- Email: [email protected]
Retinal Perforation During Strabismus Surgery*
SURGERY FOR EXOTROPIA In intermittent exotropia with poor fusional ability and in alternating constant exo tropia, a normal type of binocular single vision seldom developed after surgery, even with intensive orthoptics. The stabilizing ef fect of fusional vergences was not present and most cases re-examined four to five years after surgery were found to have an increase in the deviation as compared to two years postoperatively. In these two groups, unilat eral recession-resection gave much more con sistent and enduring effects than lateral rec tus recessions alone. The few overcorrections obtained in these two groups were well tolerated. More drastic surgery is indicated as compared to intermittent exotropia with good fusional ability. In monocular exotropia, an effort was
1167
made to confine the surgery to the deviating eye, but gross incomitance and alteration of the palpebrai fissures was avoided by limit ing medial rectus resections to four to six mm. and recession to seven to eight mm. Ad ditional surgery on the usually fixing eye was found preferable to creating these disfiguring defects of excessive surgery on the deviating eye. These data should not be interpreted as in dicating that lateral rectus recessions are im proper procedures for exotropia, but rather that results of operation can be made more consistent and enduring by concurrent medial rectus resection. This seems particularly im portant in cases lacking the stabilizing effects of normal fusional mechanisms. 3181 S.W. Jackson Park Road (1).
REFERENCES
1. Allen, J. H. : Strabismus Ophthalmic Symposium. St. Louis, Mosby, 1950. 2. Swan, K. C: Strabismus: A symposium. (A manual prepared for use of graduates in Medicine by American Academy of Ophthalmology and Otolaryngology), 1953. 3. Allen, J. H.: Strabismus Ophthalmic Symposium II. St. Louis, Mosby, 1958. 4. Swan, K. C, and Talbot, T. E.: Recession under Tenon's capsule. AMA Arch. Ophth., 51:32, 1954. 5. Swan, K. C: Resection under Tenon's capsule. AMA Arch. Ophth., 55:836, 1956.
R E T I N A L P E R F O R A T I O N DURING STRABISMUS SURGERY* J O H N M. M C L E A N , M.D.,
MILES A. GALIN, M.D.,
AND IRVING BARAS,
M.D.
New York The mechanics of muscle surgery are not unduly difficult and surgical complications are few. Most texts stress the problem of insufficient or excessive correction of a given strabismus case, rather than physical compli cations. Though the incidence of operative and postoperative difficulties is low, the va riety of potential complications is extensive. One complication that has received virtually no scrutiny, however, is retinal hole forma tion occurring during muscle surgery. A case of retinal tear formation occurring during recession of the inferior oblique ♦From the Department of Surgery (Ophthal mology) of the New York Hospital-Cornell Medi cal Center.
muscle was recently brought to our attention in a patient who was referred to us after muscle surgery elsewhere. It was not known whether to treat this tear, nor was it clear from the literature what risk there was of retinal detachment. Consequently, a detailed examination of strabismus patients was undertaken, and im mediate postoperative indirect ophthalmoscopy performed. In a rather short period of time, utilizing the private and ward pa tients of several hospitals, 16 patients were found who had unequivocal, surgically caused retinal tears about the sites of extraocular muscle manipulation. It soon became clear that a characteristically appearing tear is
J. M. McLEAN, M. A. GALIN AND I. BARAS
1168
Fig. 1 (McLean, Galin and Baras). Appearance of the retinal perforation immediately following surgery. caused, with apparently no retinal detach ment resulting. It is the purpose of this communication to report on this complication of strabismus surgery, describe its appearance, and com ment on the prognosis. '
MATERIALS AND METHODS
Patients were examined within the first 24 hours of strabismus surgery, and at regular intervals thereafter when retinal hole for mation was found. When possible, detailed drawings of the fundus were made. At other times only sketches could be drawn, as ex amination time was, of necessity, quite limited. RESULTS
A rather consistent sequence of events occurs following the induction of needle track retinal tears in young, healthy eyes, regardless of whether the needle is removed or even if the suture lies within the vitreous cavity. Initially, hemorrhage covers the per foration site (fig. 1). Some of the hemor rhage may break through into the vitreous cavity but, in the main, it remains confined to the choroid and retina. In a matter of a day or two, bare sclera is visible, usually surrounded by residual hemorrhage and light pigmentation. The area appears as if choroid
and retina were scooped out, leaving bare sclera behind.' Our follow-up is not suffi ciently long to determine the degree of pig mentation induced but it appears to be only slight (fig. 2 ) . We have come across several strabismus patients with this characteristic lesion, who have made uneventful recoveries from sur gery performed several years prior to noting this finding. Here, too, the lesion appears identical. ' DISCUSSION
It is well known that retinal tears are the forerunners of retinal detachments. This is true for both idiopathic detachments and traumatic detachments. However, more and more emphasis has been placed in recent years on the role of the vitreous in detach ment production. It is a not uncommon experience of de tachment surgeons to perforate the retina during surgery. This event may occur at the time of fluid drainage or with the use of perforating instruments. If the induced hole occurs in detached retina and choroidalretinal adhesions are not created about the hole, failure is likely. In the normal eye, however, the mild trauma induced by perforation with a short needle is well tolerated. Probably hemor-
RETINAL PERFORATION DURING STRABISMUS SURGERY
1169
4Î? .
Î?"*W!
:#lî Ä Ä Ä a i l i SÄ Ä Ä :
Fig. 2 (McLean, Galin and Baras). Appearance of the retinal perforation several weeks postoperatively. (Note the sparse pigmentation)· rhage seals the site until fibrous adhesions form. The vitreous change is negligible and consequently traction does not result. Cer tainly, one would think that any large-sized perforation would incur the risk of detach ment. It has not yet been possible to assess the frequency of this event. However, the ease with which this series was accumulated would indicate that retinal perforation during strabismus surgery is not rare. The shape of needles used in strabismus surgery would seem to be important in this complication. The recent enthusiasm for "in verted" cutting needles may have been re sponsible for most of the complications noted here. It is possible that complete choroidal or retinal perforation did not always occur, but rather that the sharp leading convex edge deep in the sclera caused the tear by tissue stress and distortion. The theory of needle design is not a primary purpose of this com munication but it would seem a reasonable conclusion that convex edges of needles used in muscle operations should not be sharp. If the surgeon always maintains pressure on his needle in the exact direction of the needle
curve and does not go too deep, these compli cations should not take place. However, if he tends to direct any force toward a sharp leading convex edge, the possibility of un recognized and undesirable deeper cutting is obvious. The remedy lies in proper needle manipulation. An added safeguard would be use of a needle which is not sharp on the convex curve. The first two cases in this series were treated with light coagulation and fared well. No other case received therapy, and in no case did detachment occur. One might infer, therefore, that no therapy is indicated. SUMMARY
The complication of surgically induced retinal tear formation occurring during strabismus surgery is described. Though un common, this problem does not appear rare. No therapy seems warranted as retinal de tachment does not occur. A characteristicappearing retinal scar results. Proper selec tion and manipulation of needles should eliminate this complication. 525 East 68th Street (21).
1167
made to confine the surgery to the deviating eye, but gross incomitance and alteration of the palpebrai fissures was avoided by limit ing medial rectus resections to four to six mm. and recession to seven to eight mm. Ad ditional surgery on the usually fixing eye was found preferable to creating these disfiguring defects of excessive surgery on the deviating eye. These data should not be interpreted as in dicating that lateral rectus recessions are im proper procedures for exotropia, but rather that results of operation can be made more consistent and enduring by concurrent medial rectus resection. This seems particularly im portant in cases lacking the stabilizing effects of normal fusional mechanisms. 3181 S.W. Jackson Park Road (1).
REFERENCES
1. Allen, J. H. : Strabismus Ophthalmic Symposium. St. Louis, Mosby, 1950. 2. Swan, K. C: Strabismus: A symposium. (A manual prepared for use of graduates in Medicine by American Academy of Ophthalmology and Otolaryngology), 1953. 3. Allen, J. H.: Strabismus Ophthalmic Symposium II. St. Louis, Mosby, 1958. 4. Swan, K. C, and Talbot, T. E.: Recession under Tenon's capsule. AMA Arch. Ophth., 51:32, 1954. 5. Swan, K. C: Resection under Tenon's capsule. AMA Arch. Ophth., 55:836, 1956.
R E T I N A L P E R F O R A T I O N DURING STRABISMUS SURGERY* J O H N M. M C L E A N , M.D.,
MILES A. GALIN, M.D.,
AND IRVING BARAS,
M.D.
New York The mechanics of muscle surgery are not unduly difficult and surgical complications are few. Most texts stress the problem of insufficient or excessive correction of a given strabismus case, rather than physical compli cations. Though the incidence of operative and postoperative difficulties is low, the va riety of potential complications is extensive. One complication that has received virtually no scrutiny, however, is retinal hole forma tion occurring during muscle surgery. A case of retinal tear formation occurring during recession of the inferior oblique ♦From the Department of Surgery (Ophthal mology) of the New York Hospital-Cornell Medi cal Center.
muscle was recently brought to our attention in a patient who was referred to us after muscle surgery elsewhere. It was not known whether to treat this tear, nor was it clear from the literature what risk there was of retinal detachment. Consequently, a detailed examination of strabismus patients was undertaken, and im mediate postoperative indirect ophthalmoscopy performed. In a rather short period of time, utilizing the private and ward pa tients of several hospitals, 16 patients were found who had unequivocal, surgically caused retinal tears about the sites of extraocular muscle manipulation. It soon became clear that a characteristically appearing tear is
J. M. McLEAN, M. A. GALIN AND I. BARAS
1168
Fig. 1 (McLean, Galin and Baras). Appearance of the retinal perforation immediately following surgery. caused, with apparently no retinal detach ment resulting. It is the purpose of this communication to report on this complication of strabismus surgery, describe its appearance, and com ment on the prognosis. '
MATERIALS AND METHODS
Patients were examined within the first 24 hours of strabismus surgery, and at regular intervals thereafter when retinal hole for mation was found. When possible, detailed drawings of the fundus were made. At other times only sketches could be drawn, as ex amination time was, of necessity, quite limited. RESULTS
A rather consistent sequence of events occurs following the induction of needle track retinal tears in young, healthy eyes, regardless of whether the needle is removed or even if the suture lies within the vitreous cavity. Initially, hemorrhage covers the per foration site (fig. 1). Some of the hemor rhage may break through into the vitreous cavity but, in the main, it remains confined to the choroid and retina. In a matter of a day or two, bare sclera is visible, usually surrounded by residual hemorrhage and light pigmentation. The area appears as if choroid
and retina were scooped out, leaving bare sclera behind.' Our follow-up is not suffi ciently long to determine the degree of pig mentation induced but it appears to be only slight (fig. 2 ) . We have come across several strabismus patients with this characteristic lesion, who have made uneventful recoveries from sur gery performed several years prior to noting this finding. Here, too, the lesion appears identical. ' DISCUSSION
It is well known that retinal tears are the forerunners of retinal detachments. This is true for both idiopathic detachments and traumatic detachments. However, more and more emphasis has been placed in recent years on the role of the vitreous in detach ment production. It is a not uncommon experience of de tachment surgeons to perforate the retina during surgery. This event may occur at the time of fluid drainage or with the use of perforating instruments. If the induced hole occurs in detached retina and choroidalretinal adhesions are not created about the hole, failure is likely. In the normal eye, however, the mild trauma induced by perforation with a short needle is well tolerated. Probably hemor-
RETINAL PERFORATION DURING STRABISMUS SURGERY
1169
4Î? .
Î?"*W!
:#lî Ä Ä Ä a i l i SÄ Ä Ä :
Fig. 2 (McLean, Galin and Baras). Appearance of the retinal perforation several weeks postoperatively. (Note the sparse pigmentation)· rhage seals the site until fibrous adhesions form. The vitreous change is negligible and consequently traction does not result. Cer tainly, one would think that any large-sized perforation would incur the risk of detach ment. It has not yet been possible to assess the frequency of this event. However, the ease with which this series was accumulated would indicate that retinal perforation during strabismus surgery is not rare. The shape of needles used in strabismus surgery would seem to be important in this complication. The recent enthusiasm for "in verted" cutting needles may have been re sponsible for most of the complications noted here. It is possible that complete choroidal or retinal perforation did not always occur, but rather that the sharp leading convex edge deep in the sclera caused the tear by tissue stress and distortion. The theory of needle design is not a primary purpose of this com munication but it would seem a reasonable conclusion that convex edges of needles used in muscle operations should not be sharp. If the surgeon always maintains pressure on his needle in the exact direction of the needle
curve and does not go too deep, these compli cations should not take place. However, if he tends to direct any force toward a sharp leading convex edge, the possibility of un recognized and undesirable deeper cutting is obvious. The remedy lies in proper needle manipulation. An added safeguard would be use of a needle which is not sharp on the convex curve. The first two cases in this series were treated with light coagulation and fared well. No other case received therapy, and in no case did detachment occur. One might infer, therefore, that no therapy is indicated. SUMMARY
The complication of surgically induced retinal tear formation occurring during strabismus surgery is described. Though un common, this problem does not appear rare. No therapy seems warranted as retinal de tachment does not occur. A characteristicappearing retinal scar results. Proper selec tion and manipulation of needles should eliminate this complication. 525 East 68th Street (21).