneal haze in the right eye, a cyclocryothermy was performed in this eye, using six applications from the 6- to the 12o'clock positions of 45 seconds each, with the temperature set at —75 C and the probe 2 mm posterior to the corneoscleral limbus. On May 3, 1967, the patient was again examined under ether anesthesia. Corneal di ameters were unchanged and intraocular pressure measured 18.9 mm Hg in the right eye and 17.3 mm Hg in the left. Both fundi appeared normal except for 50%-60% cup ping of the optic discs in both eyes. On June 14, 1967, examination under Fluothane anesthesia revealed Schijftz ten sions of 20.6 mm Hg in the right eye and 14.6 mm Hg in the left. The right fundus was normal except for 75% glaucomatous cupping of the optic disc. Examination of the left fundus revealed a retinal detachment from the 4- to the 8:45-o'clock positions, not involving the macula (fig. 1). Large pig-
mented scars corresponding to the previous cryosurgical applications were seen at the 1:30-, 3:30-, 6:30- and 9-o'clock positions, in volving the pars plana and peripheral retina. A large retinal dialysis extending from the 5:45- to the 7:30-o'clock positions was visual ized, corresponding in extent to the cry osurgical scar in this quadrant. Two demar cation lines were noted, one just posterior to the dialysis and another along the 4-o'clock edge of the detachment. On June 16, 1967, the patient underwent a procedure for retinal detachment in the left eye, consisting of a 6-mm-wide scleral groove from the 5- to the 8:30-o'clock posi tions with cryothermy in the bed of the groove, surface diathermy from the 4- to the 5-o'clock positions, and a No. 20 silicone im plant in the groove. No encircling band was placed and no sclerotomy was performed. On reexamination under anesthesia 11 days later, the retina was completely flat. COMMENT
The histopathology of clinically adequate cryosurgical lesions of the ciliary body and retina has been determined in experimental
918
AMERICAN JOURNAL OF OPHTHALMOLOGY
animals.1'2'4 Cryosurgical applications over the ciliary body immediately produce edema and detachment of the epithelium as well as edema, congestion, and hemorrhages of the ciliary body stroma. These changes persist for several days and are then followed by progressive atrophy of the epithelium and ir regular pigmentation and atrophy of the cili ary body stroma. Cryosurgical applications over the retina ultimately result in thinning, atrophy, and disorganization of the neuroretina; disorganization or absence of the pig ment epithelium with formation of chorioretinal adhesions; and atrophy of the smaller choroidal vessels with preservation of the larger ones. Retinal breaks previously have been re ported to occur within scars produced by ex cessive diathermy in operations for retinal detachment.5 The retinal detachment in the case described above was the result of a reti nal dialysis which occurred within a large chorioretinal scar produced by cyclocryo thermy. Presumably, excessive freezing pro duced a lesion extending across the ora serrata into the peripheral retina, and subse quent atrophic changes in the retina resulted in its disinsertion. There was no evidence of vitreous traction, such as vitreous strands, fixed retinal folds, or rolling of the edge of the dialysis. The pathogenesis of the detach ment in this case differs from that described following penetrating cyclodiathermy, in which ingrowth of fibrous tissue through the penetration sites results in small round reti nal breaks.8 The presence of two sets of demarcation lines would suggest a long-standing detach ment. The retinal dialysis, resulting from a degenerative process within a chorioretinal scar, presumably occurred during the first one or two months following cyclocryo thermy. Although no retinal detachment was observed during the examination on May 3, 1967, it is certainly possible that a small pe ripheral detachment was present at that time. It would seem reasonable that cyclo-
JUNE, 1968
cryothermy should be performed with cau tion. Lengthy applications, or applications over the posterior portion of the ciliary body, increase the possibility that the cry osurgical lesion will extend posteriorly across the ora serrata into the peripheral ret ina. Use of cyclocryothermy in infants in creases this hazard, due to the smaller width of the ciliary body. Cyclocryothermy for glaucoma requires colder temperatures and longer applications than does cryothermy in retinal detachment surgery, because of the relatively large distance between the sclera and the secreting epithelium of the ciliary body. In addition, a lower temperature is re quired to produce the tissue necrosis needed for cyclocryothermy than is required to pro duce the inflammatory reaction necessary in surgery for retinal detachment. Since more extensive freezing is necessary during cyclo cryothermy for glaucoma, patients should re ceive careful examinations of the retinal pe riphery following this procedure. SUMMARY
A case of rhegmatogenous retinal detach ment is described in an infant who had been treated with cyclocryothermy for congenital glaucoma. The detachment resulted from a retinal dialysis which occurred within a chorioretinal scar produced by the freezing. U. S. Naval Hospital (20014) REFERENCES
1. Bietti, G.: Surgical intervention on the ciliary body. JAMA, 142 :889, 1950. 2. Polack, F. M. and de Roetth, A., Jr.: Effect of freezing on the ciliary body (cyclocryotherapy). In vest. Ophth. 3 :164, 1964. 3. de Roetth, A., Jr.: Cryosurgery for the treat ment of glaucoma. Am. J. Ophth. 61:443, 1966. 4. McLean, J. M. and Lincoff, H. A.: Cryosur gery of the ciliary body. Tr. Am. Ophth. Soc. 62:385, 1964. 5. Schepens, C. L., Dobbie, J. G. and McMeel, J. W.: Retinal detachments with giant breaks: Pre liminary report. Tr. Am. Acad. Ophth. Otolaryn. 66:471, 1962. 6. Galainena, M. L.: Retinal detachment after penetrating cyclodiathermy. EENT Monthly, 46: 722, 1967.