|Year : 1959 | Volume
| Issue : 3 | Page : 72-75
Cataract and retinal detachment
Eye Hospital, Sitapur, India
J M Pahwa
Eye Hospital, Sitapur
|How to cite this article:|
Pahwa J M. Cataract and retinal detachment. Indian J Ophthalmol 1959;7:72-5
The subject of detachment surgery presents many perplexing problems to even an experienced ophthalmologist because it has to be modified and planned in each individual case to suit its merits.
Detachment of retina complicated by a cataract presents further difficult problems with a bad prognosis. This subject will be divided under following four heads:
1. Cataract in an eye which has been operated for retinal detachment.
2. Cataract in the other eye of the patient who has been operated for retinal detachment.
3. Retinal detachment with cataract.
4. Retinal detachment where cataract has been removed or aphakic detachment.
| I. Cataract in an Eye Operated for Retinal Detachment|| |
When cataract occurs in eyes where retinal detachment has been cured, surgical intervention is the only proper solution and this should be as light as possible. Though Arruga and Weve think that intra-capsular extraction if done carefully is much better and safer than extra-capsular extraction where subsequent needling, if required, will be more harmful, yet it is a routine in our hospital to do extra-capsular extraction in adults and linear extraction in very young individuals. The extra-capsular extraction has the advantage of not causing traction on the zonule and leaving the posterior capsule of the lens intact, thus frontal displacement of the vitreous or its herniation are avoided.
In those cases of detachment not fully cured but with useful vision such as occurs in some cases of inferior detachment that have become stationary (or where combined diathermy and scleral resection operation has been done) the cataract may be extracted again by extra-capsular method.
In cases not cured by operation or where the operation was not undertaken and has a complicated cataract with poor perception of light, the extraction has to be for cosmetic purposes only and I think intra-capsular extraction should be the procedure of choice where no remnant of capsule will be left.
| 2. Cataract in the Eye Opposite to one Operated for Retinal Detachment|| |
Examination of the other eye every now and then should always be done in all cases of retinal detachment because nearly 10-12% of the cases are bilateral and very many eyes can be saved by light diathermy or photocogulation of the degenerated areas and doubtful holes. In those cases where this has not been undertaken already, need a better care and Prof. Franceschetti advocates a prophylactic barrage usually in the upper two quadrants 12-13 mm. from the limbus because he thinks that the site of the detachment and the tears are usually in the upper half. Moreover inferior detachment which is rarer carries a better prognosis. This should be done very carefully usually with 25-30 ma current and the electrode should be rapidly passed on the sclera in order to obtain hardly visible coagulation, achieving a slightly yellowish colour of the sclera without parchment like areas. Then after a month intracapsular extraction without any injury to the vitreous can be safely undertaken. I prefer to use four bridal sutures in all the recti muscles supported of course by artery-forceps so that the eye-ball is almost pulled out of the orbit with absolutely no pressure of the speculum which is completely avoided. With the advent of Alpha-Chymotrypsin, it is worth our while to use it in such cases. But if it is a question of the only eye, I still prefer an extra-capsular extraction preceded by a. prophylactic diathermic barrage.
| 3. Retinal Detachment with Cataract|| |
A case of retinal detachment having lenticular changes but where examination of the fundus under full dilation is possible, can be dealt with in the usual way and carries a good prognosis. While in other cases where detailed examination of the fundus is not possible, an idea about the limit of detachment may be formed from the grey or red reflex of the fundus or from the visual field and photopsiae specially those seen by the patient at the commencement of the detachment. These cases can be treated by the operation of combined diathermy and scleral resection in one or two quadrants where tears are suspected to be present.
If the examination of the fundus is impossible then one will have to undertake surgery of cataract first (intracapsular extraction which will allow a complete examination of the fundus and is free from any reaction or iridocyclitis) followed after a month by the usual surgery for detachment. The patient of course during this time should take rest, use stenopic glasses and locally hydro-cortisone drops. In order not to miss detachment in cataract cases and to avoid disappointment both to the surgeon and the patient, testing for projection of light by weak coloured red and green lights must not be forgotten as a routine before the operation. Moreover if the history is available prognosis can be foretold by ERG examination.
| 4. Aphakic Detachments|| |
Detachment occurs quite frequently in aphakic eyes (Shapland 9'7% Weve 8%). A great majority of eyes are usually myopic. According to Arruga 1-2% of non-myopic aphakic eyes suffer detachment whereas those that are myopic suffer detachment in io-r5% of the cases. When the detachment occurs after six months from the date of operation, it is very probable that it has no relation to the operation in itself although it must be recognised that the greater mobility and frontal displacement of the vitreous are factors that favour the detachment.
It has been a source of controversy whether detachment is more common after an intra-capsular extraction. I think the percentage of cases does not differ much as greater number of cases seen these days after intra-capsular is due to the fact that it is a routine to do intra-capsular operation with many of the surgeons. It is rather the complication of loss of vitreous which is likely to occur more after total extraction that really matters and favours detachments. On the other hand if for any chance a subsequent needling is required after extra-capsular extraction it is more harmful, as said before, because of either actual tearing of the retina by too strenuous manipulation at the time of operation or by prolapse of vitreous in the anterior chamber and bands of vitreous extending backwards.
It is without any doubt that detachments are more common after repeated needlings or discissions of congenital cataract etc., (Shapland 10'7%, after an average interval of 24'6 years) a fact which contraindicates Fukala's operation and has also led to a modified operation for congenital cataract by Derrick Vail.
These aphakic detachments are well known for vitreous changes and for the most peripheral situations of the holes and tears. Moreover in these cases improvement with bed rest is all that can be obtained possibly. But before this examination of the fundus both by direct and indirect method is important. Binocular indirect stereoscopic ophthalmoscope with scleral depressor is an important supplement because it permits examination of the periphery and even where the media of the eye are somewhat hazy. A definite and thorough plan, must be followed during the search for tears. One should not be satisfied with one hole as it is not infrequent to have more than one hole in different quadrants. During operation the holes must be localised by the method of transillumination and each application of diathermy can be checked by ophthalmoscopic examination because this direct biological control is better than milliamperemeter readings.
As most of the cases are accompanied by vitreous retraction with multiple folds, and sometimes only doubtful holes or degenerated areas, a combined diathermy with lamellar scleral resection is the procedure of choice. In still more complicated and old cases I do an operation of combined diathermy, scleral buckling and reefing. In this operation there is production of a protuberance or buckle on the inner side of the sclera in one half in addition to the reduction of the volume of the whole eyeball achieved by a lamellar scleral resection and reefing in the two other quadrants. The buckle should be so placed that the retinal holes (if small) be on the crest or anterior slope of the buckle. If the hole is large or there are many holes lying at different distances behind the oraserrata then the buckle must be placed posterior to the most posterior break. Embedding of a polyethyline tube in the sclera creates a higher and more durable buckle.
In still old cases or cases where one or more operations have failed, Schaffer (1954) has developed a method of vitreous implantation by which 1.5cc of sterile vitreous is injected into the Vitreous cavity, thus acting not only mechanically by pushing the retina against the choroid but by opposing the traction of vitreous bands and having some flattening effect on the retinal folds.
In this group, I have dealt with following 16 aphakic cases, out of a total of 84 cases admitted in the Sitapur Eye Hospital over a period of 5 years. Out of these 13 were males and 3 females, Three cases had bilateral detachment but only one of them was operated on both eyes, making a total of 17 eyes in 16 cases. Myopia was present in only 6 of these cases.
Type of the Operation.
Extra-capsular extraction- 4 eyes.
Intra-capsular extraction-13 eyes.
(6 cases were operated elsewhere.)
Interval between retinal detachment and cataract operation was recorded and found to be more than 8 months in 12 eyes, while in two cases it was only 25 days and 7 weeks, respectively. In one case there was the maximum interval of II years. One case of Juvenile cataract was seen to occur after nearly 7 years where 3 needlings had been performed before.
Definite holes = 7 eyes.
Doubtful holes and degenerated areas = 4 eyes.
No holes = 6 eyes.
In all these cases a second operation where required was refused.
From the results and the type of cases tackled (almost total or complete detachment with multiple folds and vitreous changes etc.), the results of 7 cured (41.2%) and 3 Partial success (17.7%) being maintained for nearly 8 months to 22 years the results are not discouraging. The operation of combined diathermy and scleral resection in ordinary cases and in very old complicated cases which we often meet in our country, the operation of combined diathermy, scleral buckling and reefing is the procedure of choice. Air injection in the vitreous which has limited value in aphakic cases because it comes into the anterior chamber thus being of no consequence, was used only in 3 cases.
| References|| |
|1.||Arruga H., (1959), XXXV, Congress de la Soc. Oftalm. Hisp.-Amer. |
|2.||Chamlin M., (1956), Amer. J. Ophthal. 41, 633. |
|3.||Custodis, (1953), Ber. Deutsch. Ophthal, Gesel, 58, 102-105. |
|4.||Custodis, (1956), Monats. Augenh. 129, 476. |
|5.||Della Porta, (1956), Amer. J. Ophthal. 42, 189. |
|6.||Della Porta, (1957) Amer. J. Ophthal. 44, 776. |
|7.||Derick Vail, (1958), 2nd Curso international De oftalmologia Vol. i Barcelona Page 222. |
|8.||Everett W. G., (1955) A.N.A. Arch of Ophth, 53, 865. |
|9.||Francischetti A., (1955), Amer. J.Ophthal. 39, 189. |
|10.||Pahwa J. M., (1959), Trans. All India Ophthal. Soc. Trivandrum. |
|11.||Pierce L. H., (1958), 2nd International course of Ophthal. Barraquer's Inst. Barcelona. |
|12.||Schaffer D. L., (1957), Trans. Amer.Acad. Ophthal. 61, 194, |
|13.||Schaffer D. L., (1958), A.M.A. Archives of Ophth. 60, 255. |
|14.||Schaffer D. L., (1959), AMA Archives of Ophth. 61, 233. |
|15.||Schepens C. L., (1952), Trans. Amer. Acad. Ophthal. 56, 398. |
|16.||Schepens C. L., (1955), Trans. Amer. Aced. Ophthal. 56, 398. |
|17.||Schepens C. L., (1954), A.M.A. Arch. of Ophthal. 54, 143. |
|18.||Schepens C. L., Okamara I, D., et al (1957), A.M.A. Archives of Ophthal. 58. 797. |
|19.||Schepens C. L., Okamara I. D., et al. (1958), A.M.A. Arch. of Ophthal. 60, 84. |
|20.||Weve J. M., (1952), Irish Med. J. (reprint). |
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