|Year : 1974 | Volume
| Issue : 1 | Page : 25-29
Retinal detachment. (Operative experience in hundred consecutive cases)
B Patnaik, R Kalsi
Department of Ophthalmology, Maulana Azad Medical College and associated Irwin and G.B. Pant Hospitals, New Delhi, India
Department of Ophthalmology, Maulana Azad Medical College and associated Irwin and G.B. Pant Hospitals, New Delhi
|How to cite this article:|
Patnaik B, Kalsi R. Retinal detachment. (Operative experience in hundred consecutive cases). Indian J Ophthalmol 1974;22:25-9
|How to cite this URL:|
Patnaik B, Kalsi R. Retinal detachment. (Operative experience in hundred consecutive cases). Indian J Ophthalmol [serial online] 1974 [cited 2013 May 21];22:25-9. Available from: http://www.ijo.in/text.asp?1974/22/1/25/31384
The analysis of hundred consecutive cases of retinal detachment operated over a period of 2 years (1969-1971) by the authors is the subject of this paper. Any case with slightest hope of success was taken up for treatment.
All the cases were examined by direct and indirect ophthalmoscopy and Goldmann's three-mirror contact lens biomicroscopy. When the patient co-operated a pre-operative scleral indentation was carried out otherwise the examination of the retina down to pars plana was completed with indentation under general anxsthesia on the table.
As a routine, patients were put on complete bed rest with binocular patching for 3-4 days. The behaviour of the retina after rest was noted. Thereafter the patients were prepared for operation. The majority of the cases were operated under general anaesthesia.
Cases were Grouped for prognostication after the classification suggested by Jesberg  The anatomical reattachment was considered as success for the purposes of this paper. Redetachment was considered as failure.
| Observations|| |
The age distribution of the cases is shown in [Table - 1]. The right eye was involved in 63 cases and the left eye in 47. There were 77 male and 33 female patients.
The probable cause of detachment has been depicted in [Table - 2]. The approximate age of detachment calculated from the date, the patient had noticed visual defect suggestive of detachment of retina has been depicted in [Table - 3].
The type of operative procedure chosen in different categories of cases are shown in [Table - 4].
Percentage of success in each class in this series will be seen against the expected percentage success according to Jesberg's classification in [Table - 5].
No holes could be detected in 19 cases. The important factors responsible for this failure have been shown in [Table - 6]. [Table - 7] lists the operative and post-operative complications encountered in this series.
[Figure - 1] is a diagrammatic representation of all the holes detected in 81 cases, their types, approximate relative size and position in the fundus.
| Discussion|| |
It is encouraging to note [Table - 5] that the success rate in this series is uniformly better in all classes of detachment than the expected percentage indicated by Jesberg  who has taken into account the experience of Arruga  and Schepens  in computing the expected percentages of success. The most important factors responsible for this fairly satisfying results to our mind was the painstaking, time-consuming preoperative examination using indirect ophthalmoscope and contact lens. There were only five cases out of a total of one hundred cases where failure to detect holes could be attributed to a technical failure on the part of the investigator.
Though the detection of all the holes remains the most important element in successful management of rhegmatogenous retinal detachment, a careful pre-planning of the surgical steps, utmost concentration and lot of patience on the part of surgeons are equally important factors in the ultimate success of the case. An accurate localization of the holes by indentation on the table before diathermy and frequent checks to ascertain just adequate retinopexy is practicable only with the routine use of indirect ophthalmoscope on the table.
It is obvious that a clear media is absolutely essential for a successful operation. Constant wetting of the cornea with normal saline maintained at about body temperature is important. Cold solutions, as in the winter, unless frequently warmed, is likely to cause corneal haziness. A badly administered general anesthesia where patient struggles or tends to cough with resultant raising of venous pressure in the head and neck leads to marked rise of intraocular pressure and corneal haziness. One is likely to land up in this uncomfortable situation any time during the operation. A high intraocular pressure during drainage of subretinal fluid is dangerous. Chances of incarceration of retina and vitreous are great.
Drainage of fluid from a sclerotomy appears to us a superior procedure to drainage by a puncture diathermy. However, in presence of a shallow detachment there is a definite risk of retinal incarceration or injury to the retina. It may be noted that the major part of serious complications of retinal detachment surgery in this series stemmed from drainage of the fluid [Table - 7]. In this context the procedure advocated by Custodis 2 (1960) in cases of retinal detachment with mobile retinal breaks seems to be a highly attractive proposition. After retinopexy over the hole, a buckle is produced by passing indirect sutures across a silicon implant. No fluid is drained. The patient is mobilised immediately. The subretinal fluid rapidly disappears, almost miraculously. We have a limited experience of 6 cases in which after closing the holes, alcohol preserved homosclera was implanted on lamellar separation. The fluid was not drained and the patient was mobilized immediately after operation. The results were dramatic in all but one case, which happens to be the only case who was not mobilized for a long time (10 days) after the operation*. Scott  has emphasised the importance of immediate mobilization in this form of therapy. The mechanism of this interesting phenomenon is not clear.
Simple diathermy in the presence of continuing vitreous traction around a hole is likely to fail in producing a chorioretinal adhesion. What may be appropriate in such cases is a localised buckle with or without an encircling procedure. Similarly aphakics with evidence of vitreous loss, not responding to rest or showing evidence of vitreous traction need more extensive procedure. Multiple holes, with one or two holes situated quite posterior to the equator are best dealt with using Arruga's encirclage procedure combined with one or two radial buckles as the first procedure.
Our experience with Arruga's encirclage has been generally gratifying. Complete drainage of the fluid with judicious tightening of the string are important. When too much of subretinal fluid drains out, the intraocular pressure should be brought up by injection of air or suitable fluids into the vitreous and not by too much tightening of the string, in which case, meridional folds of retina develop across the buckle and may result in failure. Though one is apt to be apprehensive about the possibility of cutting through of the string in these cases, we have not seen erosion in any case in this series in a follow up period of 6 months to 3 years.
Photocoagulation has a limited but definite place in the management of retinal detachments. We have used this procedure in sealing macular holes, re-enforcing inadequately diathermized holes, completing the retinopexy after producing reattachment, -covering missed holes and in carefully selected cases it has been used as a prophylaxis to retinal detachment.
| Summary|| |
An objective analysis of 100 consecutive cases of retinal detachment operated has been made. Careful preoperative examination, preplanning of operative steps, routine use of indirect ophthalmoscope on the table and attention to details were thought to be factors responsible for generally satisfactory results. Special mention has been on Custodis's technique, Arruga's encircling procedure and judicious use of photocoagulation.
| References|| |
|1.||Arruga, H., 1952, Trans. Amer. Acad. Ophthal. Otolaryng., 56, 535-512. |
|2.||Custodis, E., 1960, Importance of vitreous body in retinal surgery with special reference to reoperation 175. C.V. Mosby Co., St. Louis. |
|3.||Schepens, C.L., 1952, Trans. Amer. Acad. Ophthal. Otolaryng., 56, 398-412. |
|4.||Jesberg, D.O., 1968, New and controversial aspects of retinal detachment. Edited by Me. Pherson, 158, A., Hoeber Medical Division, New York. |
|5.||Scott. J.D.. 1970, Trans. Ophthal. Soc., (U.K.), XC, 57-77. |
[Figure - 1]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7]