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The Prevention of Retinal Detachment in Cataractous Eyes by Retinal Sealing
THE PREVENTION OF RETINAL DETACHMENT IN CATARACTOUS EYES BY RETINAL SEALING ALSTON
CALLAHAN,
M.D.,
AND
LUIS
PEREZ-MARTINEZ,
M.D.
Birmingham, Alabama
In two previous articles on the prophy laxis of retinal detachment in cataractous eyes which we have written independently,1'6 a tabular description was included of the course of events in which detachment of the retina was prevented in the second eye of 11 patients. This communication increases the total to 29 and the follow-up time of the ear lier cases has now been extended to eight years; an improved surgical technique and some new observations are herewith pre sented. Lincoff's studies4 on prophylaxis of retinal detachment considers the problem in its widest aspects. His paper includes recom mendations for the management of holes in the retinal periphery, points out that pig ment demarcation lines will not limit the extent of detachment, notes the rarity of true macular holes and suggests the best method of managing them, recommends the management of various types of degen erated retinal areas which might lead to detachment, and ends by considering the prevention of retinal detachment of cata ractous eyes in which a detachment occurred idiopathically or followed a cataract extrac tion from the other eye. In this last group, Lincoff comments on the two factors which will bring on a retinal detachment in the second eye : 1. Vitreous detachment will follow cat aract removal just as certainly after extracapsular as after intracapsular extraction, and the latter method should always be used to avoid having capsular remnants in the pupillary area. He indicates that there are other reasons also why he prefers the intra capsular method. 2. If a retinal hole can be seen, it should be sealed with surface diathermy. Lincoff also recommends that at the end
of the first postoperative week after cataract extraction, a careful examination be made of the retinal periphery for holes and any found be sealed with the light coagulator. If the examination shows that a detachment has already begun, six weeks must be al lowed to elapse before the traditional method of retinopexy can be performed. During these six weeks, he bandages both eyes. He believes that a circumferential row of di athermy applications around the retinal pe riphery has only a small chance of closing a retinal hole for the hole may be behind the ring and a detachment will occur, and if the hole is anterior to the ring, fluid may spread beneath the retina and around to find an opening in the diathermy barrier or dis sect its way over it, causing a detachment. Also, he believes that the series so far re ported have been too small. We would agree that the ideal solution is to locate the hole or degenerative area of the retina and to treat it with surface di athermy before a detachment occurs. Un fortunately, many patients who had a de tachment to follow the cataract extraction in the first eye prefer to wait for the re moval of the cataract from their second eye until their vision has been reduced by the cataract to less than 20/200, and by this time, an accurate and complete examination of the fundal periphery for the location of holes is unsatisfactory. Even in patients who will submit to surgery earlier, a retinal hole may form that cannot be visualized because of the partially opaque lens. For these rea sons it is not always possible to find and seal a retinal hole. Lincoff's plan for bi lateral bandaging if a detachment has oc curred is much more confining than two days of hospitalization with the retinal seal ing operation three months prior to the
752
PREVENTION OF RETINAL DETACHMENT cataract extraction. This series of 29 is still not large, but should be more convinc ing than one of 11, since all patients, with out exception, have useful vision in the eye treated in this way. In only one did a de tachment occur, and it was limited in extent and the sealing helped to hold the retina and choroid to the sciera until a secondary opera tion could be performed. Paufique8 in his Bowman Lecture in 1959 stated that, when one eye had been affected by a retinal detachment, the other eye had a 25-percent chance of becoming similarly af fected should the lens be affected. This proba bility becomes greater when the cataract is presenile or when there is an absence of he reditary factors for the cataract, or when vitreous loss has occurred. Of the 48 patients upon whom Zuccoli used transconjunctival diathermy coagula tion, three had a detachment following the removal of a cataract and in none of these did the retina of the second eye detach after coagulation, later followed by cataract ex traction. Among the other patients, he cured three flat detachments in young myopes, one eye with pars plana uveitis and multiple holes near the ora were sealed off in 12 eyes without the complication of detachment following. A pyrometric electrode was used —first to the medial sciera and then to the lateral sciera. His coagulations were placed as far anteriorly from the macula as possi ble to permit an ophthalmoscopic observation of the coagulation. Commenting on this article in the April, 1963, Survey of Ophthalmology, Robb Mc Donald judges intrascleral diathermy to be a safe procedure. However, he recommends that the conjunctiva be reflected from the sciera, and the diathermy applied directly to the sciera to gain a better control of the choroidal reaction. In addition to the circumferential ring of diathermy adhesions, the ophthalmologist may make careful postcataract extraction observations and if a retinal hole is present posterior to the adhesions, it can be sealed.
753
Since only one of 29 eyes had a detachment occur, and this detachment was limited and was successfully repaired, fears that surface diathermy performed routinely on such eyes might frequently cause detachment are un founded. IMPROVED SURGICAL TECHNIQUE
Perforating diathermy is not necessary. For scieras of normal thickness, we use par tially penetrating electrodes (0.5 mm. and 0.75 mm. with a voltage on the Walker coagulator of 40 volts) and for thin scieras we use surface diathermy applied with a ball tip with voltage of 25 to 30 volts. Par ticular attention is paid to the site of the detachment in the first eye to see if in the second eye there is a symmetrically located thinning of the sciera with the choroid show ing through externally with a bluish tinge. Sometimes this has developed and the ball electrode is used to sear lightly the sciera over this area with the current reduced to 20 volts. We try to keep the diathermy low enough so that when looking at the retina afterwards only a faint whitish coagulated area can be seen, and we like to see pig mentary changes occur within the second postoperative week. We have continued to use the circum ferential diathermy for highly myopic eyes with evidence of choroidal and retinal stretching preparatory to cataract extractions even if this is the first eye. The conjunctiva is not cut in a complete circle around the eye, but only between each of the four muscles (fig. 1-A). It is un necessary to make a complete cut as it is possible to apply diathermy to the sciera beneath each of the rectus muscles with an insulated electrode such as Rychener's, in serting the electrode from the end of the incision (fig. 1-B). The spared conjunctiva and Tenon's capsule bridge over the rectus muscles permit a more rapid recovery from the operative reaction. The diathermy applied beneath the medial and lateral rectus muscle is diminished in
754
ALSTON CALLAHAN AND LUIS PEREZ-MARTINEZ
strength to avoid coagulation of the long posterior ciliary arteries and ciliary nerves. The sciera should be bared of episcleral tissue and dried to facilitate the diathermy action; the diathermy application should turn the sciera slightly yellow or grayish, but not brownish or black. Because of the opacity of the usual cataract at this time, indirect ophthalmoscopy may be of no value, but should be attempted unless the lens is completely opaque. To bring the surface area of the sciera into easy view for diathermy, a muscle hook can be introduced beneath two adjacent rec tus insertions, and the eye tilted so that the area between the two muscles is in the center of the palpebral fissure. Special care is necessary in extreme myopia, for the sciera may be so thin that pulling too firmly on the tendonous insertion may tear the sciera open with disastrous results. Interrupted suturing of the conjunctiva and Tenon's capsule in each of the four quadrants for more accurate reunion of tis sue is preferred to a continuous suture. In many eyes the sealing procedure has lowered
the ocular tension for several weeks or a few months, but we have not had this last for more than four months, and it has produced no side-effects such as edema of the macula. CASES OF SPECIAL I N T E R E S T
No. 19, D. C. This 52-year-old patient has three brothers who had cataracts beginning around the age of 50 years and two of them had retinal detachments either before or after cataract surgery. After the cata ract was extracted from his right eye in 1954, examination showed no retinal holes. The last routine postoperative follow-up of this patient's right eye was on January 20, 1955, at which time the retina showed no holes. However, in January, 1961, more than six years after the cataract ex traction, the lower temporal quadrant of the retina became detached and two holes were found. The scierai buckling procedure was successful in reattaching the retina for only a few months and two further attempts to reattach the retina were unsuccessful. Preparatory to the cataract extrac tion from the left eye, surface and partial pene trating diathermy was carried out on the left eye. Three months later an intracapsular cataract ex traction was performed, and there were no operative or postoperative complications. Postoperatively the fundus was subjected to careful study at intervals, and no holes were seen. However, six months after the cataract extraction the retina detached at the 12-o'clock position just anterior to the circumfer-
Fig. 1 (Callahan and Perez-Martinez). Application of diathermy current to ora for firm union of peripheral retina and choroid with the sciera. (A) Ball end of Cibis electrode used for application every two to three mm. from the edge of one rectus insertion to the next. (B) Rychener electrode used to apply diathermy current to sciera beneath rectus tendons.
TABLE 1 SURVEY OF CASES
No.
Initials Race, Sex Age (yr.)
Details of Retinal Detachment of First Eye
Date of Retinal Sealing Second Eye and Type
Date and Type of Cataract Extrac tion Second Eye
Date of Last Observation and Corrected Vision
1
C. H. w. m. 24
(Left) Dec. '51 extracapsular extraction, vitreous was fluid, no threatened loss. Oct. '53 retinopexy including scierai buckling but later complete redetachment
(Right) Nov. 12, '56 Surface diathermy
July 13, '54 Feb. 1956 Extracapsular, 20/25 small loss vitreous
2
M. J. w. m. 65
(Right) Extracapsular extraction of hypermature lens, Nov. ' 54 reattachment achieved, Nov. '56, complication of corneal dystrophy after orbital cellulitis, visual acuity never regained better than 20/200
(Left) Nov. 12, '56 partial penetrat ing diathermy
Mar. 11, '56 Intracapsular, no complications
April 1963 20/20
3
D. A. R. w. m. 56
(Right) Cataract extraction elsewhere followed 3 mo. later by detachment after the operation, and two unsuccessful attempts at reattachment
(Left) Sept. 16, '55 Surface diathermy
Dec. 28, '55 Intracapsular, no complications
Jan. 1963 20/15-1
4
W. J. W. w. m. 82
(Left) (Right) Cataract extraction performed elsewhere in Apr. '53, Aug. 16, '54 followed by hemorrhage three days postoperatively, Surface and when first examined by me seven months later mas diatherm y sive detachment of retina present. Chronic uveitis re quired enucleation, Apr. '54
Feb. 4, '55 Intracapsular, no complications
July 1955 20/50
S
J. E. C. w. f. 73
6
P. F. w. f. 55
7
W. M. Mc. w. f. 73
8
(Right) Cataract was removed Dec. '53. When first examined by me in May '54, the retina had been detached for some months Case complicated by severe senile cicatricial entropion which required surgical correction before surgery of the globe begun
(Left) July 23, '54 Partial penetrat ing diathermy
Nov. 26, '54 Intracapsular, no complications
Dec. 1960 20/40
(Left) Cataract was removed Nov. '54. When first examined by us in July '55, retina was completely detached
(Right) Oct. 23, '55 Partial penetrat ing diathermy
Apr. 16, '55 Intracapsular, no complications
Jan. 1961 20/40
(Left) Idiopathic detachment, left eye, about '45. No surgical reattachment attempted
(Right) Feb. 18, '57 Surface diathermy
May 10, '57 Intracapsular, fluid vitreous presented
June 1960 20/25
(Right) E. C. M. C. Retinal detachment after cataract operation performed in another city, then enucleation w. f. 70
(Left) Jan. 16, 1958 Partial penetrat ing
May 29, 1958 Intracapsular, no complications
Jan. 1962 20/30
(Left) Idiopathic total detachment. Unsuccessful reattach ment attempt performed elsewhere in 1948
(Right) Mar. 5, '59 Partial penetrat ing diathermy
Apr. 6, '59 Intracapsular, no complications
June 1962 20/60
9
T. B. P. w. m. 57
10
J. S. A. w. m. 58
(Right) Oct. '51 intracapsular extraction; no complications Sept. '56 Disinsertion (inferior) at the ora serrata. Un successful lamellar scierai resection
(Left) May 28, '59 Surface diathermy
Intracapsular, no complications
Sept. 1962 20/25
11
G. L. M. w. m. 63
(Right) July '59 Cataract extraction, small bead of vitreous was lost Aug. '59 Inferior retinal detachment. Unsuccessful scierai infolding with polyethylene tube
(Left) Oct. 1, '59 Partial penetrat ing diathermy
Mar. 3, '60 Intracapsular, no complications
Jan. 1963 20/20-1
12
J. M. L. w. m. 85
(Right) Dec. '59 Hypermature cataract. No light projection in lower half of eye. Retina believed to be detached
(Left) Jan. 7, '60 Partial penetrat ing
Mar. 29, '60 Intracapsular, no complications
Aug. 1962 20/30 +
13
A. Mc. M. w. m.
(Right) June '50 High pathologic myopia R. -11.00 -2.75X57 L. -20.00 -2.00X129
(Left) Feb. 4, '60 June 3, '60 Note: cataract Intracapsular O.D. was re moved same date without retinal sealing
14
P. T. w. m. 47
(Right) Complete total detachment; no details 20 years pre viously
(Left) Mar. 3, '60 Sciera thin superiorally under neath superior muscle
June 16, '60 Extracapsular, no complications
July 1961 20/20-3
15
B. T. w. f. 67
(Right) Feb. '53, cataract extraction, no complications May '53 Retinal detachment lower nasal quadrant; no holes (disinsertion) retina reattached but one month later total detachment; no further efforts to reattach it, posteriorly (1 month) suprisingly good settling of retina V. = H . M .
(Left) Mar. 24, '60 Scierai staphlomas in upper quadrant, applied surface diathermy with ball electrode
July 21, '60 Intracapsular cataract extrac tion, loss of bead of fluid vitreous
Sept. 1962 20/25
(Table 1 continued on next page)
April 1963 20/60
TABLE 1. (Continued) No.
Initials Race, Sex Age (yr.)
Details of Retinal Detachment of First Eye
D a t e of Retinal Sealing Second Eye and T y p e
D a t e of Last D a t e and T y p e of Observation Cataract Extrac and Corrected tion Second E y e Vision
(Both Eyes) High pathologic myopia R. - 1 0 . 5 0 - 3 . 0 0 X 1 0 L. - 7 . 7 5 - 3 . 7 5 X 1 8 0
(Right) June 30, '60 Surface diathermy
Dec. 15, '60 Intracapsular, n o complications
Sept. 1962 20/30
(Left) M a y '60 Cataract extraction performed elswewhere; large fiat detachment; encircling tube
(Right) Jan 5, '61 Partial penetrat ing diathermy
Mar. 30, '61 Intracapsular, no complications
Feb. 1963 20/60-1
H. C. w. f. 69
(Right) Oct. '60 Cataract extraction performed elsewhere last Jan. Discission was done in June with secondary bleed ing; almost complete retinal separation; n o tear seen, upper temporal and lower retina including macula, un successful encircling tube. 9 / 1 0 / 6 2 enucleated
(Left) Jan. 12, '61 Partial penetrat ing diathermy
Apr. 6, '61 Intracapsular, no complications
Aug. 1962 20/20-3
19
D . C. w. m. 52
(Right) '54 Cataract extraction. Jan. 13, '61 detachment lower temporal quadrant; 2 holes. Scierai bucking with supramyd tube (successful). Detached again posteriorly, detached again posteriorly, reoperated, again a failure
(Left) Jan. 19, '61 Surface and par tial penetrating diathermy
Apr. 27, '61 Intracapsular, no complications. In Oct. '61 retinal separation at 12 o'clock successful scierai buckling
April 1963 20/20
20
R. B. w. m. 65
(Right) Oct. '56, high pathologic myopia O.U. Hypermature cataract O . D . no light perception detachment
(Left) June 6, '61 Surface diathermy
Aug. 24, '61 Intracapsular, no complications
March 1963 20/30 Retinal hemorrhages due to diabetes
21
G. E. J. w. m. 48
16
P. M . G. w. m. 43
17
P. B. E. w. f. 71
18
&
22
23
L. B. w. f.
24
H . L. w. m. 79
25
H . L. Mc. w. m. 62
26
C. A. S. w. f.
27
M . E. V. w. f. 54 P.
28
J. M . c. m. P.
29
M. F. w. f. P.
(Both Eyes) (Both Eyes) N o v . 2, '61 N o v . ' 6 1 , megalocornea, mature cataracts, sciera quite thin. D u e to abnormal construction and probable fragil Partial penetrat ing diathermy ity of ocular tissues, retinal sealing indicated
(Right) Apr. 21, '60 cataract extraction uneventful, but postoperatively severe choroidal detachment which re quired draining of t A e subchoroidal fluid through scierai incisions
(Left) N o v . 30, '61
(Right) Cataract extraction elsewhere several years ago; fol lowed by a complete retinal detachment
(Left) Mar. 15, '62
(Right) Feb. 9, '61 intracapsular cataract extraction; no opera tive complications. Corrected vision 4 / 1 / 6 1 2 0 / 3 0 ; Bullous separation in upper temporal quadrant cover ing the macula with a tear a t 12:00 and a t 9 : 0 0 . 4 / 1 3 / 6 2 360° encircling tube & diathermy t o retina with injection of air i n t o vitreous. Vision, O . D . 7/21/62—20/30
(Left) Mar. 16, '62 Retinal sealing
Feb. 8, '62 Aug. 1963 Intracapsular O.S. 2 0 / 3 0 , O. S. N o complications Sept. 27, '62 Intracapsular 2 0 / 3 0 , O. D . Extraction O . D . N o complications March 1963 Apr. 5, '62 Intracapsular O.S. 2 0 / 2 0 0 Optic no complications Atrophy June 14, '62 Intracapsular, no complications
Jan. 1963 20/50
July 23, '62 Cataract extrac tion, no complica tions
Mar. 1963 20/70
1 2 / 1 7 / 6 2 the right retina detached again, the scier ai buckling was revised by Dr. Paul Cibis; vision 3 / 1 / 6 3 right 2 0 / 7 0 ; deteriorated t o 20/200 July 1963
(Right) Aug. 1948—Idopathic detachment (no details) success ful diathermy reattachment. Separation again
(Left) Mar. 2, '61
(Both Eyes) Apr. '48 High myopia; chronic glaucoma; partial optic atrophy; nuclear sclerosis Oct. 3 1 , '52 Intracapsular extraction. O.S. no compli cations D e c . 21, '53 complete detachment; retinal hole about 3 disc, size
(Right) F e b . '58 surface diathermy near equator upper quadrant. Apr. '58 surface diathermy lower quadrant (ball electrode)
(Right) Apr. '60 cataract extraction elsewhere. 3 months ago; total detachment; n o reattachment was attempted
(Left) Apr. '60 surface diathermy near equator (ball electrode)
( B o t h Eyes) Feb. '56 high pathologic myopia R. - 1 4 . 0 0 L. - 1 5 . 0 0
(Right) Apr'60 surface diathermy (ball electrode)
July 1963 Feb. 14, '63 Intracapsular O.S. 2 0 / 2 0 N o complications Oct. '58 Intracapsular extraction no complications
Jan. 1961 20/100
July '60 Intracapsular extraction no complications
N o v . 1961 20/25
Aug. '60 Intracapsular extraction small vitreous lost
Jan. 1961 20/60
PREVENTION OF RETINAL DETACHMENT ential row of diathermy points. A hole was then found in the center of this and scierai bucking, performed by Dr. Paul Cibis, resulted in reattachment. One year later, the corrected vision re mained at 20/25. It is our thought that the retina was held partly up in place by the circumferential diathermy cicatrix, and that the fate of this eye would have been similar to the patient's other one in which three retinal detachment operations failed, had it not been for the prophylactic diathermy. No. 22, L. B. In another patient, there was a severe choroidal detachment requiring drainage of the subchoroidal fluid through scierai incisions in the first eye, a month after cataract extraction. This procedure of retinal sealing was carried out on the other eye four months before cataract surgery. There were no operative complications during the time of the cataract extraction, but immediately afterwards, a small choroidal detachment developed, but subsided after two weeks without surgical intervention. No. 25, H. L. Mc. A cataract was removed from the right eye of a 62-year-old man in February, 1961, and the cor rected vision, R.E., in April, 1961, was 20/30. A few days later, a bullous detachment occurred in the upper temporal quadrant, with holes at the 12 and 9-o'clock positions. To reattach the retina, the globe was encircled with a polyethylene tube and diathermy applications were made to permit the escape of subretinal fluid. Air was injected into the viterous to hold the retina and choroid against the sciera; five months after the original cataract extraction, the corrected vision was 20/30. In March, 1962, the choroid of the left (second) eye was diathermized circumferentially and in July, 1962, the cataract was removed in its capsule from this eye. Corrected vision in the left eye after two
757
months was 20/20, and it has remained at this level to date. Meanwhile, back with the right eye. Six months after the encircling polyethylene tube and diathermy procedure was successful in reattaching the retina, it became detached again. A revision of the first operation was performed by Dr. Paul Cibis in December, 1962. By March, 1963, the right eye had recovered 20/70 vision and in April, 1963, it detached for the third time, on this occasion, along the ora in the upper half of the eye. At this writing in May, 1963, the eye has recovered 20/70 vision two weeks after the third retinal detach ment. This experience confirms the obvious that retinal sealing assures better fixation of the retina than reattachment after detachment. The course of events in the 29 patients of this series is set forth in Table 1. SUMMARY
In 29 patients with detachment of the ret ina following cataract extraction in the first eye, or in extreme myopia in which detach ment seemed likely to occur after cataract ex traction, diathermy was applied to the pe ripheral retina of the second eye three months or more before the cataract was removed. In 28 eyes, some of which have now been fol lowed for nine years, no detachment has oc curred and the one which did detach extended only to a limited degree and was successfully repaired. The results achieved by this procedure justify its continued use. 903 South 21st Street.
REFERENCES
1. Callahan, A.: Prevention of retinal detachments in cataractous eyes. Am. J. Ophth., 47:576-578 (Apr.) 1959. 2. Franceschetti, A.: New operations and some special indications and techniques in ophthalmic sur gery. Am. J. Ophth., 39:189-197 (Feb.) 1955. 3. Guyton, J. S.: Complications after cataract extraction: Pathologic aspects. In Symposium: Cataract Extraction. Tr. Am. Acad. Ophth., 58:397-407 (May-June) 1954. 4. Lincoff, H. A.: The prophylactic treatment of retinal detachment. AMA Arch. Ophth., 66:48-60 (July) 1961. 5. Maumenee, A. E.: Postoperative complications: Retinal detachment. Tr. Am. Acad. Ophth., 61:5168 (Jan.-Feb.) 1957. 6. Perez, L. F.: Profilaxia del desprendimiento de retina en la afaquia. Arq. Soc. Oftal. HispanoAm, 20:57-65, 1960. 7. Rychener, R. O.: Weve diathermy electrode: A new modification. Am. J. Ophth., 24:322-323 (Mar.) 1941. 8. Paufique, L.: The present status of the treatment of retinal detachment. Tr. Ophth. Soc. U. King dom, 69:221-226, 1959. 9. Zuccoli, A.: A new prophylactic surgical treatment for detachment. Soc. Fran. Ophtal., 72:609620, 1959. 10. : About transconjunctival diathermocoagulation in the prophylaxis of retinal detachment. Ophthalmologica, 143:333-339, 1962.
CALLAHAN,
M.D.,
AND
LUIS
PEREZ-MARTINEZ,
M.D.
Birmingham, Alabama
In two previous articles on the prophy laxis of retinal detachment in cataractous eyes which we have written independently,1'6 a tabular description was included of the course of events in which detachment of the retina was prevented in the second eye of 11 patients. This communication increases the total to 29 and the follow-up time of the ear lier cases has now been extended to eight years; an improved surgical technique and some new observations are herewith pre sented. Lincoff's studies4 on prophylaxis of retinal detachment considers the problem in its widest aspects. His paper includes recom mendations for the management of holes in the retinal periphery, points out that pig ment demarcation lines will not limit the extent of detachment, notes the rarity of true macular holes and suggests the best method of managing them, recommends the management of various types of degen erated retinal areas which might lead to detachment, and ends by considering the prevention of retinal detachment of cata ractous eyes in which a detachment occurred idiopathically or followed a cataract extrac tion from the other eye. In this last group, Lincoff comments on the two factors which will bring on a retinal detachment in the second eye : 1. Vitreous detachment will follow cat aract removal just as certainly after extracapsular as after intracapsular extraction, and the latter method should always be used to avoid having capsular remnants in the pupillary area. He indicates that there are other reasons also why he prefers the intra capsular method. 2. If a retinal hole can be seen, it should be sealed with surface diathermy. Lincoff also recommends that at the end
of the first postoperative week after cataract extraction, a careful examination be made of the retinal periphery for holes and any found be sealed with the light coagulator. If the examination shows that a detachment has already begun, six weeks must be al lowed to elapse before the traditional method of retinopexy can be performed. During these six weeks, he bandages both eyes. He believes that a circumferential row of di athermy applications around the retinal pe riphery has only a small chance of closing a retinal hole for the hole may be behind the ring and a detachment will occur, and if the hole is anterior to the ring, fluid may spread beneath the retina and around to find an opening in the diathermy barrier or dis sect its way over it, causing a detachment. Also, he believes that the series so far re ported have been too small. We would agree that the ideal solution is to locate the hole or degenerative area of the retina and to treat it with surface di athermy before a detachment occurs. Un fortunately, many patients who had a de tachment to follow the cataract extraction in the first eye prefer to wait for the re moval of the cataract from their second eye until their vision has been reduced by the cataract to less than 20/200, and by this time, an accurate and complete examination of the fundal periphery for the location of holes is unsatisfactory. Even in patients who will submit to surgery earlier, a retinal hole may form that cannot be visualized because of the partially opaque lens. For these rea sons it is not always possible to find and seal a retinal hole. Lincoff's plan for bi lateral bandaging if a detachment has oc curred is much more confining than two days of hospitalization with the retinal seal ing operation three months prior to the
752
PREVENTION OF RETINAL DETACHMENT cataract extraction. This series of 29 is still not large, but should be more convinc ing than one of 11, since all patients, with out exception, have useful vision in the eye treated in this way. In only one did a de tachment occur, and it was limited in extent and the sealing helped to hold the retina and choroid to the sciera until a secondary opera tion could be performed. Paufique8 in his Bowman Lecture in 1959 stated that, when one eye had been affected by a retinal detachment, the other eye had a 25-percent chance of becoming similarly af fected should the lens be affected. This proba bility becomes greater when the cataract is presenile or when there is an absence of he reditary factors for the cataract, or when vitreous loss has occurred. Of the 48 patients upon whom Zuccoli used transconjunctival diathermy coagula tion, three had a detachment following the removal of a cataract and in none of these did the retina of the second eye detach after coagulation, later followed by cataract ex traction. Among the other patients, he cured three flat detachments in young myopes, one eye with pars plana uveitis and multiple holes near the ora were sealed off in 12 eyes without the complication of detachment following. A pyrometric electrode was used —first to the medial sciera and then to the lateral sciera. His coagulations were placed as far anteriorly from the macula as possi ble to permit an ophthalmoscopic observation of the coagulation. Commenting on this article in the April, 1963, Survey of Ophthalmology, Robb Mc Donald judges intrascleral diathermy to be a safe procedure. However, he recommends that the conjunctiva be reflected from the sciera, and the diathermy applied directly to the sciera to gain a better control of the choroidal reaction. In addition to the circumferential ring of diathermy adhesions, the ophthalmologist may make careful postcataract extraction observations and if a retinal hole is present posterior to the adhesions, it can be sealed.
753
Since only one of 29 eyes had a detachment occur, and this detachment was limited and was successfully repaired, fears that surface diathermy performed routinely on such eyes might frequently cause detachment are un founded. IMPROVED SURGICAL TECHNIQUE
Perforating diathermy is not necessary. For scieras of normal thickness, we use par tially penetrating electrodes (0.5 mm. and 0.75 mm. with a voltage on the Walker coagulator of 40 volts) and for thin scieras we use surface diathermy applied with a ball tip with voltage of 25 to 30 volts. Par ticular attention is paid to the site of the detachment in the first eye to see if in the second eye there is a symmetrically located thinning of the sciera with the choroid show ing through externally with a bluish tinge. Sometimes this has developed and the ball electrode is used to sear lightly the sciera over this area with the current reduced to 20 volts. We try to keep the diathermy low enough so that when looking at the retina afterwards only a faint whitish coagulated area can be seen, and we like to see pig mentary changes occur within the second postoperative week. We have continued to use the circum ferential diathermy for highly myopic eyes with evidence of choroidal and retinal stretching preparatory to cataract extractions even if this is the first eye. The conjunctiva is not cut in a complete circle around the eye, but only between each of the four muscles (fig. 1-A). It is un necessary to make a complete cut as it is possible to apply diathermy to the sciera beneath each of the rectus muscles with an insulated electrode such as Rychener's, in serting the electrode from the end of the incision (fig. 1-B). The spared conjunctiva and Tenon's capsule bridge over the rectus muscles permit a more rapid recovery from the operative reaction. The diathermy applied beneath the medial and lateral rectus muscle is diminished in
754
ALSTON CALLAHAN AND LUIS PEREZ-MARTINEZ
strength to avoid coagulation of the long posterior ciliary arteries and ciliary nerves. The sciera should be bared of episcleral tissue and dried to facilitate the diathermy action; the diathermy application should turn the sciera slightly yellow or grayish, but not brownish or black. Because of the opacity of the usual cataract at this time, indirect ophthalmoscopy may be of no value, but should be attempted unless the lens is completely opaque. To bring the surface area of the sciera into easy view for diathermy, a muscle hook can be introduced beneath two adjacent rec tus insertions, and the eye tilted so that the area between the two muscles is in the center of the palpebral fissure. Special care is necessary in extreme myopia, for the sciera may be so thin that pulling too firmly on the tendonous insertion may tear the sciera open with disastrous results. Interrupted suturing of the conjunctiva and Tenon's capsule in each of the four quadrants for more accurate reunion of tis sue is preferred to a continuous suture. In many eyes the sealing procedure has lowered
the ocular tension for several weeks or a few months, but we have not had this last for more than four months, and it has produced no side-effects such as edema of the macula. CASES OF SPECIAL I N T E R E S T
No. 19, D. C. This 52-year-old patient has three brothers who had cataracts beginning around the age of 50 years and two of them had retinal detachments either before or after cataract surgery. After the cata ract was extracted from his right eye in 1954, examination showed no retinal holes. The last routine postoperative follow-up of this patient's right eye was on January 20, 1955, at which time the retina showed no holes. However, in January, 1961, more than six years after the cataract ex traction, the lower temporal quadrant of the retina became detached and two holes were found. The scierai buckling procedure was successful in reattaching the retina for only a few months and two further attempts to reattach the retina were unsuccessful. Preparatory to the cataract extrac tion from the left eye, surface and partial pene trating diathermy was carried out on the left eye. Three months later an intracapsular cataract ex traction was performed, and there were no operative or postoperative complications. Postoperatively the fundus was subjected to careful study at intervals, and no holes were seen. However, six months after the cataract extraction the retina detached at the 12-o'clock position just anterior to the circumfer-
Fig. 1 (Callahan and Perez-Martinez). Application of diathermy current to ora for firm union of peripheral retina and choroid with the sciera. (A) Ball end of Cibis electrode used for application every two to three mm. from the edge of one rectus insertion to the next. (B) Rychener electrode used to apply diathermy current to sciera beneath rectus tendons.
TABLE 1 SURVEY OF CASES
No.
Initials Race, Sex Age (yr.)
Details of Retinal Detachment of First Eye
Date of Retinal Sealing Second Eye and Type
Date and Type of Cataract Extrac tion Second Eye
Date of Last Observation and Corrected Vision
1
C. H. w. m. 24
(Left) Dec. '51 extracapsular extraction, vitreous was fluid, no threatened loss. Oct. '53 retinopexy including scierai buckling but later complete redetachment
(Right) Nov. 12, '56 Surface diathermy
July 13, '54 Feb. 1956 Extracapsular, 20/25 small loss vitreous
2
M. J. w. m. 65
(Right) Extracapsular extraction of hypermature lens, Nov. ' 54 reattachment achieved, Nov. '56, complication of corneal dystrophy after orbital cellulitis, visual acuity never regained better than 20/200
(Left) Nov. 12, '56 partial penetrat ing diathermy
Mar. 11, '56 Intracapsular, no complications
April 1963 20/20
3
D. A. R. w. m. 56
(Right) Cataract extraction elsewhere followed 3 mo. later by detachment after the operation, and two unsuccessful attempts at reattachment
(Left) Sept. 16, '55 Surface diathermy
Dec. 28, '55 Intracapsular, no complications
Jan. 1963 20/15-1
4
W. J. W. w. m. 82
(Left) (Right) Cataract extraction performed elsewhere in Apr. '53, Aug. 16, '54 followed by hemorrhage three days postoperatively, Surface and when first examined by me seven months later mas diatherm y sive detachment of retina present. Chronic uveitis re quired enucleation, Apr. '54
Feb. 4, '55 Intracapsular, no complications
July 1955 20/50
S
J. E. C. w. f. 73
6
P. F. w. f. 55
7
W. M. Mc. w. f. 73
8
(Right) Cataract was removed Dec. '53. When first examined by me in May '54, the retina had been detached for some months Case complicated by severe senile cicatricial entropion which required surgical correction before surgery of the globe begun
(Left) July 23, '54 Partial penetrat ing diathermy
Nov. 26, '54 Intracapsular, no complications
Dec. 1960 20/40
(Left) Cataract was removed Nov. '54. When first examined by us in July '55, retina was completely detached
(Right) Oct. 23, '55 Partial penetrat ing diathermy
Apr. 16, '55 Intracapsular, no complications
Jan. 1961 20/40
(Left) Idiopathic detachment, left eye, about '45. No surgical reattachment attempted
(Right) Feb. 18, '57 Surface diathermy
May 10, '57 Intracapsular, fluid vitreous presented
June 1960 20/25
(Right) E. C. M. C. Retinal detachment after cataract operation performed in another city, then enucleation w. f. 70
(Left) Jan. 16, 1958 Partial penetrat ing
May 29, 1958 Intracapsular, no complications
Jan. 1962 20/30
(Left) Idiopathic total detachment. Unsuccessful reattach ment attempt performed elsewhere in 1948
(Right) Mar. 5, '59 Partial penetrat ing diathermy
Apr. 6, '59 Intracapsular, no complications
June 1962 20/60
9
T. B. P. w. m. 57
10
J. S. A. w. m. 58
(Right) Oct. '51 intracapsular extraction; no complications Sept. '56 Disinsertion (inferior) at the ora serrata. Un successful lamellar scierai resection
(Left) May 28, '59 Surface diathermy
Intracapsular, no complications
Sept. 1962 20/25
11
G. L. M. w. m. 63
(Right) July '59 Cataract extraction, small bead of vitreous was lost Aug. '59 Inferior retinal detachment. Unsuccessful scierai infolding with polyethylene tube
(Left) Oct. 1, '59 Partial penetrat ing diathermy
Mar. 3, '60 Intracapsular, no complications
Jan. 1963 20/20-1
12
J. M. L. w. m. 85
(Right) Dec. '59 Hypermature cataract. No light projection in lower half of eye. Retina believed to be detached
(Left) Jan. 7, '60 Partial penetrat ing
Mar. 29, '60 Intracapsular, no complications
Aug. 1962 20/30 +
13
A. Mc. M. w. m.
(Right) June '50 High pathologic myopia R. -11.00 -2.75X57 L. -20.00 -2.00X129
(Left) Feb. 4, '60 June 3, '60 Note: cataract Intracapsular O.D. was re moved same date without retinal sealing
14
P. T. w. m. 47
(Right) Complete total detachment; no details 20 years pre viously
(Left) Mar. 3, '60 Sciera thin superiorally under neath superior muscle
June 16, '60 Extracapsular, no complications
July 1961 20/20-3
15
B. T. w. f. 67
(Right) Feb. '53, cataract extraction, no complications May '53 Retinal detachment lower nasal quadrant; no holes (disinsertion) retina reattached but one month later total detachment; no further efforts to reattach it, posteriorly (1 month) suprisingly good settling of retina V. = H . M .
(Left) Mar. 24, '60 Scierai staphlomas in upper quadrant, applied surface diathermy with ball electrode
July 21, '60 Intracapsular cataract extrac tion, loss of bead of fluid vitreous
Sept. 1962 20/25
(Table 1 continued on next page)
April 1963 20/60
TABLE 1. (Continued) No.
Initials Race, Sex Age (yr.)
Details of Retinal Detachment of First Eye
D a t e of Retinal Sealing Second Eye and T y p e
D a t e of Last D a t e and T y p e of Observation Cataract Extrac and Corrected tion Second E y e Vision
(Both Eyes) High pathologic myopia R. - 1 0 . 5 0 - 3 . 0 0 X 1 0 L. - 7 . 7 5 - 3 . 7 5 X 1 8 0
(Right) June 30, '60 Surface diathermy
Dec. 15, '60 Intracapsular, n o complications
Sept. 1962 20/30
(Left) M a y '60 Cataract extraction performed elswewhere; large fiat detachment; encircling tube
(Right) Jan 5, '61 Partial penetrat ing diathermy
Mar. 30, '61 Intracapsular, no complications
Feb. 1963 20/60-1
H. C. w. f. 69
(Right) Oct. '60 Cataract extraction performed elsewhere last Jan. Discission was done in June with secondary bleed ing; almost complete retinal separation; n o tear seen, upper temporal and lower retina including macula, un successful encircling tube. 9 / 1 0 / 6 2 enucleated
(Left) Jan. 12, '61 Partial penetrat ing diathermy
Apr. 6, '61 Intracapsular, no complications
Aug. 1962 20/20-3
19
D . C. w. m. 52
(Right) '54 Cataract extraction. Jan. 13, '61 detachment lower temporal quadrant; 2 holes. Scierai bucking with supramyd tube (successful). Detached again posteriorly, detached again posteriorly, reoperated, again a failure
(Left) Jan. 19, '61 Surface and par tial penetrating diathermy
Apr. 27, '61 Intracapsular, no complications. In Oct. '61 retinal separation at 12 o'clock successful scierai buckling
April 1963 20/20
20
R. B. w. m. 65
(Right) Oct. '56, high pathologic myopia O.U. Hypermature cataract O . D . no light perception detachment
(Left) June 6, '61 Surface diathermy
Aug. 24, '61 Intracapsular, no complications
March 1963 20/30 Retinal hemorrhages due to diabetes
21
G. E. J. w. m. 48
16
P. M . G. w. m. 43
17
P. B. E. w. f. 71
18
&
22
23
L. B. w. f.
24
H . L. w. m. 79
25
H . L. Mc. w. m. 62
26
C. A. S. w. f.
27
M . E. V. w. f. 54 P.
28
J. M . c. m. P.
29
M. F. w. f. P.
(Both Eyes) (Both Eyes) N o v . 2, '61 N o v . ' 6 1 , megalocornea, mature cataracts, sciera quite thin. D u e to abnormal construction and probable fragil Partial penetrat ing diathermy ity of ocular tissues, retinal sealing indicated
(Right) Apr. 21, '60 cataract extraction uneventful, but postoperatively severe choroidal detachment which re quired draining of t A e subchoroidal fluid through scierai incisions
(Left) N o v . 30, '61
(Right) Cataract extraction elsewhere several years ago; fol lowed by a complete retinal detachment
(Left) Mar. 15, '62
(Right) Feb. 9, '61 intracapsular cataract extraction; no opera tive complications. Corrected vision 4 / 1 / 6 1 2 0 / 3 0 ; Bullous separation in upper temporal quadrant cover ing the macula with a tear a t 12:00 and a t 9 : 0 0 . 4 / 1 3 / 6 2 360° encircling tube & diathermy t o retina with injection of air i n t o vitreous. Vision, O . D . 7/21/62—20/30
(Left) Mar. 16, '62 Retinal sealing
Feb. 8, '62 Aug. 1963 Intracapsular O.S. 2 0 / 3 0 , O. S. N o complications Sept. 27, '62 Intracapsular 2 0 / 3 0 , O. D . Extraction O . D . N o complications March 1963 Apr. 5, '62 Intracapsular O.S. 2 0 / 2 0 0 Optic no complications Atrophy June 14, '62 Intracapsular, no complications
Jan. 1963 20/50
July 23, '62 Cataract extrac tion, no complica tions
Mar. 1963 20/70
1 2 / 1 7 / 6 2 the right retina detached again, the scier ai buckling was revised by Dr. Paul Cibis; vision 3 / 1 / 6 3 right 2 0 / 7 0 ; deteriorated t o 20/200 July 1963
(Right) Aug. 1948—Idopathic detachment (no details) success ful diathermy reattachment. Separation again
(Left) Mar. 2, '61
(Both Eyes) Apr. '48 High myopia; chronic glaucoma; partial optic atrophy; nuclear sclerosis Oct. 3 1 , '52 Intracapsular extraction. O.S. no compli cations D e c . 21, '53 complete detachment; retinal hole about 3 disc, size
(Right) F e b . '58 surface diathermy near equator upper quadrant. Apr. '58 surface diathermy lower quadrant (ball electrode)
(Right) Apr. '60 cataract extraction elsewhere. 3 months ago; total detachment; n o reattachment was attempted
(Left) Apr. '60 surface diathermy near equator (ball electrode)
( B o t h Eyes) Feb. '56 high pathologic myopia R. - 1 4 . 0 0 L. - 1 5 . 0 0
(Right) Apr'60 surface diathermy (ball electrode)
July 1963 Feb. 14, '63 Intracapsular O.S. 2 0 / 2 0 N o complications Oct. '58 Intracapsular extraction no complications
Jan. 1961 20/100
July '60 Intracapsular extraction no complications
N o v . 1961 20/25
Aug. '60 Intracapsular extraction small vitreous lost
Jan. 1961 20/60
PREVENTION OF RETINAL DETACHMENT ential row of diathermy points. A hole was then found in the center of this and scierai bucking, performed by Dr. Paul Cibis, resulted in reattachment. One year later, the corrected vision re mained at 20/25. It is our thought that the retina was held partly up in place by the circumferential diathermy cicatrix, and that the fate of this eye would have been similar to the patient's other one in which three retinal detachment operations failed, had it not been for the prophylactic diathermy. No. 22, L. B. In another patient, there was a severe choroidal detachment requiring drainage of the subchoroidal fluid through scierai incisions in the first eye, a month after cataract extraction. This procedure of retinal sealing was carried out on the other eye four months before cataract surgery. There were no operative complications during the time of the cataract extraction, but immediately afterwards, a small choroidal detachment developed, but subsided after two weeks without surgical intervention. No. 25, H. L. Mc. A cataract was removed from the right eye of a 62-year-old man in February, 1961, and the cor rected vision, R.E., in April, 1961, was 20/30. A few days later, a bullous detachment occurred in the upper temporal quadrant, with holes at the 12 and 9-o'clock positions. To reattach the retina, the globe was encircled with a polyethylene tube and diathermy applications were made to permit the escape of subretinal fluid. Air was injected into the viterous to hold the retina and choroid against the sciera; five months after the original cataract extraction, the corrected vision was 20/30. In March, 1962, the choroid of the left (second) eye was diathermized circumferentially and in July, 1962, the cataract was removed in its capsule from this eye. Corrected vision in the left eye after two
757
months was 20/20, and it has remained at this level to date. Meanwhile, back with the right eye. Six months after the encircling polyethylene tube and diathermy procedure was successful in reattaching the retina, it became detached again. A revision of the first operation was performed by Dr. Paul Cibis in December, 1962. By March, 1963, the right eye had recovered 20/70 vision and in April, 1963, it detached for the third time, on this occasion, along the ora in the upper half of the eye. At this writing in May, 1963, the eye has recovered 20/70 vision two weeks after the third retinal detach ment. This experience confirms the obvious that retinal sealing assures better fixation of the retina than reattachment after detachment. The course of events in the 29 patients of this series is set forth in Table 1. SUMMARY
In 29 patients with detachment of the ret ina following cataract extraction in the first eye, or in extreme myopia in which detach ment seemed likely to occur after cataract ex traction, diathermy was applied to the pe ripheral retina of the second eye three months or more before the cataract was removed. In 28 eyes, some of which have now been fol lowed for nine years, no detachment has oc curred and the one which did detach extended only to a limited degree and was successfully repaired. The results achieved by this procedure justify its continued use. 903 South 21st Street.
REFERENCES
1. Callahan, A.: Prevention of retinal detachments in cataractous eyes. Am. J. Ophth., 47:576-578 (Apr.) 1959. 2. Franceschetti, A.: New operations and some special indications and techniques in ophthalmic sur gery. Am. J. Ophth., 39:189-197 (Feb.) 1955. 3. Guyton, J. S.: Complications after cataract extraction: Pathologic aspects. In Symposium: Cataract Extraction. Tr. Am. Acad. Ophth., 58:397-407 (May-June) 1954. 4. Lincoff, H. A.: The prophylactic treatment of retinal detachment. AMA Arch. Ophth., 66:48-60 (July) 1961. 5. Maumenee, A. E.: Postoperative complications: Retinal detachment. Tr. Am. Acad. Ophth., 61:5168 (Jan.-Feb.) 1957. 6. Perez, L. F.: Profilaxia del desprendimiento de retina en la afaquia. Arq. Soc. Oftal. HispanoAm, 20:57-65, 1960. 7. Rychener, R. O.: Weve diathermy electrode: A new modification. Am. J. Ophth., 24:322-323 (Mar.) 1941. 8. Paufique, L.: The present status of the treatment of retinal detachment. Tr. Ophth. Soc. U. King dom, 69:221-226, 1959. 9. Zuccoli, A.: A new prophylactic surgical treatment for detachment. Soc. Fran. Ophtal., 72:609620, 1959. 10. : About transconjunctival diathermocoagulation in the prophylaxis of retinal detachment. Ophthalmologica, 143:333-339, 1962.