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Retinal Detachment in Aphakia*
R E T I N A L D E T A C H M E N T IN EDWARD
W .
D.
APHAKIA*
NORTON,
M.D.
Miami, Florida
O n e o f the most serious sequelae to cata
1955, to December, 1960, have been studied.
ract surgery is the development o f a retinal
All patients had a minimum o f a six-month
detachment. Prior to Gonin's* treatment of
follow-up after their last surgical procedure.
the retinal tear, this complication resulted in
Six additional patients w h o did not have a
the total loss of useful vision in the involved
six-month
eye. Even after the dramatic results reported
from
follow-up
have
been excluded
the series, despite the fact that the
by Gonin and other workers, however, the
retinas were attached
results of treatment o f retinal detachment in
patients whose retinas were detached when
when last seen. All
aphakia remained disappointing. Throughout
last seen have been included as failures. T h e
the literature, the best results reported in
424 eyes underwent 495 operations. In this
unselected series range from
18 to 59 per-
cent^-*" successful reattachment of the retina
series, 139 eyes were aphakic, an incidence of 33 percent.
in aphakia, in contrast to reports of success
In an effort to be objective, the data on
rates of 50 to 8 0 + percent*''* in phakic eyes.
each case were catalogued at the time o f hos
T h e purpose o f this paper is: ( 1 ) to e x
pitalization on a chart
(fig. 1) for subse
plore some o f the differences between apha
quent I B M analysis. T h e appropriate data
kic and phakic retinal detachments; ( 2 ) to
were entered on these charts at the time o f
try to account for the discrepancy in surgi
the initial examination,
cal results;
( 3 ) to see if this discrepancy
at the time o f discharge from the hospital
still persists despite the recent advances in
and at a period o f more than six months
retinal detachment surgery.
following
T h e actual incidence o f retinal detachment
the
following
surgery. It
surgery,
is believed that
such a progressive record tends to reduce
in aphakia is unknown because of the diffi
the
culty in getting long-term follow-up studies,
tive study. Data that are difficult to evaluate,
but it has been estimated to be one to three
such as vitreous traction, were recorded be
inherent
bias o f
the usual
retrospec
percent*'" o f all cataract extractions. T h e
fore the surgeon knew the outcome o f the
incidence
case. While each surgeon would vary
of
aphakic
detachment
series of retinal detachments
in
ranges
seven to 25 percent."'" T h e higher
any from
figures
to be an extremely helpful one and is recom
undoubtedly represent the tendency of the
mended
ophthalmologist to refer aphakic detachments
records.
for much greater
to "retinal centers." This review does not attempt to study the incidence, of retinal de tachment in cataract extraction and accepts the figures previously published. MATERIAL
A N D
the
f o r m of the chart, the technique was found
ANALYSIS AGE
OF
OF
use in medical
DATA
ONSET
In phakic eyes the highest incidence of detachment occurred in the 40-59 year age group, whereas the aphakic eyes showed the
METHOD
Four hundred and twenty-four eyes with retinal detachment, operated upon consecu tively o n my private service from January, * From llic liascoiii Palmer Kye [nstitiite, Deparmient of Opiiflialmology, Univer.sity of Miami School of Medicine. This paper was submitted for membership in the American Ophthalmological Society. 111
highest incidence in the 60 and over age group (table 1 ) . This age distribution is con sistent with other studies.^' SIZE,
LOCATION
A N D
NUMBER
OF
RETINAL
BREAKS
Several authors have emphasized that the retinal breaks in aphakic retinal detachment
E D W A R D W . D. N O R T O N
112
CODE SHEEÍ fOR RETINAL OErACHMENT STUDY -YEAB OPEfcATED-
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Fig. 1 (Norton). Code sheet for retinal detachment study.
20/13-30/30 30/40-30/30 20/7frlO/100 30/300 -20/300
nATUS EVt E X A M I PON-OP(CoLn)
TfU
R E T I N A L D E T A C H M E N T IN A P H A K I A
tend to be small and difficult to find, s-«-«." In addition, the breaks have been said to be
TABLE
in the superior
(yr.)
The present study re-emphasizes the small size of the retinal breaks. Ninety-two percent of
the aphakic cases with breaks showed
Phakia
Aphakia
nasal
quadrant."
1
AGE OF ONSET OF RETINAL DETACHMENT
most commonly at or near the ora,* as well as more frequently
113
0-39 40-59
6 0 & over
%
No. Cases
Series
18 46 75
13 33 54
No. Cases 59 148 78
% Series 20 52 27
small breaks, in contrast to 67 percent o f the phakic
cases.
Clear-cut
breaks
were
not
found in 23 ( 1 6 percent) of the aphakic
has found breaks that were no larger than the
cases, whereas in only 12 ( f o u r percent) of
caliber of a retinal vessel as it passes between
the phakic cases did the examiner fail to
the equator and the ora (fig. 2 - A and B ) .
detect a break. This is in sharp conflict with
I am sure that similar breaks have frequently
Schepens''^ figure of 2.5 percent o f aphakic
been missed. The technique of positioning
detachments without a break. The difference
the patient so that the head is in a dependent
must reside in the interpretation of the many
position, thereby shifting the subretinal fluid,
suspicious areas one sees at the ora serrata in
as emphasized by Pierce,''^ has been found
the aphakic eye.
helpful in confirming small superior breaks.
In this series binocular indirect ophthal
While there is no doubt that the breaks in
moscopy with scleral depression, direct oph
aphakic detachment
thalmoscopy and slitlamp examination with
to the ora, I was surprised to find that 60
frequently occur close
the three-way Goldmann lens were utilized,
percent of the aphakic cases had their most
but nothing was classified a break
unless
posterior break at or near the equator (table
consistendy identified and confirmed at sur
2 ) . This finding is similar to that o f W e l c h . ' "
gery. In many aphakic cases the examiner
Only 19 percent o f the aphakic cases had
Fig. 2 (Norton). ( A ) Small break near ora serrata is the same size as the caliber of a retinal vein. ( B ) One diathermy mark applied to break cured detachment, proving relationship between the break and the detachment.
E D W A R D W . D. N O R T O N
114
TABLE
2
LOCATION OF MOST POSTERIOR BREAK IN MM. FROM LIMBUS mm, or Less
10
%
No. Aphakic* ( 1 1 6 cases) Phakic* ( 2 7 3 cases)
11- - 1 5
mm.
16
%
No.
mm. or More
%
No.
24
21
70
60
22
19
33
12
141
52
99
36
* Excludes cases where no break found.
posterior to the equator, however,
nizing the disturbance of vision and that this
while 36 percent of the phakic cases had
would explain the greater extent of the de
breaks in this location (table 2 ) .
tachment. H o w e v e r , as is seen in Table 4,
breaks
A detailed study of the distribution of re
there was no difference
in the
estimated
tinal breaks is shown in Table 3. The usual
duration o f the detachment in the two groups,
frequency of breaks in the superior temporal
based on the history and findings at the time
quadrant occurs, as well as the usual distri
of the initial examination. These facts sug
bution in the other quadrants. There is no
gest that once the aphakic detachment be
evidence in this study of a preponderance of
comes symptomatic it is likely to spread much
superior nasal breaks in aphakic retinal de
more rapidly than the phakic
tachments.
The
detachment
extended
detachment.
across the
ora
serrata in 14 percent of the cases in each EXTENT
OF
DETACHMENT
group.
T h e aphakic detachments were more ex tensive at the time of initial examination, 54
STATUS
OF
VITREOUS
PREOPERATIVEI.V
percent having all four quadrants involved,
Except for changes in the vitreous face
while only 27 percent o f the phakic detach
which will be discussed later, there was sur
ments had all four quadrants involved. A s a
prisingly little difference between the aphakic
corollary to this finding, 18 percent of the
and phakic groups. Vitreous detachment was
aphakic detachments presented
recognized in 42 percent of each g r o u p ; vit
without in
volvement of the macula, while 32 percent
reous hemorrhage was noted in 25 percent
of the phakic detachments presented with the
of the aphakic group and in 31 percent o f the
macula in place. O n e might suspect that an
phakic group. Only six percent of each group
aphakic patient would be slower in recog-
showed
significant
settling
with
bilateral
patching. This figure is lower than usually TABLE
reported" and probably reflects the tendency
3
DISTRIBUTION OF RETINAL BREAKS EXCLUDING LATTICE
No.
quadrant
TABLE
Phakic
Aphakic
Superior temporal quadrant Superior nasal quadrant Inferior temporal quadrant Inferior nasal
of the author to operate early and give only
%*
4
ESTIMATED DURATION OF THE DETACHMENT Phakic
Aphakic 78
56
184
65
52
37
118
41
36
26
85
30
17
12
31
11
* > 1 0 0 % because of nudtiple breaks.
No.
%
No,
% 43
<2
wk.
59
44
116
> 2
wk. ) mo, /
39
29
90
33
< 2 > 2
mo.
36
27
66
24
115
R E T I N A L D E T A C H M E N T IN A P H A K I A
There were 109 primary* aphakic cases
TABLE 5
with a reattachment rate of 84.5 percent and
FINAL VISUAL ACUITY IN THOSE REATTACHED Aphakia
20/50 or better 20/70-20/100 20/200 or less
230 primary phakic cases with a reattach
Phakia
ment rate o f 91 percent. In 30 secondary^
No.
%
No.
%
52 32 34
44 27 27
134 57 61
54 23 24
aphakic cases the rate o f reattachment was 87 percent, a result not significantly different from that achieved in primary aphakic cases. H o w e v e r , in 55 secondary phakic cases the reattachment rate was 78 percent, a signifi
brief trials of preoperative patching. O f the aphakic cases, 45 percent showed
cantly poorer result ( P = 0 . 0 0 8 2 ) .
evidence o f vitreous traction, while similar
Visual results in those cases successfully
changes were seen in 38 percent of the pha
reattached are shown in Table 5. There was
kic group. T h e diagnosis of vitreous traction
little difference between the visual results in
is extremely unsatisfactory and may be diffi
the aphakic and phakic groups. Each showed
cult for even the most skilled examiner. In
approximately 50 percent with visual acuity
this series rolled edges of the breaks, stellate
of 2 0 / 5 0 or better and 25 percent with visual
folds, meridional folds, equatorial folds and
acuity o f 2 0 / 2 0 0 or less.
rigid retinal folds were taken as evidence o f
These
visual
results
are
significantly
poorer than those reported by Braley and
vitreous traction.
Ostler ;^ 84 percent o f their successful cases SURGICAL
RESULTS
In this consecutive series, including pri mary* and secondary^ cases, successful re attachment was achieved in 85 percent of the aphakic g r o u p and in 89 percent of the pha kic group. O f the aphakic cases, 71 percent were re attached
in one operation; 14 percent
re
quired a second operative procedure. Eightyone percent o f the phakic cases were reat tached in one operation. The remaining eight percent required a second or third operation before they were reattached.
had a visual acuity of 2 0 / 5 0 or better. H o w ever, in a larger series reported by H u g h e s , ' 80 percent of the patients had a postopera tive visual acuity o f 2 0 / 1 0 0 or better, in comparison with 75 percent in this series. This is not significantly difl^erent, especially when one considers the greater number of aphakic cases, and the higher percentage o f successful cases in this series. A l s o , H u g h e s ' series contained only primary cases. Table 6 shows a correlation between the preoperative and postoperative vision in all reattached cases. These results compare fa
* Primary defined as no previous detachment surgery. t Secondary defined as those cases that had under gone one or more previous detachment operations elsewhere.
vorably with the results reported by Hughes,' suggesting that the difference in the type o f surgery utilized in this series, to be discussed later, was not a responsible factor in the
TABLE 6 CORRELATION OF PREOPERATIVE AND POSTOPERATIVE VISUAL ACUITY IN ALL REATTACHED CASES Postoperative Vision Preoperative Vision
20/20-20/50 20/70-20/100 20/200 or less
No. Cases
103 44 213
20/50 or Better
20/70-20/100
20/200 or less
No.
%
No.
%
No.
%
89 25 65
87 57 31
12 12 64
12 27 30
2 7 84
2 16 39
116
E D W A R D W . D. N O R T O N
final visual acuity, if the retina was attached.
232 successful cases in which the macula was
In 30 percent o f the cases presenting with
recorded as detached preoperatively, only 88
acuity o f 2 0 / 2 0 0 or less and reattached, a
( 3 8 percent) had subsequent visual acuity
final acuity o f 2 0 / 5 0 or better was achieved,
of 2 0 / 5 0 or better. In 110 successful cases
a figure almost identical with that found by
in which the macula had not been detached,
Hughes.
92 ( 8 4 percent) had subsequent vision of FACTORS FINAL
2 0 / 5 0 or better. There was no significant
INFLUENCING
VISUAL
difference between the phakic and aphakic
ACUITY
groups. A.
EVIDENCE
OF
PREOPERATIVE
VITREOUS
TRACTION
C.
ESTIMATED DURATION
O f the 51 aphakic cases with recognizable vitreous
traction
reattached,
which were successfully
only 18 (35 percent)
attained
vision of 2 0 / 5 0 or better. In the phakic group of 88 cases with vit reous traction which were reattached, 31 (35 percent) attained vision o f 2 0 / 5 0 o r better. In the two groups there were 231 cases without
preoperative
evidence of vitreous
traction which were reattached; 137 (60 per cent) of these obtained a visual acuity of 2 0 / 5 0 or better. This difference in visual
OF
DETACHMENT
Table 7 shows the relationship between the estimated duration of detachment and final visual acuity in cases in which the macula was detached. It is to be emphasized that approximately one fifth of all the detach ments of over two months' duration, in which the macula was involved, attained a vision of 2 0 / 5 0 or better, if the retina was reat tached. The final visual acuity was not related to the location or the size of the retinal tear, if the retina was reattached.
results is not surprising since rigid retinal folds were used as evidence f o r vitreous
FACTORS
INFLUENCING
traction and these folds often involve the posterior polar area. Even when the retina is successfully replaced these folds tend to
OF
A.
VITREOUS
REATTACHMENT
RETINA
TRACTION
In both the aphakic and phakic groups
persist and reduce visual acuity.
those cases with evidence of vitreous traction B.
INVOLVEMENT
OF
T H E
MACULA
BY
had an 18 percent failure rate, in contrast to
DETACHMENT
a failure rate o f 13 percent in the aphakic
A s one would expect, when the macula has
and seven percent in the phakic groups with
been detached, the visual result is poorer. In
out evidence of vitreous traction.
TABLE
7
EFFFXT OF DURATION DETACHMENT ON FINAL VISUAL ACUITY Patients with 20/50 or Better Visual Acuity Duration Detachment
No. Cases* Aphakic
Aphakic
Phakic
Phakic
No.
%
No.
%
< 2 wk.
37
53
16
43
23
43
> 2 wk. "1 < 2 mo. /
25
55
16
64
24
45
> 2 mo.
26
41
4
IS
9
22
* Only cases with macula detached included.
R E T I N A L D E T A C H M E N T IN A P H A K I A
117
TABLE 8 RELATIONSHIP OF NUMBER OF BREAKS FOUND AND END-RESULT Reattachment Aphakia No. Cases
None 1-3 4 or more
B.
ΕΧΤΕ,ΝΤ OF
Phakia
Aphakia
No. of Breaks Found
% Series
23 94 19
No. Cases
% Series
12 200 72
16 57 14
DETACHMENT
E.
Phakia
No.
%
No.
%
4 70 25
20 79 16
87 84 84
8 179 64
67 90 89
LOCATION
OF
BREAKS
In the total series, 150 patients presented
Table 9 shows that, in both the aphakic
with all four quadrants detached; 36 ( 2 4
and phakic groups, breaks located 16 mm. or
percent) of these were failures. In contrast,
more from the limbus carried a more serious
there were 274 patients with detachment of
prognosis. It is interesting to note that in
three quadrants or less; 18 (seven percent)
phakic cases when the most posterior break
were failures. The incidence of total detach
was 11 to 15 mm. from the limbus a 97 per
ment was 34 percent in the aphakic group
cent rate of reattachment was attained. This
with 21 percent failures, 16 percent in the
is probably related to the relative technical
phakic group with 30 percent failures. Total
ease o f placing the break or breaks on a
detachment gives a poorer prognosis for re
buckle in this location.
attachment, more so in the phakic than in F.
the aphakic group.
GIANT
BREAKS
Giant breaks o f greater than one quadrant C.
D E T A C H M E N T OF T H E ORA
In
general,
detachments
SERRATA
that
carry a serious prognosis. There were 13
extended
such cases in this series, with eight reattach
across the ora serrata had a slightly poorer
ments ; only three o f these attained a visual
prognosis ( 8 0 percent success rate). This is
acuity of 2 0 / 1 0 0 or better.
probably related to the higher incidence o f total detachment
( 3 8 percent) and vitreous
G.
traction ( 6 0 percent) in this group.
SURGERY
FOR
BETTER
VISUALIZATION
OF
RETINA
There were not enough cases that required D.
INABILITY
TO F I N D RETINAL
BREAKS
surgery to study the retina better to pro
Table 8 shows that, in aphakia, out o f 23 cases in which the break could not be found, 20 were reattached. In contrast to this, fail ure to find breaks in the phakic eye, while less common, is a poorer prognostic sign.
vide significant data. H o w e v e r , it is my im pression that uncomplicated iridectomy in phakic eyes creates little additional problem in the management o f the retinal detachment. In contrast, lens extraction for better vis-
TABLE 9 PERCENTAGE OF SUCCESS RELATED TO DISTANCE OF POSTERIOR BREAK FROM LIMBUS 10 mm. or Less No. Cases Aphakia Phakia
21 28
% 87 85
11-15 mm. No. Cases 59 136
16 mm. or More % 85 97
No. Cases 17 80
% 77 81
118
E D W A R D
TABLE
W,
10
RATE OF FAILURE RELATED TO SURGICAL COMPLICATIONS Failures
Cases Complication No. Large choroidal detachments Hemorrhages, retinal, choroidal, or vitreous Vitreous loss at surgery Subsequent problems with synthetic im plant
Series
No.
%
43
10
12
28
35
8
10
28
19
4
4
21
21
5
4
19
ualization of the retinal detachment has fre quently been followed by massive .vitreous traction. A t the present time, if a retinal break can be found that adequately explains the detachment, surgery will be undertaken even though lens opacities preclude proper visualization of the entire fundus. H.
COMPLICATIONS
AT
SURGERY
A s one would expect, complications at surgery, or immediately postoperatively, adversely affected the percentage of reattach ment. Table 10 shows the percentage of failure with each complication. FACTORS
FAILING OF
TO INFLUENCE
RESULTS
SURGERY
There was no correlation between pre vious retinal detachment surgical failures and the results obtained in the second eye. O f 32 cases that had unsuccessful detach ment surgery in one eye, 30 had a successful operation in the second eye. One generally associates poor prognosis with evidence of vitreous hemorrhage. In this series 29 percent of all the cases presented with evidence of vitreous hemorrhage, usually of a mild degree; 89 percent of these were reattached, thus vitreous hemorrhage did not prove to be a sign of poor prognosis. Active uveitis ( m o r e than the few cells and flare that are usually seen in retinal detachment) occurred in 23 cases in this
D.
N O R T O N
series; 87 percent of these were successfully reattached. A family history of retinal detachment was obtained in 13 cases, only two of which were failures. Table 8 shows that the presence of multiple breaks had little prognostic value ; 51 percent of the cases in this series had more than one break. There was no relationship between asso ciated glaucoma or immature cataracts and the rate o f reattachment. SPECIAL
FEATURES
OF
APHAKIC
GROUP
It is said that a retinal detachment occur ring in the first few months after cataract surgery has a poorer prognosis than those occurring later.'* In 119 cases of this series, the time between cataract surgery and the onset of the retinal detachment was recorded. Table 11 shows the relationship o f time of onset of the retinal detachment after cataract surgery and the percentage of successful re attachment ; there is no significant diiference between detachments that occurred early and those that occurred late. There was no significant difference in the rate of reattachment between the cases which had had an intracapsular lens extraction and those which had had an extracapsular lens extraction (table 13) ; between the cases with an intact vitreous face and those in which vitreous was known to be lost at the time of surgery, or in which examination showed rupture o f the vitreous face a n d / o r vitreous adherent to the corneal wound. It
TABLE
11
TIME RELATIONSHIP BETWEEN CATARACT SURGERY AND ONSET OF DETACHMENT AS IT AFFECTS REATTACHMENT Time Detachment Postcataract <1 1-3 4-6 > 6
mo. mo. mo. mo.
Reattached No. of Cases
%
11
82
27
85
7
86
74
89
R E T I N A L D E T A C H M E N T IN A P H A K I A
119
T A B L E 12
T A B L E 13
RELATIONSHIP TYPE OF CATARACT SURGERY AND STATUS VITREOUS FACE TO REATTACHMENT
NUMBER CASES WITH SCLERAL SYNTHETIC IMPLANT Phakia
Aphakia Reattached No. Cases Intracapsular extraction intracapsular extraction Vitreous face intact Vitreous loss known Vitreous face ruptured Vitreous adherent to corneal wound Round pupil Full iridectomy
%
120 19 65
86 86 85
76
85
92 47
88 79
None Segmental implant 360° implant
No.
% Series
No.
14 16 108
10 12 78
37 66 182
Series 13 23 64
by Schepens, et al.,'^--" have, with minor modifications, been followed in this series. I tend to d o fewer resections (undermining) when the breaks are confined to a small area.
should be emphasized that this does not say
It can be seen from Table 14 that the re
that retinal detachment is more or less com
sections in the aphakic cases are more ex
mon when these changes in the vitreous o c
tensive than those in the phakic cases. The
c u r ; this has not been studied. H o w e v e r , it
extensive resection, combined with an encir
does say that, when these changes in the
cling element, was used to create a new ora
vitreous face are present with a retinal de
which would serve as a barrier against missed
tachment, they in themselves d o not appear
breaks. I believe that this method contributed
to influence adversely the chances for re
substantially to the success rate in the more
attachment.
difficult aphakic detachment cases (tables 15
The advocates of full iridectomy in cata
and 1 6 ) .
ract surgery have taught that, if a retinal
Figure 3-A and Β demonstrates the value
detachment occurs, the prognosis is poorer
of
in the presence of a round pupil than in the
band in aphakic cases. The operat'on was
presence of a fviU iridectomy.'^ T h e material
directed at closing three small breaks on the
in this series (table 12) fails to support this
equator. A buckle was placed beneath these
extensive resection with an
encircling
claim. I believe this is due to the ease o f ex
breaks and extended to the limits o f the de
amining the periphery of aphakic eyes with
tachment. Postoperatively the retina detached
the indirect ophthalmoscope and scleral de
anterior to the buckle. N o additional breaks
pression even in the presence of a relatively
have been found on repeated examinations,
small pupil. It should be noted that in 50 per
although one must certainly exist. The exten
cent of the cases in which the examiner was
sive buckle served to protect the posterior
unable to find a definite break a full iridec
retina and the patient continues to have good
tomy had been performed.
visual function several years postoperatively.
SURGICAL TECHNIQUE
The surgical technique used in this series varied according to the preoperative ap pearance of the detachment but, by and large, scleral buckling operations were per formed using synthetic implants o f poly ethylene silicone or polyviol. T h e implants were made wide enough to cover the breaks and usually included an encircling compo nent (table 1 3 ) . These techniques, reported
T o close all breaks should always be the T A B L E 14 CASES WITH SCLERAL RESECTION (UNDERMINING) Aphakia
None <180° >180°
No. Cases
% Series
53 27 58
38 19 42
Phakia No. Cases 178 63 44
% Series 63 22 15
E D W A R D W . D. N O R T O N
120
T A B L E 15 RELATIONSHIP OF EXTENT OF RESECTION (UNDERMINING) TO REATTACHMENT Phakia
Aphakia
Reattached
Reattached No. Cases
%
No. No resection <90'' 90°-180° >180°
53 2 25 58
91 100 88 78
48 2 22 45
No. Cases
%
No.
89 100 91 82
158 6 52 36
178 6 57 44
T A B L E 16 RELATIONSHIP OF EXTENT SYNTHETIC IMPLANT TO REATTACHMENT Phakia
Aphakia
Reattached
Reattached No. Cases
None Se.gmental implant 360° implant
14 16 108
O
No.
%
13 14 90
93 88 83
No. Cases 37 66 182
No.
%
34 61 157
92 93 86
o
Fig. 3 (Norton). ( A ) Preoperative condition. ( B ) Postoperative condition (see text).
R E T I N A L D E T A C H M E N T IN A P H A K I A
object o f the surgeon; to wall off breaks is a useful compromise when the main objective cannot be achieved. POSTOPERATIVE
CARE
Early ambulation was practiced, with the majority o f patients getting up the first post operative day and being discharged about the seventh postoperative day. O f the pa tients in this series, 70 percent spent less than two weeks in the hospital pre- and post operatively combined; 91 percent less than three weeks. COM.MENTS
The technique for collecting data for this study is unique in my medical experience. The principle of recording basic data before the final results are known would appear sound in any statistical study. H o w e v e r , to date, most similar studies have been based upon retrospective analysis of hospital rec ords and have the inherent weakness o f retrospective bias. T h e data in this series were collected progressively and once re corded were no longer subject to the emo tional bias of future events. It is to be hoped that this technique will have considerable growth in the years ahead, with the advent o f more medical computer centers. The data when compared with previous reports show that marked strides have been made in the past decade in the surgical reat tachment o f the retina, particularly in apha kic cases. In fact, the rate o f success with aphakic detachment is approaching that at tained in phakic cases and fails to support Arruga's statement" "aphakia also reduces by approximately one-third the percentages of cures indicated." I believe that these ad vances are due in part to the re-introduction of the binocular indirect ophthalmoscope by Schepens which enables a better examination of the retina; to the use of scleral resection, as described by Lindner and modified by Shapland,-" which provides consistent dia thermy to the choroid; and to the implanta
121
tion o f synthetic material in the sclera to form a buckle, as introduced by Custodis'* and modified by Schepens,-" which effects apposition o f the treated choroid and pig ment epithelium to the retinal defects. T h e significance o f the extent o f the retinal detachment was emphasized by the striking difference in results between those cases with four quadrants involved and those with three quadrants or less. O f those cases in which three quadrants or less were involved, 93 percent were successfully reattached, in con trast to 76 percent when the detachment was more extensive. T h i s probably reflects the greater incidence o f vitreous traction in total detachments, 64 percent in contrast to 27 percent when three quadrants or less were involved. The difiiculty in successfully reattaching the retina when definite retinal breaks have not been found is generally acknowledged. However, this series points out a striking difference in this respect between phakic and aphakic cases. Despite not finding definite breaks, one can still get good results in aphakic detachments by extensive surgery that walls off the ora. In the phakic cases, however, in which a hole is not found, the results are considerably poorer. It is generally accepted that primary cases have a better prognosis than secondary cases. This was found to be true when all the sur gery was done by the same surgeon. H o w ever, when the initial surgery was performed by surgeons with a wide variation in their detachment experience, this held true only for the phakic group. T h e results with sec ondary aphakic cases were essentially the same as the results achieved in the primary aphakic cases. It is my opinion that the rea son for the significant difference in results in primary versus secondary phakic cases rests in factors other than localization of retinal breaks. In these cases the breaks were often found and treated by the origi nal surgeon; other factors caused the failure. In contrast, the aphakic cases treated else-
122
E D W A R D \ \ ' . D, N O R T O N
where usually presented with breaks un touched at the original surgery (reflecting the difficulty in finding breaks in aphakia) and, therefore, were to a certain extent "pri mary" cases. If this is true, the similarity of results between primary and secondary cases in aphakia is not too surprising.
vitreous face and a loss of vitreous at the time o f cataract surgery were poor prognos tic signs when they were followed by a ret inal detachment. In this series, the cases with an intact vitreous face had the same success rate as those in which the vitreous face was ruptured.
While satisfaction can be gained from the improvement in our present ability to reat tach the retina, we are still often faced with the serious problem of poor postoperative visual acuity. While the surgeon is content with a reattachment and preservation of field of vision, the patient is unhappy with the poor visual acuity. There is no evidence that the use o f a buckling procedure gives poorer visual results than diathermy.
Second, it has been held that aphakic de tachments occurring up to six months after cataract extraction have a poorer prognosis than those occurring later. N o significant flifference in results was noted between these two groups in this series.
The data presented here confirm the view that poor vision postoperatively is related to the presence and duration of macula detach ment preoperatively. The influence of pre operative vitreous traction on the final visual acuity has not been emphasized in the litera ture. The data obtained in this study show that, if vitreous traction (as defined) is rec ognized preoperatively, the chances of the patient attaining visual acuity of 2 0 / 5 0 or better if successfully reattached are about 35 percent. This is not surprising since these patients frequently have folds involving the macular area which tend to persist after re attachment. The disconcerting thing about these three factors associated with p o o r visual acuity is that, at the present time, none are under the control of the surgeon and, therefore, significant improvement in the visual results in detachment surgery cannot be anticipated by variation of present techniques. It is not surprising, when one considers this observa tion, that the photocoagulator has aroused interest in the prophylactic treatment o f retinal disease.-° Unfortunately, it will take many years and controlled studies to evalu ate the results. In studying the aphakic cases in this series three attitudes that are generally held do not find support: First, it has been held that rupture of the
Third, full iridectomy at the time of cata ract surgery has been held to be an ad vantage if the retina should subsequently become detached. While it is accepted that a full iridectomy facilitates visualization of the upper half of the fundus, the data from this series lead one to question that it in creases the success o f retinal surgery (table 12). If other studies confirm these findings, the recent editorial by Brockhurst** stating, "therefore, any patient who has had, or w h o may have, a retinal detachment and w h o is to have a cataract extraction should have a full iridectomy" will need to be re-evaluated. Obviously, an undilatable pupil is an indica tion for a full iridectomy at the time of cata ract extraction but, if the pupil can be read ily dilated, I do not believe a full iridectomy is mandatory. Since the great majority of patients in this series were ambulated on the first or second postoperative day and more recently only monocularly patched, I believe that the long time custom of routine prolonged bedrest postoperatively for retinal detachment pa tients should be abandoned. O u r findings would confirm the suggestion o f Jervey^" that, for the most part, retinal detachments are cured in the operating room, and are rarely influenced by the postoperative man agement of the patient. SUMMARY
1. A series of 424 consecutive cases o f retinal detachment has been studied with
123
RETINAL DETACHMENT IN APHAKIA
special emphasis on the difference between aphakic and phakic detachments. A n o b jective and progressive technique for collec tion o f data was utilized. 2. Eighty-five percent o f 139 aphakic cases and 89 percent of 285 phakic cases were successfully reattached. O f 109 primary aphakic cases, 84.5 percent, and, o f 230 pri mary phakic cases, 91 percent were success fully reattached. Eighty-seven percent of 30 secondary aphakic cases and 78 percent of 55 secondary phakic cases were successfully reattached. 3. W h i l e many aphakic breaks are found close to the ora, 60 percent of this series had their most posterior break in the area of the equator. 4. There was no particular difference in the quadrantic distribution of the breaks in the aphakic and phakic groups. 5. Aphakic detachments were more exten sive and more frequently involved the macu lar area than the phakic group. 6. Preoperatively, the aphakic group showed only slightly more evidence o f vitre ous traction than the phakic group. 7. The final visual acuity results were ap proximately the same in the two groups: 50 percent with an acuity o f 2 0 / 5 0 or better, 25 percent with visual acuity of 2 0 / 2 0 0 or less. 8. The final visual acuity was related to vitreous traction, involvement o f the macula, and the duration o f the detachment, in both groups.
9. A higher rate o f failure was noted in cases where the retina had shown fixed folds preoperatively, when the retina was totally detached, and when there were posteriorly located breaks or giant breaks. 10. The failure to find a retinal break in aphakic cases did not seriously influence the final results, whereas it was a poor prog nostic sign in phakic detachments. 11. Failure o f previous detachment sur gery in the fellow eye, vitreous hemorrhage, active uveitis, family history and multiple breaks did not adversely affect the surgical results in either group. 12. T h e final surgical results were not influenced by whether the detachment o c curred early o r late after cataract surgery, the type of extraction used (intra- or extra capsular), or defects in the vitreous face. 13. T h e success o f detachment surgery was unrelated to the presence o f a full iri dectomy or a round pupil. 14. In aphakic cases I tend to carry out more extensive scleral resections (undermin ing) with 360-degree circling foreign-body implants ; the improved results in aphakic de tachments are attributed to these factors. 15. With the surgical techniques currently utilized, early ambulation with monocular patching is an acceptable postoperative man agement.
1638 N.W.
Tenth Avenue
(36).
REFERENCES
1. Gonin, J.: The treatment of detached retina by searing the retinal tears. Arch. Ophth., 4:621, 1930. 2. Bagley, C. H . : Retinal detachment; Survey of etiology and results of treatment on phakics and aphakics. Am. J. Ophth., 31:285-298, 1948. 3. Dunnington, I. H . : What is the prognosis on retinal detachments? In: Symposium on retinal de tachments. Am. I. Oplith., 25:1247, 1942. 4. Shapland, C. D . : Retinal detachment in aphakia. Tr. Ophth. Soc. U. Kingdom, 54:176-196, 1934. 5. Braley, A. E., and Ostler, H. B.: Statistics on 100 cases of retinal detachment surgerv. J. Iowa M. Soc, 45:473-476, 1955. 6. Schepens, C. L.: Retinal detachment and aphakia, A M A Arch, Ophth,, 45:1-17, 1951. 7. Hughes, W . F., Jr.: Evaluation of results of retinal detachment surgery, Tr, Am, Acad, Ophth,, 56:439-448, 1952. 8. Colyear, B, H., and Pischel, D, K , : Causes of failure in retinal detachment surgery. A M A Arch. Ophth., 56:274-281, 1956, 9. Taubitz, VV,: Report on 206 operations for retinal detachment. Klin. Monatsbl. Augenh., 128:473479, 1956. 10. Sedan, J,, and Farnarier, G.: Our assessment of scleral resection in aphakic retinal detachments. Ann. ocul., 193 :721-732, 1960,
124
E D W A R D W . D. N O R T O N
11. Lister, A . : Detachment of the retina. Practitioner, 178 :540-551, 1957. 12. Schapens, C. L., and Marden, D . : Data on the natural history of retinal detachment. A M A Arch. Ophth., 66:631-642, 1961. 13. Hudson. J.: Late complications of aphakia. Tr. Ophth. Soc. U. Kingdom, 81:75-83, 1961. 14. Schepens, C. L . : Personal communication. 15. Pierce, H . : Personal communication. 16. Maumenee, A. E . : Retinal detachment. In Symposium postoperative cataract complications. T r Am. Acad. Ophth., 57 :62, 1957. 17. Arruga, Η . : Ocular Surgery. New York, McGraw-Hill, 1956, ed. 2, p. 604. 18. Pischel, D. K., and Pierce, H . : Importance of vitreous body in retina surgery with .'special cmpliasis on reoperations. St. Louis, Mosbv, 1960, pp. 151-152, 159. 19. Brockhurst, R. J.: Editorial. A M A Arch. Ophth., 69:1-2, 1963. 20. Schepens, C. L . : Scleral buckling procedures. In Svmposium scleral resection procedures. Tr. Am. Acad. Ophth., 56 :206-218, 1958. 21. Schepens, C. L., Okamura, I. D., Brockhurst, R. J., and Regan, C. D . : The scleral buckling prr)cedures: V. Synthetic sutures and silicone implants. A M A Arch. Ophth., 64:868-881, 1960. 22. Arruga, Η . : Ocular Surgcrv. New York, McGraw-Hill, 1962, cd. 3, p. 686. 23. Shapland, C. D . : Scleral resection. Proc. Roy. Soc. Med., 44:413-422, 1951. 24. Custodis, E.: Is the suturing of scleral implantations an advance in the surgery of retinal detach ment? Ber. Itscli. Ophthal. Ges. Heidelberg, 58:102-105, 1953. 25. Heinzen, Η . : Die Prophylaktische Behandlung der Neízhaufahlosung. Ferdinand Enke \'erlag, Stuttgart, 1960. 26. Jervey, J. W . : Postoperative care of major eye surgery. Southern M. T., 45:139-141, 1952.
OPHTHALMIC
MINIATURE
One rather unusual thing occurred in connection with the use of eserine in this case. A violent conjunctivitis followed its constant use several times daily, the lids became swollen, and
there was present the most profuse
lachrymation. These symptoms, which are eserine
conjunctivitis,
those of what I should call
disappeared entirely when I stopped using the drug.
T h e disease no doubt resembles in its history what is known as atropine conjunctivitis. I have never seen any mention made in the books of this effect of eserine. Robert L. Randolph
(Baltimore),
" H e m o r r h a g i c glaucoma with an analysis o f three cases," T r . Ophth. Section A . M . A . , 1891, p. 264.
W .
D.
APHAKIA*
NORTON,
M.D.
Miami, Florida
O n e o f the most serious sequelae to cata
1955, to December, 1960, have been studied.
ract surgery is the development o f a retinal
All patients had a minimum o f a six-month
detachment. Prior to Gonin's* treatment of
follow-up after their last surgical procedure.
the retinal tear, this complication resulted in
Six additional patients w h o did not have a
the total loss of useful vision in the involved
six-month
eye. Even after the dramatic results reported
from
follow-up
have
been excluded
the series, despite the fact that the
by Gonin and other workers, however, the
retinas were attached
results of treatment o f retinal detachment in
patients whose retinas were detached when
when last seen. All
aphakia remained disappointing. Throughout
last seen have been included as failures. T h e
the literature, the best results reported in
424 eyes underwent 495 operations. In this
unselected series range from
18 to 59 per-
cent^-*" successful reattachment of the retina
series, 139 eyes were aphakic, an incidence of 33 percent.
in aphakia, in contrast to reports of success
In an effort to be objective, the data on
rates of 50 to 8 0 + percent*''* in phakic eyes.
each case were catalogued at the time o f hos
T h e purpose o f this paper is: ( 1 ) to e x
pitalization on a chart
(fig. 1) for subse
plore some o f the differences between apha
quent I B M analysis. T h e appropriate data
kic and phakic retinal detachments; ( 2 ) to
were entered on these charts at the time o f
try to account for the discrepancy in surgi
the initial examination,
cal results;
( 3 ) to see if this discrepancy
at the time o f discharge from the hospital
still persists despite the recent advances in
and at a period o f more than six months
retinal detachment surgery.
following
T h e actual incidence o f retinal detachment
the
following
surgery. It
surgery,
is believed that
such a progressive record tends to reduce
in aphakia is unknown because of the diffi
the
culty in getting long-term follow-up studies,
tive study. Data that are difficult to evaluate,
but it has been estimated to be one to three
such as vitreous traction, were recorded be
inherent
bias o f
the usual
retrospec
percent*'" o f all cataract extractions. T h e
fore the surgeon knew the outcome o f the
incidence
case. While each surgeon would vary
of
aphakic
detachment
series of retinal detachments
in
ranges
seven to 25 percent."'" T h e higher
any from
figures
to be an extremely helpful one and is recom
undoubtedly represent the tendency of the
mended
ophthalmologist to refer aphakic detachments
records.
for much greater
to "retinal centers." This review does not attempt to study the incidence, of retinal de tachment in cataract extraction and accepts the figures previously published. MATERIAL
A N D
the
f o r m of the chart, the technique was found
ANALYSIS AGE
OF
OF
use in medical
DATA
ONSET
In phakic eyes the highest incidence of detachment occurred in the 40-59 year age group, whereas the aphakic eyes showed the
METHOD
Four hundred and twenty-four eyes with retinal detachment, operated upon consecu tively o n my private service from January, * From llic liascoiii Palmer Kye [nstitiite, Deparmient of Opiiflialmology, Univer.sity of Miami School of Medicine. This paper was submitted for membership in the American Ophthalmological Society. 111
highest incidence in the 60 and over age group (table 1 ) . This age distribution is con sistent with other studies.^' SIZE,
LOCATION
A N D
NUMBER
OF
RETINAL
BREAKS
Several authors have emphasized that the retinal breaks in aphakic retinal detachment
E D W A R D W . D. N O R T O N
112
CODE SHEEÍ fOR RETINAL OErACHMENT STUDY -YEAB OPEfcATED-
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Moto
linMON (CW. II
4 a
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1
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7
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BEST VISION » E - O P SAME (Cel. 14) 0 10ΜΜΟΊΟ J »/«ϊβ» 3 4 s
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3
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4 5 » 7 t «
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0
9
0
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TENSION 1. SAME tCol II) 0 - i 0 m « . Hb 1 10-1S I IMS
0 None 1 -90· 3 90-ΙβΟ· 3 180770* 4 360* 5 Míridionol 6 Cult HEIGHT BUCKLE (Col.él)
1 1
0 lo» 1 AAedium I Hijh
« DATS AlSOlUn ICO REST
CLINICAL IMP-
WITH PATCHES P t i - O P (Cel J * l
INTfNSITT DIATHERMY (Col. « )
0
0
Rdioal tchiih
Λ
ADO. EVE FINDINOS SAME (C«« [Col. M) 1 RolFolMI. f b
3 Oth.. ADO EVE FINDINOS OFHER ICol. 34] 0 Normal If*. 1 N u d » r lot. 1 Corlicol « I 3 Pe.i. wbiop cel. 4 Subl»>. 0· diil«. I » . t Cry.tel, bodr ot o'o β A . » t Bio»»"» 7 A.»( ™ t i . - e t l i « ) »oiaidBl d*>och 9 R.li'il
SEnlINO OH itO BEST CoLiri
0 M5% 1 23-30% 3 30-73% 3 73-n% 3
0
lieM
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3 OlW
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D I A T H E M Y MACHINE (Col.*4)
0
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M A C U l * STATUS (( I 3»)
1
Drr.nllrir a
7
O-fhor,!-, feU
« 4DEFINITE MaculoU Ehel* A K S (Col M) 0 None 5 2
Pig. » degen
3
3
« SUSPICIOUS BREAKS (Col. 41)
S
S O' mer*
TYPE DEFINITE BREAK t-11 ICol. 41) • Hel* •ilhout operculum 1 Hel* »ilh opeiculum 5 H = . . . , h „ - i , h flot Hep
DRAItlAOl nun MTU (Col U)
B I S K T I O N (Col. 1«) 0 Mo>H 1 Foil thitkeeu 3 Loowllor - 9 0 * 1 tcirMitar 90-1 Μ ' 4 lamellar 1Μ)-ΐ70* 5 lemello. + 3 7 0 · - l e 6 tomolU»3«-
Í 6 7
Diolyiii 3 qiKidtont. Dioly.:. 'r 3 quodrooti Ijitic*
4 } 6
Dialyti. 1 qMOdront Dioly.-! 3 qiiadtaiiti Dioly«! + 3 q>
0 1 Ϊ 3 4 3 6 7
Hoi* -ilheel oporculeKi Hole will, epercolyoi Her>..h«o « Μ «αΙ Bop Ho'Htko. « Μ Itop DIolyii. 1 qeodroni Dioly.>i 3 quodtoirit Diolyiii + 1 qeodfont. lolllce
SIIE I A R O E » BRCAK IM 41} 0 Smell lo e.«roge
C O I F U A l HNimVIIV Β POST-Of # DAYS PATCHED O.U. POiT-OP (Col. 671
4 13-13 3 16-11 6 IB c » . · DAYS ΡΟΐΙ.ΘΝ PH GLASSES O.C.
(Col. M ) 0 1 3 3
Nono * » d 1 monifc 3 »o-*. 3 moottn or longer
9
Honorrfiovo. lil.
COMPLICATIONS (Com I (Col. 731 0 Mot υ Id (hofieoi ? W.V η in 3 MuuleproWo4 Noeriiii, C I . V . 3 Oplicotroplni 6 Phtl.)Hb«lbi 7 Tubo »iTvdocl k r. Β Tobo JnfocriM 9 UyeW«. t o w o
0
AbMHt
COKNEAl S W t l T I V I T Y NOT TUT»
STATUS EYE I X A M * MOMTMI 0 « M O I I Ρ Ο Π · Ο Ρ (CoL 7*1 0 lotina nt»idi»d
0 1 3 3 4
3-7
1-10
3O/IJ-3OÍ30 30/40-10/30 30/70-20/100 20/100 -20/300
vmON Τ T l A l POST-OP (Cot. 7·)
t1-lt 14-1f 19« +30
0 1 3 3 4
H O » . ( C J . 71)
0 M4 1 )M1 1 33-3« 3 39-40 4 +40
POIT-OP (COL τη 0 Mo>*Ml
COMPLICATIONS (CoL 71) « DAYS U D POST-OP ( C I . U )
ροπ·ορ
0 OJ
3 3
Normal
•
7 0¡n>¡KiM
Otbof w - p B c o W o w
# DAYS MMP. POfT-OP (Cot 70) D 1 I 3 4 5
6
COMPtlCATlONf ¡C*m».i [CoL 74}
0 1 t 3 J 3 3 4-7 4 >M«oro
rOTAl « M Y »
Monrt>M3
m-or raooMOSis (COLM) 0 '10% ) »0-30% 1 I I 40% 1 4140% 4 AI .00% 3 (190% # DATS P A T C W i . US i m WITH W . P«-OP(ColM) 0 D
h i i . i o ' t,-np
Fon pleno t r ' "
g DAYS HOIP. PIE-OP (Col. 1*1
TYPE DIATHERMY (Col. SI
4
h».
EVE flNOtmS SAME (Col. 13) N o ™ l l.n. N u c I « . col. Coiliiol to). Poll. u b o p . <«.
BUCKLE (TUBE) (Cot. U )
# D A V l PATCHES-UP AD II
Hoi* -
4 3 6 7
TYP« DEFINITE U E A K 11-1 (Cet 44) 0 Hoi.-irhoutopercJem
1
0
I
1
DiKioien .1 Diui>.ion ,1 o' mo>e Iridectomy Pupil poriiolly « ( .
ICol IS)
3 2åiO
lOCATFON MOST POST. U E A K (ROM I I M H H (Cot. 4*) 0 «mm. 1 I » . 3 10 3 11
TVPI KFINirt U E A K 11-11 ( C I 431 0 Hole wittie». operc»l.n
yiniotitOTMfi (CoJ-ii)
ADO 0 1 1 3
4 Dioly.» 1 <|uad>oM 5 Dioly». } q . « l c . n l , A Dwlrii. + l q - » d t e n t . 7 leltk*
BEST VISION riE-Of OTHER
• E F U C T I V f N I O * (Co). M )
# iniNA OF DONE IT OTHWS SAME ITE (C«l J l ) O O
Other
1 V i t t « « . <|.ι«λ3 CoorM K b « . 3 Fluid TitTHM.
5 for. ptsno tritt
# RETINA OV. OOMi I T US SAME ETi 1C*I. M) O 1
J
F APHAKIC (Cel. M)
vmfOUS SAME (Col M ) FAMILY KISI. DHACH (C«l. 31) 0 Non* 1 Poiinli 3 Sibling. 3 Otii-.
Λ MMXlrtH
3
leWSIOH 5. Ο Τ Κ β (Co*. » I 0 -10 Hb 1 10-15 3 le-IS 3 ΙβΐΟ
Ko'ool
Oo«.colaM«cd
Fig. 1 (Norton). Code sheet for retinal detachment study.
20/13-30/30 30/40-30/30 20/7frlO/100 30/300 -20/300
nATUS EVt E X A M I PON-OP(CoLn)
TfU
R E T I N A L D E T A C H M E N T IN A P H A K I A
tend to be small and difficult to find, s-«-«." In addition, the breaks have been said to be
TABLE
in the superior
(yr.)
The present study re-emphasizes the small size of the retinal breaks. Ninety-two percent of
the aphakic cases with breaks showed
Phakia
Aphakia
nasal
quadrant."
1
AGE OF ONSET OF RETINAL DETACHMENT
most commonly at or near the ora,* as well as more frequently
113
0-39 40-59
6 0 & over
%
No. Cases
Series
18 46 75
13 33 54
No. Cases 59 148 78
% Series 20 52 27
small breaks, in contrast to 67 percent o f the phakic
cases.
Clear-cut
breaks
were
not
found in 23 ( 1 6 percent) of the aphakic
has found breaks that were no larger than the
cases, whereas in only 12 ( f o u r percent) of
caliber of a retinal vessel as it passes between
the phakic cases did the examiner fail to
the equator and the ora (fig. 2 - A and B ) .
detect a break. This is in sharp conflict with
I am sure that similar breaks have frequently
Schepens''^ figure of 2.5 percent o f aphakic
been missed. The technique of positioning
detachments without a break. The difference
the patient so that the head is in a dependent
must reside in the interpretation of the many
position, thereby shifting the subretinal fluid,
suspicious areas one sees at the ora serrata in
as emphasized by Pierce,''^ has been found
the aphakic eye.
helpful in confirming small superior breaks.
In this series binocular indirect ophthal
While there is no doubt that the breaks in
moscopy with scleral depression, direct oph
aphakic detachment
thalmoscopy and slitlamp examination with
to the ora, I was surprised to find that 60
frequently occur close
the three-way Goldmann lens were utilized,
percent of the aphakic cases had their most
but nothing was classified a break
unless
posterior break at or near the equator (table
consistendy identified and confirmed at sur
2 ) . This finding is similar to that o f W e l c h . ' "
gery. In many aphakic cases the examiner
Only 19 percent o f the aphakic cases had
Fig. 2 (Norton). ( A ) Small break near ora serrata is the same size as the caliber of a retinal vein. ( B ) One diathermy mark applied to break cured detachment, proving relationship between the break and the detachment.
E D W A R D W . D. N O R T O N
114
TABLE
2
LOCATION OF MOST POSTERIOR BREAK IN MM. FROM LIMBUS mm, or Less
10
%
No. Aphakic* ( 1 1 6 cases) Phakic* ( 2 7 3 cases)
11- - 1 5
mm.
16
%
No.
mm. or More
%
No.
24
21
70
60
22
19
33
12
141
52
99
36
* Excludes cases where no break found.
posterior to the equator, however,
nizing the disturbance of vision and that this
while 36 percent of the phakic cases had
would explain the greater extent of the de
breaks in this location (table 2 ) .
tachment. H o w e v e r , as is seen in Table 4,
breaks
A detailed study of the distribution of re
there was no difference
in the
estimated
tinal breaks is shown in Table 3. The usual
duration o f the detachment in the two groups,
frequency of breaks in the superior temporal
based on the history and findings at the time
quadrant occurs, as well as the usual distri
of the initial examination. These facts sug
bution in the other quadrants. There is no
gest that once the aphakic detachment be
evidence in this study of a preponderance of
comes symptomatic it is likely to spread much
superior nasal breaks in aphakic retinal de
more rapidly than the phakic
tachments.
The
detachment
extended
detachment.
across the
ora
serrata in 14 percent of the cases in each EXTENT
OF
DETACHMENT
group.
T h e aphakic detachments were more ex tensive at the time of initial examination, 54
STATUS
OF
VITREOUS
PREOPERATIVEI.V
percent having all four quadrants involved,
Except for changes in the vitreous face
while only 27 percent o f the phakic detach
which will be discussed later, there was sur
ments had all four quadrants involved. A s a
prisingly little difference between the aphakic
corollary to this finding, 18 percent of the
and phakic groups. Vitreous detachment was
aphakic detachments presented
recognized in 42 percent of each g r o u p ; vit
without in
volvement of the macula, while 32 percent
reous hemorrhage was noted in 25 percent
of the phakic detachments presented with the
of the aphakic group and in 31 percent o f the
macula in place. O n e might suspect that an
phakic group. Only six percent of each group
aphakic patient would be slower in recog-
showed
significant
settling
with
bilateral
patching. This figure is lower than usually TABLE
reported" and probably reflects the tendency
3
DISTRIBUTION OF RETINAL BREAKS EXCLUDING LATTICE
No.
quadrant
TABLE
Phakic
Aphakic
Superior temporal quadrant Superior nasal quadrant Inferior temporal quadrant Inferior nasal
of the author to operate early and give only
%*
4
ESTIMATED DURATION OF THE DETACHMENT Phakic
Aphakic 78
56
184
65
52
37
118
41
36
26
85
30
17
12
31
11
* > 1 0 0 % because of nudtiple breaks.
No.
%
No,
% 43
<2
wk.
59
44
116
> 2
wk. ) mo, /
39
29
90
33
< 2 > 2
mo.
36
27
66
24
115
R E T I N A L D E T A C H M E N T IN A P H A K I A
There were 109 primary* aphakic cases
TABLE 5
with a reattachment rate of 84.5 percent and
FINAL VISUAL ACUITY IN THOSE REATTACHED Aphakia
20/50 or better 20/70-20/100 20/200 or less
230 primary phakic cases with a reattach
Phakia
ment rate o f 91 percent. In 30 secondary^
No.
%
No.
%
52 32 34
44 27 27
134 57 61
54 23 24
aphakic cases the rate o f reattachment was 87 percent, a result not significantly different from that achieved in primary aphakic cases. H o w e v e r , in 55 secondary phakic cases the reattachment rate was 78 percent, a signifi
brief trials of preoperative patching. O f the aphakic cases, 45 percent showed
cantly poorer result ( P = 0 . 0 0 8 2 ) .
evidence o f vitreous traction, while similar
Visual results in those cases successfully
changes were seen in 38 percent of the pha
reattached are shown in Table 5. There was
kic group. T h e diagnosis of vitreous traction
little difference between the visual results in
is extremely unsatisfactory and may be diffi
the aphakic and phakic groups. Each showed
cult for even the most skilled examiner. In
approximately 50 percent with visual acuity
this series rolled edges of the breaks, stellate
of 2 0 / 5 0 or better and 25 percent with visual
folds, meridional folds, equatorial folds and
acuity o f 2 0 / 2 0 0 or less.
rigid retinal folds were taken as evidence o f
These
visual
results
are
significantly
poorer than those reported by Braley and
vitreous traction.
Ostler ;^ 84 percent o f their successful cases SURGICAL
RESULTS
In this consecutive series, including pri mary* and secondary^ cases, successful re attachment was achieved in 85 percent of the aphakic g r o u p and in 89 percent of the pha kic group. O f the aphakic cases, 71 percent were re attached
in one operation; 14 percent
re
quired a second operative procedure. Eightyone percent o f the phakic cases were reat tached in one operation. The remaining eight percent required a second or third operation before they were reattached.
had a visual acuity of 2 0 / 5 0 or better. H o w ever, in a larger series reported by H u g h e s , ' 80 percent of the patients had a postopera tive visual acuity o f 2 0 / 1 0 0 or better, in comparison with 75 percent in this series. This is not significantly difl^erent, especially when one considers the greater number of aphakic cases, and the higher percentage o f successful cases in this series. A l s o , H u g h e s ' series contained only primary cases. Table 6 shows a correlation between the preoperative and postoperative vision in all reattached cases. These results compare fa
* Primary defined as no previous detachment surgery. t Secondary defined as those cases that had under gone one or more previous detachment operations elsewhere.
vorably with the results reported by Hughes,' suggesting that the difference in the type o f surgery utilized in this series, to be discussed later, was not a responsible factor in the
TABLE 6 CORRELATION OF PREOPERATIVE AND POSTOPERATIVE VISUAL ACUITY IN ALL REATTACHED CASES Postoperative Vision Preoperative Vision
20/20-20/50 20/70-20/100 20/200 or less
No. Cases
103 44 213
20/50 or Better
20/70-20/100
20/200 or less
No.
%
No.
%
No.
%
89 25 65
87 57 31
12 12 64
12 27 30
2 7 84
2 16 39
116
E D W A R D W . D. N O R T O N
final visual acuity, if the retina was attached.
232 successful cases in which the macula was
In 30 percent o f the cases presenting with
recorded as detached preoperatively, only 88
acuity o f 2 0 / 2 0 0 or less and reattached, a
( 3 8 percent) had subsequent visual acuity
final acuity o f 2 0 / 5 0 or better was achieved,
of 2 0 / 5 0 or better. In 110 successful cases
a figure almost identical with that found by
in which the macula had not been detached,
Hughes.
92 ( 8 4 percent) had subsequent vision of FACTORS FINAL
2 0 / 5 0 or better. There was no significant
INFLUENCING
VISUAL
difference between the phakic and aphakic
ACUITY
groups. A.
EVIDENCE
OF
PREOPERATIVE
VITREOUS
TRACTION
C.
ESTIMATED DURATION
O f the 51 aphakic cases with recognizable vitreous
traction
reattached,
which were successfully
only 18 (35 percent)
attained
vision of 2 0 / 5 0 or better. In the phakic group of 88 cases with vit reous traction which were reattached, 31 (35 percent) attained vision o f 2 0 / 5 0 o r better. In the two groups there were 231 cases without
preoperative
evidence of vitreous
traction which were reattached; 137 (60 per cent) of these obtained a visual acuity of 2 0 / 5 0 or better. This difference in visual
OF
DETACHMENT
Table 7 shows the relationship between the estimated duration of detachment and final visual acuity in cases in which the macula was detached. It is to be emphasized that approximately one fifth of all the detach ments of over two months' duration, in which the macula was involved, attained a vision of 2 0 / 5 0 or better, if the retina was reat tached. The final visual acuity was not related to the location or the size of the retinal tear, if the retina was reattached.
results is not surprising since rigid retinal folds were used as evidence f o r vitreous
FACTORS
INFLUENCING
traction and these folds often involve the posterior polar area. Even when the retina is successfully replaced these folds tend to
OF
A.
VITREOUS
REATTACHMENT
RETINA
TRACTION
In both the aphakic and phakic groups
persist and reduce visual acuity.
those cases with evidence of vitreous traction B.
INVOLVEMENT
OF
T H E
MACULA
BY
had an 18 percent failure rate, in contrast to
DETACHMENT
a failure rate o f 13 percent in the aphakic
A s one would expect, when the macula has
and seven percent in the phakic groups with
been detached, the visual result is poorer. In
out evidence of vitreous traction.
TABLE
7
EFFFXT OF DURATION DETACHMENT ON FINAL VISUAL ACUITY Patients with 20/50 or Better Visual Acuity Duration Detachment
No. Cases* Aphakic
Aphakic
Phakic
Phakic
No.
%
No.
%
< 2 wk.
37
53
16
43
23
43
> 2 wk. "1 < 2 mo. /
25
55
16
64
24
45
> 2 mo.
26
41
4
IS
9
22
* Only cases with macula detached included.
R E T I N A L D E T A C H M E N T IN A P H A K I A
117
TABLE 8 RELATIONSHIP OF NUMBER OF BREAKS FOUND AND END-RESULT Reattachment Aphakia No. Cases
None 1-3 4 or more
B.
ΕΧΤΕ,ΝΤ OF
Phakia
Aphakia
No. of Breaks Found
% Series
23 94 19
No. Cases
% Series
12 200 72
16 57 14
DETACHMENT
E.
Phakia
No.
%
No.
%
4 70 25
20 79 16
87 84 84
8 179 64
67 90 89
LOCATION
OF
BREAKS
In the total series, 150 patients presented
Table 9 shows that, in both the aphakic
with all four quadrants detached; 36 ( 2 4
and phakic groups, breaks located 16 mm. or
percent) of these were failures. In contrast,
more from the limbus carried a more serious
there were 274 patients with detachment of
prognosis. It is interesting to note that in
three quadrants or less; 18 (seven percent)
phakic cases when the most posterior break
were failures. The incidence of total detach
was 11 to 15 mm. from the limbus a 97 per
ment was 34 percent in the aphakic group
cent rate of reattachment was attained. This
with 21 percent failures, 16 percent in the
is probably related to the relative technical
phakic group with 30 percent failures. Total
ease o f placing the break or breaks on a
detachment gives a poorer prognosis for re
buckle in this location.
attachment, more so in the phakic than in F.
the aphakic group.
GIANT
BREAKS
Giant breaks o f greater than one quadrant C.
D E T A C H M E N T OF T H E ORA
In
general,
detachments
SERRATA
that
carry a serious prognosis. There were 13
extended
such cases in this series, with eight reattach
across the ora serrata had a slightly poorer
ments ; only three o f these attained a visual
prognosis ( 8 0 percent success rate). This is
acuity of 2 0 / 1 0 0 or better.
probably related to the higher incidence o f total detachment
( 3 8 percent) and vitreous
G.
traction ( 6 0 percent) in this group.
SURGERY
FOR
BETTER
VISUALIZATION
OF
RETINA
There were not enough cases that required D.
INABILITY
TO F I N D RETINAL
BREAKS
surgery to study the retina better to pro
Table 8 shows that, in aphakia, out o f 23 cases in which the break could not be found, 20 were reattached. In contrast to this, fail ure to find breaks in the phakic eye, while less common, is a poorer prognostic sign.
vide significant data. H o w e v e r , it is my im pression that uncomplicated iridectomy in phakic eyes creates little additional problem in the management o f the retinal detachment. In contrast, lens extraction for better vis-
TABLE 9 PERCENTAGE OF SUCCESS RELATED TO DISTANCE OF POSTERIOR BREAK FROM LIMBUS 10 mm. or Less No. Cases Aphakia Phakia
21 28
% 87 85
11-15 mm. No. Cases 59 136
16 mm. or More % 85 97
No. Cases 17 80
% 77 81
118
E D W A R D
TABLE
W,
10
RATE OF FAILURE RELATED TO SURGICAL COMPLICATIONS Failures
Cases Complication No. Large choroidal detachments Hemorrhages, retinal, choroidal, or vitreous Vitreous loss at surgery Subsequent problems with synthetic im plant
Series
No.
%
43
10
12
28
35
8
10
28
19
4
4
21
21
5
4
19
ualization of the retinal detachment has fre quently been followed by massive .vitreous traction. A t the present time, if a retinal break can be found that adequately explains the detachment, surgery will be undertaken even though lens opacities preclude proper visualization of the entire fundus. H.
COMPLICATIONS
AT
SURGERY
A s one would expect, complications at surgery, or immediately postoperatively, adversely affected the percentage of reattach ment. Table 10 shows the percentage of failure with each complication. FACTORS
FAILING OF
TO INFLUENCE
RESULTS
SURGERY
There was no correlation between pre vious retinal detachment surgical failures and the results obtained in the second eye. O f 32 cases that had unsuccessful detach ment surgery in one eye, 30 had a successful operation in the second eye. One generally associates poor prognosis with evidence of vitreous hemorrhage. In this series 29 percent of all the cases presented with evidence of vitreous hemorrhage, usually of a mild degree; 89 percent of these were reattached, thus vitreous hemorrhage did not prove to be a sign of poor prognosis. Active uveitis ( m o r e than the few cells and flare that are usually seen in retinal detachment) occurred in 23 cases in this
D.
N O R T O N
series; 87 percent of these were successfully reattached. A family history of retinal detachment was obtained in 13 cases, only two of which were failures. Table 8 shows that the presence of multiple breaks had little prognostic value ; 51 percent of the cases in this series had more than one break. There was no relationship between asso ciated glaucoma or immature cataracts and the rate o f reattachment. SPECIAL
FEATURES
OF
APHAKIC
GROUP
It is said that a retinal detachment occur ring in the first few months after cataract surgery has a poorer prognosis than those occurring later.'* In 119 cases of this series, the time between cataract surgery and the onset of the retinal detachment was recorded. Table 11 shows the relationship o f time of onset of the retinal detachment after cataract surgery and the percentage of successful re attachment ; there is no significant diiference between detachments that occurred early and those that occurred late. There was no significant difference in the rate of reattachment between the cases which had had an intracapsular lens extraction and those which had had an extracapsular lens extraction (table 13) ; between the cases with an intact vitreous face and those in which vitreous was known to be lost at the time of surgery, or in which examination showed rupture o f the vitreous face a n d / o r vitreous adherent to the corneal wound. It
TABLE
11
TIME RELATIONSHIP BETWEEN CATARACT SURGERY AND ONSET OF DETACHMENT AS IT AFFECTS REATTACHMENT Time Detachment Postcataract <1 1-3 4-6 > 6
mo. mo. mo. mo.
Reattached No. of Cases
%
11
82
27
85
7
86
74
89
R E T I N A L D E T A C H M E N T IN A P H A K I A
119
T A B L E 12
T A B L E 13
RELATIONSHIP TYPE OF CATARACT SURGERY AND STATUS VITREOUS FACE TO REATTACHMENT
NUMBER CASES WITH SCLERAL SYNTHETIC IMPLANT Phakia
Aphakia Reattached No. Cases Intracapsular extraction intracapsular extraction Vitreous face intact Vitreous loss known Vitreous face ruptured Vitreous adherent to corneal wound Round pupil Full iridectomy
%
120 19 65
86 86 85
76
85
92 47
88 79
None Segmental implant 360° implant
No.
% Series
No.
14 16 108
10 12 78
37 66 182
Series 13 23 64
by Schepens, et al.,'^--" have, with minor modifications, been followed in this series. I tend to d o fewer resections (undermining) when the breaks are confined to a small area.
should be emphasized that this does not say
It can be seen from Table 14 that the re
that retinal detachment is more or less com
sections in the aphakic cases are more ex
mon when these changes in the vitreous o c
tensive than those in the phakic cases. The
c u r ; this has not been studied. H o w e v e r , it
extensive resection, combined with an encir
does say that, when these changes in the
cling element, was used to create a new ora
vitreous face are present with a retinal de
which would serve as a barrier against missed
tachment, they in themselves d o not appear
breaks. I believe that this method contributed
to influence adversely the chances for re
substantially to the success rate in the more
attachment.
difficult aphakic detachment cases (tables 15
The advocates of full iridectomy in cata
and 1 6 ) .
ract surgery have taught that, if a retinal
Figure 3-A and Β demonstrates the value
detachment occurs, the prognosis is poorer
of
in the presence of a round pupil than in the
band in aphakic cases. The operat'on was
presence of a fviU iridectomy.'^ T h e material
directed at closing three small breaks on the
in this series (table 12) fails to support this
equator. A buckle was placed beneath these
extensive resection with an
encircling
claim. I believe this is due to the ease o f ex
breaks and extended to the limits o f the de
amining the periphery of aphakic eyes with
tachment. Postoperatively the retina detached
the indirect ophthalmoscope and scleral de
anterior to the buckle. N o additional breaks
pression even in the presence of a relatively
have been found on repeated examinations,
small pupil. It should be noted that in 50 per
although one must certainly exist. The exten
cent of the cases in which the examiner was
sive buckle served to protect the posterior
unable to find a definite break a full iridec
retina and the patient continues to have good
tomy had been performed.
visual function several years postoperatively.
SURGICAL TECHNIQUE
The surgical technique used in this series varied according to the preoperative ap pearance of the detachment but, by and large, scleral buckling operations were per formed using synthetic implants o f poly ethylene silicone or polyviol. T h e implants were made wide enough to cover the breaks and usually included an encircling compo nent (table 1 3 ) . These techniques, reported
T o close all breaks should always be the T A B L E 14 CASES WITH SCLERAL RESECTION (UNDERMINING) Aphakia
None <180° >180°
No. Cases
% Series
53 27 58
38 19 42
Phakia No. Cases 178 63 44
% Series 63 22 15
E D W A R D W . D. N O R T O N
120
T A B L E 15 RELATIONSHIP OF EXTENT OF RESECTION (UNDERMINING) TO REATTACHMENT Phakia
Aphakia
Reattached
Reattached No. Cases
%
No. No resection <90'' 90°-180° >180°
53 2 25 58
91 100 88 78
48 2 22 45
No. Cases
%
No.
89 100 91 82
158 6 52 36
178 6 57 44
T A B L E 16 RELATIONSHIP OF EXTENT SYNTHETIC IMPLANT TO REATTACHMENT Phakia
Aphakia
Reattached
Reattached No. Cases
None Se.gmental implant 360° implant
14 16 108
O
No.
%
13 14 90
93 88 83
No. Cases 37 66 182
No.
%
34 61 157
92 93 86
o
Fig. 3 (Norton). ( A ) Preoperative condition. ( B ) Postoperative condition (see text).
R E T I N A L D E T A C H M E N T IN A P H A K I A
object o f the surgeon; to wall off breaks is a useful compromise when the main objective cannot be achieved. POSTOPERATIVE
CARE
Early ambulation was practiced, with the majority o f patients getting up the first post operative day and being discharged about the seventh postoperative day. O f the pa tients in this series, 70 percent spent less than two weeks in the hospital pre- and post operatively combined; 91 percent less than three weeks. COM.MENTS
The technique for collecting data for this study is unique in my medical experience. The principle of recording basic data before the final results are known would appear sound in any statistical study. H o w e v e r , to date, most similar studies have been based upon retrospective analysis of hospital rec ords and have the inherent weakness o f retrospective bias. T h e data in this series were collected progressively and once re corded were no longer subject to the emo tional bias of future events. It is to be hoped that this technique will have considerable growth in the years ahead, with the advent o f more medical computer centers. The data when compared with previous reports show that marked strides have been made in the past decade in the surgical reat tachment o f the retina, particularly in apha kic cases. In fact, the rate o f success with aphakic detachment is approaching that at tained in phakic cases and fails to support Arruga's statement" "aphakia also reduces by approximately one-third the percentages of cures indicated." I believe that these ad vances are due in part to the re-introduction of the binocular indirect ophthalmoscope by Schepens which enables a better examination of the retina; to the use of scleral resection, as described by Lindner and modified by Shapland,-" which provides consistent dia thermy to the choroid; and to the implanta
121
tion o f synthetic material in the sclera to form a buckle, as introduced by Custodis'* and modified by Schepens,-" which effects apposition o f the treated choroid and pig ment epithelium to the retinal defects. T h e significance o f the extent o f the retinal detachment was emphasized by the striking difference in results between those cases with four quadrants involved and those with three quadrants or less. O f those cases in which three quadrants or less were involved, 93 percent were successfully reattached, in con trast to 76 percent when the detachment was more extensive. T h i s probably reflects the greater incidence o f vitreous traction in total detachments, 64 percent in contrast to 27 percent when three quadrants or less were involved. The difiiculty in successfully reattaching the retina when definite retinal breaks have not been found is generally acknowledged. However, this series points out a striking difference in this respect between phakic and aphakic cases. Despite not finding definite breaks, one can still get good results in aphakic detachments by extensive surgery that walls off the ora. In the phakic cases, however, in which a hole is not found, the results are considerably poorer. It is generally accepted that primary cases have a better prognosis than secondary cases. This was found to be true when all the sur gery was done by the same surgeon. H o w ever, when the initial surgery was performed by surgeons with a wide variation in their detachment experience, this held true only for the phakic group. T h e results with sec ondary aphakic cases were essentially the same as the results achieved in the primary aphakic cases. It is my opinion that the rea son for the significant difference in results in primary versus secondary phakic cases rests in factors other than localization of retinal breaks. In these cases the breaks were often found and treated by the origi nal surgeon; other factors caused the failure. In contrast, the aphakic cases treated else-
122
E D W A R D \ \ ' . D, N O R T O N
where usually presented with breaks un touched at the original surgery (reflecting the difficulty in finding breaks in aphakia) and, therefore, were to a certain extent "pri mary" cases. If this is true, the similarity of results between primary and secondary cases in aphakia is not too surprising.
vitreous face and a loss of vitreous at the time o f cataract surgery were poor prognos tic signs when they were followed by a ret inal detachment. In this series, the cases with an intact vitreous face had the same success rate as those in which the vitreous face was ruptured.
While satisfaction can be gained from the improvement in our present ability to reat tach the retina, we are still often faced with the serious problem of poor postoperative visual acuity. While the surgeon is content with a reattachment and preservation of field of vision, the patient is unhappy with the poor visual acuity. There is no evidence that the use o f a buckling procedure gives poorer visual results than diathermy.
Second, it has been held that aphakic de tachments occurring up to six months after cataract extraction have a poorer prognosis than those occurring later. N o significant flifference in results was noted between these two groups in this series.
The data presented here confirm the view that poor vision postoperatively is related to the presence and duration of macula detach ment preoperatively. The influence of pre operative vitreous traction on the final visual acuity has not been emphasized in the litera ture. The data obtained in this study show that, if vitreous traction (as defined) is rec ognized preoperatively, the chances of the patient attaining visual acuity of 2 0 / 5 0 or better if successfully reattached are about 35 percent. This is not surprising since these patients frequently have folds involving the macular area which tend to persist after re attachment. The disconcerting thing about these three factors associated with p o o r visual acuity is that, at the present time, none are under the control of the surgeon and, therefore, significant improvement in the visual results in detachment surgery cannot be anticipated by variation of present techniques. It is not surprising, when one considers this observa tion, that the photocoagulator has aroused interest in the prophylactic treatment o f retinal disease.-° Unfortunately, it will take many years and controlled studies to evalu ate the results. In studying the aphakic cases in this series three attitudes that are generally held do not find support: First, it has been held that rupture of the
Third, full iridectomy at the time of cata ract surgery has been held to be an ad vantage if the retina should subsequently become detached. While it is accepted that a full iridectomy facilitates visualization of the upper half of the fundus, the data from this series lead one to question that it in creases the success o f retinal surgery (table 12). If other studies confirm these findings, the recent editorial by Brockhurst** stating, "therefore, any patient who has had, or w h o may have, a retinal detachment and w h o is to have a cataract extraction should have a full iridectomy" will need to be re-evaluated. Obviously, an undilatable pupil is an indica tion for a full iridectomy at the time of cata ract extraction but, if the pupil can be read ily dilated, I do not believe a full iridectomy is mandatory. Since the great majority of patients in this series were ambulated on the first or second postoperative day and more recently only monocularly patched, I believe that the long time custom of routine prolonged bedrest postoperatively for retinal detachment pa tients should be abandoned. O u r findings would confirm the suggestion o f Jervey^" that, for the most part, retinal detachments are cured in the operating room, and are rarely influenced by the postoperative man agement of the patient. SUMMARY
1. A series of 424 consecutive cases o f retinal detachment has been studied with
123
RETINAL DETACHMENT IN APHAKIA
special emphasis on the difference between aphakic and phakic detachments. A n o b jective and progressive technique for collec tion o f data was utilized. 2. Eighty-five percent o f 139 aphakic cases and 89 percent of 285 phakic cases were successfully reattached. O f 109 primary aphakic cases, 84.5 percent, and, o f 230 pri mary phakic cases, 91 percent were success fully reattached. Eighty-seven percent of 30 secondary aphakic cases and 78 percent of 55 secondary phakic cases were successfully reattached. 3. W h i l e many aphakic breaks are found close to the ora, 60 percent of this series had their most posterior break in the area of the equator. 4. There was no particular difference in the quadrantic distribution of the breaks in the aphakic and phakic groups. 5. Aphakic detachments were more exten sive and more frequently involved the macu lar area than the phakic group. 6. Preoperatively, the aphakic group showed only slightly more evidence o f vitre ous traction than the phakic group. 7. The final visual acuity results were ap proximately the same in the two groups: 50 percent with an acuity o f 2 0 / 5 0 or better, 25 percent with visual acuity of 2 0 / 2 0 0 or less. 8. The final visual acuity was related to vitreous traction, involvement o f the macula, and the duration o f the detachment, in both groups.
9. A higher rate o f failure was noted in cases where the retina had shown fixed folds preoperatively, when the retina was totally detached, and when there were posteriorly located breaks or giant breaks. 10. The failure to find a retinal break in aphakic cases did not seriously influence the final results, whereas it was a poor prog nostic sign in phakic detachments. 11. Failure o f previous detachment sur gery in the fellow eye, vitreous hemorrhage, active uveitis, family history and multiple breaks did not adversely affect the surgical results in either group. 12. T h e final surgical results were not influenced by whether the detachment o c curred early o r late after cataract surgery, the type of extraction used (intra- or extra capsular), or defects in the vitreous face. 13. T h e success o f detachment surgery was unrelated to the presence o f a full iri dectomy or a round pupil. 14. In aphakic cases I tend to carry out more extensive scleral resections (undermin ing) with 360-degree circling foreign-body implants ; the improved results in aphakic de tachments are attributed to these factors. 15. With the surgical techniques currently utilized, early ambulation with monocular patching is an acceptable postoperative man agement.
1638 N.W.
Tenth Avenue
(36).
REFERENCES
1. Gonin, J.: The treatment of detached retina by searing the retinal tears. Arch. Ophth., 4:621, 1930. 2. Bagley, C. H . : Retinal detachment; Survey of etiology and results of treatment on phakics and aphakics. Am. J. Ophth., 31:285-298, 1948. 3. Dunnington, I. H . : What is the prognosis on retinal detachments? In: Symposium on retinal de tachments. Am. I. Oplith., 25:1247, 1942. 4. Shapland, C. D . : Retinal detachment in aphakia. Tr. Ophth. Soc. U. Kingdom, 54:176-196, 1934. 5. Braley, A. E., and Ostler, H. B.: Statistics on 100 cases of retinal detachment surgerv. J. Iowa M. Soc, 45:473-476, 1955. 6. Schepens, C. L.: Retinal detachment and aphakia, A M A Arch, Ophth,, 45:1-17, 1951. 7. Hughes, W . F., Jr.: Evaluation of results of retinal detachment surgery, Tr, Am, Acad, Ophth,, 56:439-448, 1952. 8. Colyear, B, H., and Pischel, D, K , : Causes of failure in retinal detachment surgery. A M A Arch. Ophth., 56:274-281, 1956, 9. Taubitz, VV,: Report on 206 operations for retinal detachment. Klin. Monatsbl. Augenh., 128:473479, 1956. 10. Sedan, J,, and Farnarier, G.: Our assessment of scleral resection in aphakic retinal detachments. Ann. ocul., 193 :721-732, 1960,
124
E D W A R D W . D. N O R T O N
11. Lister, A . : Detachment of the retina. Practitioner, 178 :540-551, 1957. 12. Schapens, C. L., and Marden, D . : Data on the natural history of retinal detachment. A M A Arch. Ophth., 66:631-642, 1961. 13. Hudson. J.: Late complications of aphakia. Tr. Ophth. Soc. U. Kingdom, 81:75-83, 1961. 14. Schepens, C. L . : Personal communication. 15. Pierce, H . : Personal communication. 16. Maumenee, A. E . : Retinal detachment. In Symposium postoperative cataract complications. T r Am. Acad. Ophth., 57 :62, 1957. 17. Arruga, Η . : Ocular Surgery. New York, McGraw-Hill, 1956, ed. 2, p. 604. 18. Pischel, D. K., and Pierce, H . : Importance of vitreous body in retina surgery with .'special cmpliasis on reoperations. St. Louis, Mosbv, 1960, pp. 151-152, 159. 19. Brockhurst, R. J.: Editorial. A M A Arch. Ophth., 69:1-2, 1963. 20. Schepens, C. L . : Scleral buckling procedures. In Svmposium scleral resection procedures. Tr. Am. Acad. Ophth., 56 :206-218, 1958. 21. Schepens, C. L., Okamura, I. D., Brockhurst, R. J., and Regan, C. D . : The scleral buckling prr)cedures: V. Synthetic sutures and silicone implants. A M A Arch. Ophth., 64:868-881, 1960. 22. Arruga, Η . : Ocular Surgcrv. New York, McGraw-Hill, 1962, cd. 3, p. 686. 23. Shapland, C. D . : Scleral resection. Proc. Roy. Soc. Med., 44:413-422, 1951. 24. Custodis, E.: Is the suturing of scleral implantations an advance in the surgery of retinal detach ment? Ber. Itscli. Ophthal. Ges. Heidelberg, 58:102-105, 1953. 25. Heinzen, Η . : Die Prophylaktische Behandlung der Neízhaufahlosung. Ferdinand Enke \'erlag, Stuttgart, 1960. 26. Jervey, J. W . : Postoperative care of major eye surgery. Southern M. T., 45:139-141, 1952.
OPHTHALMIC
MINIATURE
One rather unusual thing occurred in connection with the use of eserine in this case. A violent conjunctivitis followed its constant use several times daily, the lids became swollen, and
there was present the most profuse
lachrymation. These symptoms, which are eserine
conjunctivitis,
those of what I should call
disappeared entirely when I stopped using the drug.
T h e disease no doubt resembles in its history what is known as atropine conjunctivitis. I have never seen any mention made in the books of this effect of eserine. Robert L. Randolph
(Baltimore),
" H e m o r r h a g i c glaucoma with an analysis o f three cases," T r . Ophth. Section A . M . A . , 1891, p. 264.