- Email: [email protected]
Treating Avulsed Vessels With a Temporary Balloon Buckle
Treating Avulsed Vessels With a Temporary Balloon Buckle H. Lincoff, M.D., I. Kreissig, M.D., and G. Richard, M.D.
We treated nine patients with avulsed retinal vessels by first expanding a balloon in the parabulbar space to buckle the vessel temporarily and then applying a laser beam to the avulsed segment. In three patients the avulsed vessel was an artery and in six it was a vein. The avulsion was the only abnormality in three patients; in six it was combined with a retinal break, which was accompanied by a detachment in five. The balloon brought the avulsed portion of the vessel into contact with the retina and the pigment epithelium and made it receptive to laser coagulation. Flow in the vessel could be slowed or stopped while the patient was undergoing laser treatment by further expanding the balloon. OUR EXPERIENCE with the balloon buckle in treating retinal detachments suggested that it might be useful in patients with avulsed retinal vessels. Buckles had been previously tried, with indifferent results, by Robertson, Curtin, and Norton! and De Bustros and Welch. 2 Only Chatzoulis and associates" credited buckling with preventing hemorrhage. All these buckles were composed of episcleral silicone sponges and were intended to relieve traction on the vessel. The purpose of the balloon buckle in our patient was to bring the retina and the pigment epithelium temporarily into contact with the avulsed segment so that laser energy could be effectively transferred to the vessel. The balloon could be expected to produce a Accepted for publication Oct. 25, 1985. From the Department of Ophthalmology, New York Hospital-Cornell Medical Center, New York, New York (Dr. Lincoff); and the Universitats-Augenklinik, Tiibingen, German Federal Republic (Drs. Kreissig and Richard). This study was presented in part before the International Laser Symposium in Interlaken, Switzerland, June 6, 1985. Reprint requests to H. Lincoff, M.D., Department of Ophthalmology, New York Hospital, 525 E. 68th St., New York, NY 10021.
90
buckle high enough for this purpose. Such a buckle might cause morbid effects, such as sector ischemia, if it were permanent. After treating the first patient in March 1982, we treated eight other patients with avulsed retinal vessels prospectively with the combined buckle-laser technique. Although the number of patients is small, the results have been uniform enough to justify this report.
Subjects and Methods The balloon used to treat avulsed vessels is identical to that used for treating retinal detachments.' An injection of 1 ml of saline expands the balloon to a diameter of 1.2 cm and buckles an area of retina approximately 6 mm in diameter, or one clock hour at the equator. We inserted the balloon into the Tenon's space through a 1.5-mm puncture in the anterior conjunctiva, maneuvered it beneath the avulsed segment, and expanded it until the retina came into contact with the vessel. Expanding the balloon displaces ocular contents and increases intraocular pressure. A highly elevated vessel might not come into contact with the balloon buckle immediately but as intraocular pressure diminishes the buckle becomes higher. If contact had not been made when the intraocular pressure reached normal levels, we added more saline to the balloon in increments of 0.3 to 0.5 ml, with a pause between injections to allow the intraocular pressure to return to normal. If a retinal detachment was present, the balloon was expanded beneath the retinal break; the position of the break always coincided with that of the avulsed vessel. If the retina became reattached but the vessel was still elevated, we expanded the balloon further until it reached the vessel. In procedures performed in Tiibingen, the balloon was inserted with the patient under topical
©AMERICAN JOURNAL OF OPHTHALMOLOGY 101:90-94, JANUARY, 1986
Vol. 101, No. 1
91
Balloon Buckle for Avulsed Vessels
anesthesia (a subconjunctival injection of 5% cocaine in the operative quadrant). In those done in New York, the balloon was inserted with the patient under retrobulbar anesthesia (2% lidocaine with hyaluronidase 1:10,000). The laser beam was applied to the avulsed vessel after it came into contact with the retina and the pigment epithelium. At first we used a spot size of 500 to 800 urn at energy settings just sufficient to whiten the retina around the vessel to protect the choroid. Then the balloon was expanded further to slow or stop the flow of blood in the vessel and we applied a spot of 100 to 200 urn at energy settings sufficient to constrict the vessel. We worked in an energy range of 100 to 400 mW at a time setting of 0.2 to 0.5 second. We used an argon blue laser beam in patients whose eyes had clear media and an argon green beam if there was any interference from cataractous changes in the lens. The beam was applied to the entire length of the avulsed segment of the vessel. We examined the vessel 30 minutes later and treated it again if it had reopened. The vessel was examined daily thereafter and subjected to additional laser applications if there was any evidence of blood flow. If the vessel remained closed for two consecutive days, the balloon was deflated and removed. Examinations were performed after six weeks, three months, and six months and were augmented by angiography if there was any doubt about the patency of the vessel. We used this balloon technique in nine patients with avulsed vessels. In three patients avulsion of a vessel was the only abnormality; in six the avulsion was accompanied by a retinal break and an operculum was attached to the vessel. Five of the six torn retinas were detached; four detachments were confined to the vicinity of the tear, whereas one filled a quadrant and extended to the ora serrata. An artery was avulsed in three patients and a vein in six. The avulsion occurred in the course of the superotemporal vessels in eight patients and in the superonasal vessels in one. All avulsions were beyond the second bifurcation. In seven patients the avulsion was accompanied by some hemorrhage. When the hemorrhage was large enough to cloud the media, both eyes were occluded, and these patients were positioned with their heads elevated until the blood settled to the inferior periphery. Seven patients were seen shortly after the initial episode; one was examined one year after the probable occurrence of the avulsion, at the time of a second
hemorrhage. One, whose case we have selected for a more detailed description, was examined two years after the avulsion on the occasion of her third hemorrhage.
Case Report A 60-year-old woman underwent an intracapsular cataract operation in 1979 and Experienced three subsequent hemorrhages. Each of the three was severe and caused visual clouding. The first two hemorrhages occurred during the following year. After the first hemorrhage cleared, an avulsed vessel was coagulated by laser. After the second hemorrhage a vitrecto my was performed to remove the blood and sever the traction on the vessel. Cryopexy was applied in an attempt to close the vessel. The third hemorrhage, for which the patient sought our advice, occurred 11 months after the vitrectomy. By the time we examined her, the hemorrhage had cleared enough for additional therapy to be considered. Examination disclosed that a segment of the superotemporal artery was avulsed. The separation began just beyond the second bifurcation and extended to the equator (Figs. 1 to 3). The vessel vibrated with each pulse wave. Cryopexy-induced chorioretinal scars were present beneath the vessel. The optic disk and
Fig. 1 (Lincoff, Kreissig, and Richard). Drawing of retina in a 60-year-old woman with an avulsed vessel. The avulsion begins distal to the second bifurcation of the superotemporal artery. The underlying tissues are scarred from previous laser and cryopexy treatments.
92
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Lincoff, Kreissig, and Richard). Fundus showing the proximal part of the avulsed vessel (arrows).
January, 1986
macula were slightly obscured by a fibrous net in the vitreous. Corrected visual acuity was 20/30. With the patient under retrobulbar anesthesia, the midpoint of the avulsed segment was localized transconjunctivally by depression and was found to be 17 mm from the corneoscleral limbus and in the 2:30 0' clock meridian. The anterior conjunctiva was punctured at the . 2:30 o'clock meridian, 8 mm from the corneoscleral limbus, and the baIIoon catheter was inserted to a distance of 17 mm and expanded with 1 ml of normal saline. One hour later, when the intraocular pressure had returned to normal, the avulsed vessel appeared to be in loose contact with the buckle; the vessel quivered on the buckle's retinal surface with each pulse wave. The addition of 0.5 ml of saline to the baIIoon stretched the vessel tightly across the buckle and stopped the pulse wave (Fig. 4). An argon green laser beam was applied to the pulseless vessel, beginning just beyond the
Fig. 3 (Lincoff, Kreissig, and Richard). Montage of two angiograms of avulsed segment (between arrows). Proximal part is at 18 seconds in fluorescein transit and distal part at 39 seconds.
Vol. 101, No. 1
Balloon Buckle for Avulsed Vessels
93
September 1985, when the patient was reexamined, only a white nubbin representing the proximal end of the vessel was still attached to the retinal vasculature. The remainder of the avulsed segment had separated and was floating in the midvitreous, attached to the posterior hyaloid membrane.
Results
Fig. 4 (Lincoff', Kreissig, and Richard). Inflating the balloon beneath the avulsed segment stretches the vessel tightly across the surface of the retina.
bifurcation. The laser applications temporarily closed the vessel, but by the next day it had reopened. The vessel was treated again, with a 200-fLm beam for 0.2 second. The vessel closed easily and this time remained closed. Two days after the second laser treatment the balloon was deflated and removed. After six weeks, three months (Fig. 5), and six months the vessel appeared as a white cord. It did not pulsate and there was no evidence of blood in its lumen. Visual acuity was 20/30. In
Fig. 5. (Lincoff, Kreissig, and Richard). After three months the proximal part of the artery (arrows) shows no evidence of blood flow.
Five of the nine vessels were closed with one laser treatment, one required two treatments, two required three, and one required four. All the vessels have remained closed during follow-up periods of six to 42 months. No symptoms or signs of bleeding have occurred.
Discussion Our balloon buckle-laser technique differs only slightly from laser and buckling techniques that we and others have used previously. The better results obtained with the balloon are probably a product of applying the laser along the entire length of the avulsed segment while it is in contact with pigment epithelium and the flow of blood has been slowed or stopped. Inflating the balloon sufficiently to stop flow is painful for the patient, but no more so than pressing a gonioscopic lens against the eye to stop flow. One of us (I.K.) uses the moment when the patient reports darkening of vision as the end point for inflating the balloon and the patient's report that vision has returned as the indication that retinal blood flow has resumed. 5 An additional advantage of the balloon technique is that it makes it possible to confine the laser applications to the avulsed segment of the vessel. The alternative is to apply the laser to the vessel proximal and distal to the avulsion. However, avulsions tend to end proximally at a bifurcation because bifurcations are a point of increased resistance; thus, subjecting an adequate length of the vessel to laser coagulation with this method usually entails closing a branch of the vessel, often a major one. In our patient, such treatment would have necessitated closing the second superior branch of the temporal artery and would have significantly increased the extent of the scotoma.
94
AMERICAN JOURNAL OF OPHTHALMOLOGY
References 1. Robertson, D., Curtin, V., and Norton, E: Avulsed retinal vessels with retinal breaks. Arch. Ophthalmol. 85:669, 1971. 2. De Bustros, S., and Welch, R.: The avulsed retinal vessel syndrome and its variants. Ophthalmology 91:86, 1984. 3. Chatzoulis, D., Theodossiadis. G. P., Apostopoulos, M., and Koitsandrea, c.: Rezidi-
January, 1986
vierende Glaskorperblutungen infolge eines in die Glaskerperhohle hereingezogenen Netzhautgefasses. Klin. Monatsbl. Augenheilkd. 183: 256, 1983. 4. Lincoff, H., Kreissig, I., and Hahn, Y. S.: A temporary balloon buckle for the treatment of small retinal detachments. Ophthalmology 86:586, 1979. 5. Kreissig, I., Stanowsky, A., Lincoff, H., and Richard, G.: The treatment of difficult retinal detachments with an expanding gas bubble without vitrectomy. Graefes Arch. Clin. Exp. Ophthalmol., in press.
We treated nine patients with avulsed retinal vessels by first expanding a balloon in the parabulbar space to buckle the vessel temporarily and then applying a laser beam to the avulsed segment. In three patients the avulsed vessel was an artery and in six it was a vein. The avulsion was the only abnormality in three patients; in six it was combined with a retinal break, which was accompanied by a detachment in five. The balloon brought the avulsed portion of the vessel into contact with the retina and the pigment epithelium and made it receptive to laser coagulation. Flow in the vessel could be slowed or stopped while the patient was undergoing laser treatment by further expanding the balloon. OUR EXPERIENCE with the balloon buckle in treating retinal detachments suggested that it might be useful in patients with avulsed retinal vessels. Buckles had been previously tried, with indifferent results, by Robertson, Curtin, and Norton! and De Bustros and Welch. 2 Only Chatzoulis and associates" credited buckling with preventing hemorrhage. All these buckles were composed of episcleral silicone sponges and were intended to relieve traction on the vessel. The purpose of the balloon buckle in our patient was to bring the retina and the pigment epithelium temporarily into contact with the avulsed segment so that laser energy could be effectively transferred to the vessel. The balloon could be expected to produce a Accepted for publication Oct. 25, 1985. From the Department of Ophthalmology, New York Hospital-Cornell Medical Center, New York, New York (Dr. Lincoff); and the Universitats-Augenklinik, Tiibingen, German Federal Republic (Drs. Kreissig and Richard). This study was presented in part before the International Laser Symposium in Interlaken, Switzerland, June 6, 1985. Reprint requests to H. Lincoff, M.D., Department of Ophthalmology, New York Hospital, 525 E. 68th St., New York, NY 10021.
90
buckle high enough for this purpose. Such a buckle might cause morbid effects, such as sector ischemia, if it were permanent. After treating the first patient in March 1982, we treated eight other patients with avulsed retinal vessels prospectively with the combined buckle-laser technique. Although the number of patients is small, the results have been uniform enough to justify this report.
Subjects and Methods The balloon used to treat avulsed vessels is identical to that used for treating retinal detachments.' An injection of 1 ml of saline expands the balloon to a diameter of 1.2 cm and buckles an area of retina approximately 6 mm in diameter, or one clock hour at the equator. We inserted the balloon into the Tenon's space through a 1.5-mm puncture in the anterior conjunctiva, maneuvered it beneath the avulsed segment, and expanded it until the retina came into contact with the vessel. Expanding the balloon displaces ocular contents and increases intraocular pressure. A highly elevated vessel might not come into contact with the balloon buckle immediately but as intraocular pressure diminishes the buckle becomes higher. If contact had not been made when the intraocular pressure reached normal levels, we added more saline to the balloon in increments of 0.3 to 0.5 ml, with a pause between injections to allow the intraocular pressure to return to normal. If a retinal detachment was present, the balloon was expanded beneath the retinal break; the position of the break always coincided with that of the avulsed vessel. If the retina became reattached but the vessel was still elevated, we expanded the balloon further until it reached the vessel. In procedures performed in Tiibingen, the balloon was inserted with the patient under topical
©AMERICAN JOURNAL OF OPHTHALMOLOGY 101:90-94, JANUARY, 1986
Vol. 101, No. 1
91
Balloon Buckle for Avulsed Vessels
anesthesia (a subconjunctival injection of 5% cocaine in the operative quadrant). In those done in New York, the balloon was inserted with the patient under retrobulbar anesthesia (2% lidocaine with hyaluronidase 1:10,000). The laser beam was applied to the avulsed vessel after it came into contact with the retina and the pigment epithelium. At first we used a spot size of 500 to 800 urn at energy settings just sufficient to whiten the retina around the vessel to protect the choroid. Then the balloon was expanded further to slow or stop the flow of blood in the vessel and we applied a spot of 100 to 200 urn at energy settings sufficient to constrict the vessel. We worked in an energy range of 100 to 400 mW at a time setting of 0.2 to 0.5 second. We used an argon blue laser beam in patients whose eyes had clear media and an argon green beam if there was any interference from cataractous changes in the lens. The beam was applied to the entire length of the avulsed segment of the vessel. We examined the vessel 30 minutes later and treated it again if it had reopened. The vessel was examined daily thereafter and subjected to additional laser applications if there was any evidence of blood flow. If the vessel remained closed for two consecutive days, the balloon was deflated and removed. Examinations were performed after six weeks, three months, and six months and were augmented by angiography if there was any doubt about the patency of the vessel. We used this balloon technique in nine patients with avulsed vessels. In three patients avulsion of a vessel was the only abnormality; in six the avulsion was accompanied by a retinal break and an operculum was attached to the vessel. Five of the six torn retinas were detached; four detachments were confined to the vicinity of the tear, whereas one filled a quadrant and extended to the ora serrata. An artery was avulsed in three patients and a vein in six. The avulsion occurred in the course of the superotemporal vessels in eight patients and in the superonasal vessels in one. All avulsions were beyond the second bifurcation. In seven patients the avulsion was accompanied by some hemorrhage. When the hemorrhage was large enough to cloud the media, both eyes were occluded, and these patients were positioned with their heads elevated until the blood settled to the inferior periphery. Seven patients were seen shortly after the initial episode; one was examined one year after the probable occurrence of the avulsion, at the time of a second
hemorrhage. One, whose case we have selected for a more detailed description, was examined two years after the avulsion on the occasion of her third hemorrhage.
Case Report A 60-year-old woman underwent an intracapsular cataract operation in 1979 and Experienced three subsequent hemorrhages. Each of the three was severe and caused visual clouding. The first two hemorrhages occurred during the following year. After the first hemorrhage cleared, an avulsed vessel was coagulated by laser. After the second hemorrhage a vitrecto my was performed to remove the blood and sever the traction on the vessel. Cryopexy was applied in an attempt to close the vessel. The third hemorrhage, for which the patient sought our advice, occurred 11 months after the vitrectomy. By the time we examined her, the hemorrhage had cleared enough for additional therapy to be considered. Examination disclosed that a segment of the superotemporal artery was avulsed. The separation began just beyond the second bifurcation and extended to the equator (Figs. 1 to 3). The vessel vibrated with each pulse wave. Cryopexy-induced chorioretinal scars were present beneath the vessel. The optic disk and
Fig. 1 (Lincoff, Kreissig, and Richard). Drawing of retina in a 60-year-old woman with an avulsed vessel. The avulsion begins distal to the second bifurcation of the superotemporal artery. The underlying tissues are scarred from previous laser and cryopexy treatments.
92
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Lincoff, Kreissig, and Richard). Fundus showing the proximal part of the avulsed vessel (arrows).
January, 1986
macula were slightly obscured by a fibrous net in the vitreous. Corrected visual acuity was 20/30. With the patient under retrobulbar anesthesia, the midpoint of the avulsed segment was localized transconjunctivally by depression and was found to be 17 mm from the corneoscleral limbus and in the 2:30 0' clock meridian. The anterior conjunctiva was punctured at the . 2:30 o'clock meridian, 8 mm from the corneoscleral limbus, and the baIIoon catheter was inserted to a distance of 17 mm and expanded with 1 ml of normal saline. One hour later, when the intraocular pressure had returned to normal, the avulsed vessel appeared to be in loose contact with the buckle; the vessel quivered on the buckle's retinal surface with each pulse wave. The addition of 0.5 ml of saline to the baIIoon stretched the vessel tightly across the buckle and stopped the pulse wave (Fig. 4). An argon green laser beam was applied to the pulseless vessel, beginning just beyond the
Fig. 3 (Lincoff, Kreissig, and Richard). Montage of two angiograms of avulsed segment (between arrows). Proximal part is at 18 seconds in fluorescein transit and distal part at 39 seconds.
Vol. 101, No. 1
Balloon Buckle for Avulsed Vessels
93
September 1985, when the patient was reexamined, only a white nubbin representing the proximal end of the vessel was still attached to the retinal vasculature. The remainder of the avulsed segment had separated and was floating in the midvitreous, attached to the posterior hyaloid membrane.
Results
Fig. 4 (Lincoff', Kreissig, and Richard). Inflating the balloon beneath the avulsed segment stretches the vessel tightly across the surface of the retina.
bifurcation. The laser applications temporarily closed the vessel, but by the next day it had reopened. The vessel was treated again, with a 200-fLm beam for 0.2 second. The vessel closed easily and this time remained closed. Two days after the second laser treatment the balloon was deflated and removed. After six weeks, three months (Fig. 5), and six months the vessel appeared as a white cord. It did not pulsate and there was no evidence of blood in its lumen. Visual acuity was 20/30. In
Fig. 5. (Lincoff, Kreissig, and Richard). After three months the proximal part of the artery (arrows) shows no evidence of blood flow.
Five of the nine vessels were closed with one laser treatment, one required two treatments, two required three, and one required four. All the vessels have remained closed during follow-up periods of six to 42 months. No symptoms or signs of bleeding have occurred.
Discussion Our balloon buckle-laser technique differs only slightly from laser and buckling techniques that we and others have used previously. The better results obtained with the balloon are probably a product of applying the laser along the entire length of the avulsed segment while it is in contact with pigment epithelium and the flow of blood has been slowed or stopped. Inflating the balloon sufficiently to stop flow is painful for the patient, but no more so than pressing a gonioscopic lens against the eye to stop flow. One of us (I.K.) uses the moment when the patient reports darkening of vision as the end point for inflating the balloon and the patient's report that vision has returned as the indication that retinal blood flow has resumed. 5 An additional advantage of the balloon technique is that it makes it possible to confine the laser applications to the avulsed segment of the vessel. The alternative is to apply the laser to the vessel proximal and distal to the avulsion. However, avulsions tend to end proximally at a bifurcation because bifurcations are a point of increased resistance; thus, subjecting an adequate length of the vessel to laser coagulation with this method usually entails closing a branch of the vessel, often a major one. In our patient, such treatment would have necessitated closing the second superior branch of the temporal artery and would have significantly increased the extent of the scotoma.
94
AMERICAN JOURNAL OF OPHTHALMOLOGY
References 1. Robertson, D., Curtin, V., and Norton, E: Avulsed retinal vessels with retinal breaks. Arch. Ophthalmol. 85:669, 1971. 2. De Bustros, S., and Welch, R.: The avulsed retinal vessel syndrome and its variants. Ophthalmology 91:86, 1984. 3. Chatzoulis, D., Theodossiadis. G. P., Apostopoulos, M., and Koitsandrea, c.: Rezidi-
January, 1986
vierende Glaskorperblutungen infolge eines in die Glaskerperhohle hereingezogenen Netzhautgefasses. Klin. Monatsbl. Augenheilkd. 183: 256, 1983. 4. Lincoff, H., Kreissig, I., and Hahn, Y. S.: A temporary balloon buckle for the treatment of small retinal detachments. Ophthalmology 86:586, 1979. 5. Kreissig, I., Stanowsky, A., Lincoff, H., and Richard, G.: The treatment of difficult retinal detachments with an expanding gas bubble without vitrectomy. Graefes Arch. Clin. Exp. Ophthalmol., in press.