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ORIGINAL ARTICLE
Year : 1985  |  Volume : 33  |  Issue : 1  |  Page : 23-26

Scleral buckling for retinal breaks without detachment


Aravind Eye Hospital & Postgraduate Institute of Ophthalmology Madurai, India

Correspondence Address:
Taraprasad Das
Aravind Eye Hospital & Postgraduate Institute of Ophthalmology Madurai
India
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Source of Support: None, Conflict of Interest: None


PMID: 4077200

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How to cite this article:
Das T, Namperumalsamy P. Scleral buckling for retinal breaks without detachment. Indian J Ophthalmol 1985;33:23-6

How to cite this URL:
Das T, Namperumalsamy P. Scleral buckling for retinal breaks without detachment. Indian J Ophthalmol [serial online] 1985 [cited 2019 Aug 20];33:23-6. Available from: http://www.ijo.in/text.asp?1985/33/1/23/27326



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The reported frequency of retinal breaks without detachment varies between 5% to 21 % among patients examined[1]. The series analysed consists of autopsy eyes, patients complaining of light flashes or floa­ters, patients with posterior vitreous detach­ment, patients with vitreous haemorrhage or asymptomatic patients. Commonly cryoretino­pexy, photocoagulation or combination of both are recommended, especially for the sympto­matic retinal breaks[2],[3],[4],[5],[6],[7] Reports of retinal detachment following prophylactic treatment ranges from 0 to 6% with the observed rate of new break formation upto 11.5% This entails that certain retinal breaks without detachment need surgical intervention.

This communication deals with the criteria for selecting cases for scleral buckling instead of cryoretinopexy or photocoagulation in the treatment of retinal breaks without detach­ment and eleven eyes operated for the same in our Institute forms the basis of this report.


  Materials and method Top


In four and half years period, June 1979 to December 1983, 94 individuals underwent prophylactic treatment. chiefly cryoretinopexy, for symptomatic retinal breaks. Eleven eyes of ten patients (11.70%) were operated. There were eight males and two females. with an average age of 45.2 (25-65 years). ten eyes were phakic and one eye was s phakic. Out of ten phakic eyes seven were high myopes (equal to or more than 6D) and three were less myopic. In seven cases single horse shoe tears were present (case 1-4, 8, 9, 11). in one eye one horseshoe tear and a round hole was seen (case 5), other three eyes had multiple round holes with lattice degeneration (case 6,7.10). In six individuals (seven eyes) retinal breaks were symptomatic with complaints of light flashes and in three individuals retinal breaks were detected on routine examination. One patient reported with sudden loss of vision and was found to have fresh vitreous haemorrhage of unknown aetiology. After adequate bed rest when the vitreous haemorrhage cleared, a single horse shoe tear in the upper temporal quadrant was detected. In ten cases the retinal breaks were in the upper half, and in nine of them it was located in the upper temporal quadrant.

Examination of the fellow eyes showed that in two of them detachment surgery was done before and lost (case 1.3), one patient (case 11) had total retinal detachment with massive preretinal retraction (MPR). in two patients fellow eye had asymptomatic retinal breaks (2. 6), one patient had extensive lattice degeneration (case 8) and in two fellow eyes there were complicated cataract where retinal detachment was detected ultrasonically (case 7, 10). In one case fellow eyes was normal (case 9) and one had symptomatic retinal breaks in both the eyes (case 4, 5). One patient had undergone prophylactic cryore­tinopexy one year back (case 3) and a single horse shoe tear was detected in the untreated area when he reported with flashes of light. The details of the presenting symptoms, fundus finding, refractive status and condi­tion of the fellow eye are shown in [Table - 1].

Preoperative examination included a detailed ophthalmic history, visual acuity determination, external eye examination, estimation of refractive error, applanation tonometry, binocular indirect ophthalmos­copy with scleral depressor, and examination with three mirror contact lens, when indicated.

All the operations were done using solid silicone implants and 360 degree encircling band. In cases of single horse shoe tears meridional wedge implants and in other cases circumferential implants were used. In all the cases 36U degree encircling was done. Intravenous 20% Mannitol drip was given in all the cases during operation since there was no sub retinal fluid to drain and at the end of the surgery intra ocular pressure was always measured with a sterile Schiotz tono­meter to ensure that it is not unduly raised. Diathermy was used to create chorioretinal adhesions in all the cases except when the tears were found to be located close to or over the anterior ciliary arteries; in those cases cryo instead of diathermy was used.


  Observations and discussions Top


There were no operative or postoperative complications. In all the cases the preo­perative visual acuity was retained. One patient who was beginning to have nuclear sclerosis underwent successful cataract surgery twenty months following scleral buckling. All the cases were followed for a period varying from six months to two and half years, with an average follow up time of 14 months.

The usual modality of treatment of sym­ptomatic retinal breaks without detachment is cryoretinopexy or photocoagulation[1],[2]. Reports of retinal detachment following such treatment ranges from 0 to 6% with the observed rate of new break formation upto 11.5% either in the treated or in the untrea­ted area and fresh retinal breaks are thought more likely to cause retinal detachment. In an observation of retinal breaks without detachment or subclinical detachment not treated prophylactically, 18% progressed and it was found that 30% to 50% of eyes with fresh horse shoe tears would go for detachment left untreated. This entails that a selected and risky group of patients with retinal breaks without detachment need be treated surgically. It requires detection and accurate localisation of predisposing lesions and their adequate treatment by seal­ing of actual or potential retinal breaks and release of vitreo retinal traction. Photocoa­gulation or cryoretinopexy is done in cases of symptomatic retinal breaks not associated with vitreo retinal traction.

In cases of retinal breaks with vitreous traction like horse shoe tears and operculated holes traction has to be relieved to prevent detachment of retina in future. Similarly when there are multiple round holes distri­buted in more than one quadrant scleral buckling is a more logical procedure to adopt than prophylactic cryoretinopexy. In this series eight out of eleven eyes had horse shoe tear with evident vitreoretinal traction and one of them had undergone cryoretinopexy a year prior to the development of a fresh horse shoe tear in the untreated area.

Consideration of the fellow eye is also an important criteria for selecting the patients for scleral buckling for retinal break without detachment. Five out of eleven eyes in our series had retinal detachment, two of them operated and lost and two had developed complicated cataract where retinal detach­ment was detected ultrasonically. In one patient the fellow eye had one round hole with anisometropic amblyopia. One patient had horse shoe tears in both the eyes and one patient had extensive lattice degeneration in the fellow eye. Only one fellow eye was normal. Considering about refractive error nine out of eleven eyes were myopes, five of them equal to or more than 6D, one patient was aphakic and only one patient was emmetrope.

Hence it emerges that certain types of breaks without detachment need be treated surgically and various indications, in our opinion, are:

(i) Horse shoe tear with vitreous traction

(ii) Multiple retinal breaks with lattice degeneration distributed in more than one quadrant

(iii) State of the fellow eye (iv) Aphakia

Prophylactic encirclement and local scleral buckling for horse shoe tears, especially if situated in supero-temporal quadrant are advocated by Hudson et al[6]. and Lincoff[7] respectively. But in our patients, in addition to scleral buckling with wedge or circumferential implants, 360 degree encircling was done in all the cases as this ensures permanency of the buckle of predictable height and width and reduces traction on existing and potential retinal breaks in the equatorial region continuously over 360 degree21.

Successful surgery was done in all the cases in our series and the fact that one of them bad prophylactic cryoretinopexy earlier, and a new horse shoe tear with vitreous traction appeared a year later, underlines the need for scleral buckling in the cases discussed and demands for identification as these retinal breaks different from other symptoma­tic or asymptomatic retinal breaks without detachment.


  Summary Top


Eleven eyes with retinal breaks without detachment, operated by scleral buckling and 360 degree encerclage using solid silicone implants and band are described. This constitutes 11.70% of prophylactic treatment done in four and half years period.

 
  References Top

1.
Morse, P.H., 1977: "Controversy in Ophthal­mology", Philadelphia W.B. Saunders pp-518-24 R.J., et al (ed)  Back to cited text no. 1
    
2.
Chignell. A.B. and Shilling, J., 1973: Brit. J. Ophthalmol. 57: 291  Back to cited text no. 2
    
3.
Kanski, J.J. and Daniel, R., 1975: Amer. J. Ophthalmol. 79: 197.  Back to cited text no. 3
    
4.
Morse, P.H., Scbeie H.G., 1974: Arch. Ophthalmol. 92 :204  Back to cited text no. 4
    
5.
Okun, E. and Cibis, P.A., 1968. "New and Controversial aspects of retinal detachment" Mcpher­son, A. (ed) New York. Haprer and Row pp-164-72, 1968  Back to cited text no. 5
    
6.
Hudson, J.R , Kanski, J.J. & Elkington, A.R., 1973 : Brit. J. Ophthalmol. 57 : 531   Back to cited text no. 6
    
7.
Lincoff, H.A. , 1961, Arch: Ophthalmol. 66 : 74  Back to cited text no. 7
    



 
 
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