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ARTICLE
Year : 1966  |  Volume : 14  |  Issue : 4  |  Page : 171-175

Arruga's encircling operation in detachment of retina


Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India

Date of Web Publication17-Jan-2008

Correspondence Address:
S.R.K Malik
Department of Ophthalmology, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Malik S, Sethi D V, Sood G C, Gupta A N. Arruga's encircling operation in detachment of retina. Indian J Ophthalmol 1966;14:171-5

How to cite this URL:
Malik S, Sethi D V, Sood G C, Gupta A N. Arruga's encircling operation in detachment of retina. Indian J Ophthalmol [serial online] 1966 [cited 2020 Feb 27];14:171-5. Available from: http://www.ijo.in/text.asp?1966/14/4/171/38638

A variety of methods have been devised for treating cases of retinal detachment since Gonin (1929) emphasized the importance of closure of retinal tears. They are all based on the same principle, that of inducing aseptic regional chorioretinitis to seal the tears and to drain the subretinal fluid that prevents reattachment of the retina. Many earlier methods aimed at merely sealing the tears failed because of the presence of vitreo-retinal adhesions which prevented the reattachment of the retina. In such cases, apart from diathermy, surgical techniques are required which promote the contact of retina with the choroid. This is usually achieved by two ways

(i) By reducing the size of the eye ball,

(ii) By injecting air, physiologic salt solutions, silicon fluids or vitreous in the vitreous cavity.

Lindner (1949) introduced full thickness scleral resection. Shapland (1953) modified it to lamellar resection. Custodis (1951) used polyviol cylinder to cause a ridge in the sclera in the affected quadrant to reduce the intraocular volume. Schepens (1958) used polyethylene tube with the same object. Arruga (1958) passed a nylon thread around the globe in the equatorial region. Many other workers have successfully used Arruga's technique. A somewhat more complicated technique has been reported by Girard and McPherson (1962) who used silicon rubber for circlage and photo coagulator for sealing the holes. Havner and Oslon (1962) and Moor (1963) have preferred fascial strips over nylon sutures.

The aim of the present study is to report our experience with Arruga's circlage operation.


  Methods and Material Top


In this study, we used the classical technique described by Arruga.


  Technique of operation Top


After conventional anesthesia and akinesia the conjunctiva is injected between the four recti with 2% xylocain. The conjunctiva is incised at four places 6 to 8 mm away and concentric with the limbus and the incisions undermined and enlarged as required by spreading the scissors in the 4 zones between the recti muscles. The zone of the retinal holes is diathermized. A nylon 3/0 suture on a flat scleral needle is passed in the superficial layers of sclera between the recti muscles parallel to the equator and behind the zone of retinal holes. The needle is passed backwards from the blunt end under the muscle. After the suture has been passed all-round the eye ball the subretinal fluid is drained by diathermy puncture and the suture is tied to build up the intraocular pressure to normal or slightly above.

Conjunctiva) sutures, atropine and binocular bandage, complete the procedure.

14 cases of retinal detachment were operated by this technique.

--Total retinal detachment ... 8 cases.

(in one case scleral resection with diathermy had already been done)

--Long standing aphakic detachment... 2 cases

--Failure with diathermy of scleral resection... 2 cases.

--High myopia... I case.

--Traumatic detachment with multiple tears...I case.


  Observations Top


Age: This series of 14 cases covered all ages between 11 and 70 years, the maximum being in the age groups of 11-20 (4) and 41-50(4).

Sex : Thirteen were males and only one female.

Refraction: Eight were emmetropic and six had myopia.

Holes: None were detected in eight cases. In two there was a single hole and in four the holes were multiple. Cases no. 2 and i i had anterior dialysis.

Type of detachment : Three were cases of aphakia, in two the detachment was traumatic, in four it was simple (exudative?) whereas six were myopic.

Re-attachment: Detachment settled completely in 8 cases. In 4 cases, shallow detachment persisted. There was no improvement in the remaining two cases.


  Complications Top


Infection: Occurred in one case with exudative detachment of retina. Organisms were resistant to all antibiotics.

Severe post operative reaction : Occurred in one case which was controlled by removing the suture after two weeks.

Stay in the hospital: Average stay in the hospital was three weeks. In cases where complications occurred or the detachment did not settle, the stay was prolonged.


  Discussion Top


The success in retinal detachment surgery depends not only on a careful and elaborate examination and accurate charting of the condition of the retina and location of holes by indirect and direct ophthalmoscopy but also on a thorough examination of the condition of the vitreous which is equally important for planning and success of the operation. At present our knowledge about the vitreous is limited, but it is possible to recognize vitreous retraction and vitreoretinal adhesions which are of great importance in retinal detachment. The presence of these vitreo retinal adhesions can be suspected when the retina does not settle after sufficient bed rest and closure of both eyes.

Good results are still being obtained with classical diathermy operation in 75% or more of all retinal detachments (Pico 1958) but in the remaining cases, vitreous disease itself plays a more important part than the retinal disease. The high incidence of detachment of vitreous without retinal detachment and the high incidence of retinal tears without retinal detachment indicate that it is not these factors alone which produce a retinal detachment. An added requirement is the presence of firm and deep vitreo retinal adhesions. Such attachments have been demonstrated with silver stains. When there is vitreous disease numerous firm and deep attachments occur between the vitreous and the retina. The stage is then set for true retinal detachment. If the theory of retraction of the diseased vitreous in these cases of retinal detachment is accepted, then simply reducing the volume of the globe, theoretically should result in reattachment of retina. Whatever volume reducing procedure is selected, one should be careful that there is not too much trauma which may not further enhance retraction of the already diseased vitreous.

Total scleral resection of Lindner is difficult, time consuming and hazardous. Lamellar resection of Shapland is easier but the shortening in a single quadrant or half circle at times is not sufficient to reduce the volume of the eyeball sufficiently and has to be repeated in the other half circle making the technique difficult and prolonging the stay of the patient in bed. Also thinned sclera due to resection and diathermy makes it difficult for other procedures to be performed if the need arises. Custodis' (1951) and Schepens' (1958) techniques, though good, are not without hazards. Arruga's technique (1958) offers the following advantages: -

(i) The technique is simple.

(ii) The dangers of lamellar resection are eliminated such as injury to Vortex Veins, inadvertent damage to choroid with subsequent haemorrhage and premature loss of sub-retinal fluid with or without vitreous loss.

(iii) No muscle has to be detached and hence no after effect.

(iv) No anchoring sutures etc. are required.

(v) Displacement of circling suture is uncommon.

(vi) Repetition of operation is without difficulty as no anatomical disturbance of the structures takes place.

(vii) Ambulation is early and hence suitable for elderly patients. Hospitalization is for a shorter period.

In our cases the period of hospitalization was rather long because we had no experience with this technique. Hence we were cautious. The average stay of patients in Owen's (1963) experience was 2 weeks. In our cases it was about three weeks. In one case where infection occurred the stay was unusually prolonged.

Few post operative complications such as infection, allergic reaction and glaucoma have been reported in the literature. Infection usually results either from lack of proper sterilization or when suture material does not allow thorough sterilization as by autoclaving etc. It occurred in one case in this series (Case No. 10) where organisms were resistant to all the antibiotics. The infection though coming under control has not yet subsided and in all probability we shall have to remove the nylon thread.

Allergic reaction probably to the nylon suture, occurred in one case (Case No. 14) where intense swelling of lids and chemosis of conjunctiva etc. did not subside even after the 15th post-operative day and the suture had to be removed, after which the reaction subsided. Law (1963) also reported this complication in one case.

No glaucoma occurred in any of our cases. Foulds (1963) noted that a number of eyes after the operation had raised intraocular tension for 2 to 3 months after operation. In our cases the tension was at the higher limits of normal in some cases but raised intraocular pressure was not met with.

Out of 14 eyes the detachment completely settled after the operation in 8 eyes and the ridge showed up all round. In 3 partially successful cases the ridge could only be seen in the area where the retina had settled and not in the detached portion. In 3 cases the retina did not settle. Amongst these was one eye where a reaction necessitated the removal of the suture and the other 2 eyes were those of high myopia which were operated for detachment twice before, resulting in complicated cataracts which had to be removed before scleral encirclage operation was done.

Amongst 3 partially successful cases, case No. 10 showed complete reattachment of retina in the immediate post operative period but later developed an exudative detachment when the wound got infected.

Law (1963) while reporting on 28 cases where circlage operation was done, got 12 complete successes, 4 partial successes and 12 unsuccessful results. The relatively higher success rate in our cases was probably because our cases were of comparatively recent origin than those selected by Law and not many bands had formed in th-_ retina. In our 3 unsuccessful eyes, in one the suture had to be removed due to reaction while the other 2 eyes were of long standing detachment.

The results have been encouraging and suggest that the operation may be employed in properly selected cases.[15]

 
  References Top

1.
Arruga. H., Bull. Soc. Fs. d'o 1958.  Back to cited text no. 1
    
2.
Arruga, H. (1951), American Jr. of Ophth. 35: 1573.  Back to cited text no. 2
    
3.
Arruga. H., Highlights of Ophthal. Edited by Benjamin J. Boyd Part 11, 1958 P. 170-172.  Back to cited text no. 3
    
4.
Arruga, H., Ocular Surgery, Mc. Grow Hill Book Co., ICN, New York. third ed'tion 1962, P. 638.  Back to cited text no. 4
    
5.
Brockhurst, R. .I. Scheiens. C. L. and Okanura. I. D.. A.M.A. Arch. Ophthal. 60: 1003.  Back to cited text no. 5
    
6.
Girard, L. J., Highlights of Ophthall. 4: 42. 1960-196).  Back to cited text no. 6
    
7.
Girard. L. J.. and M1c Pherson, A. R. (1962), Arch. Opthal. 67: 409.  Back to cited text no. 7
    
8.
Havner. W. H. Oslon R. S. (1962). Arch. Ophthal. 67: 721.  Back to cited text no. 8
    
9.
Law. F. L. (1963), hrans. Ophthal. Soc. U.K. 171.  Back to cited text no. 9
    
10.
l.indner, K (1949), Arch. Ophthal. 42: 634. 1949.  Back to cited text no. 10
    
11.
Okanura. I. D. Schepens. G. L. and Brockhurst, k. J. (1959), A.M.A. Arch. Ophthal. 62: 445.  Back to cited text no. 11
    
12.
Pico. G. (1958). Amer. .I. Ophthal. 45: 227.  Back to cited text no. 12
    
13.
Schepens, C. L. Okanura, J.D.. and Brockhurst, R. J. (1958), A.M.A. Arch. 60: 84.  Back to cited text no. 13
    
14.
Shapland. C. D. (1951), Trans. Of Ophthal. Soc. C. Kingdom, 71: 29.  Back to cited text no. 14
    
15.
Shapland. C.D. (1953), Brit. Jr. Ophthal. 37: 177.  Back to cited text no. 15
    


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