|Year : 1964 | Volume
| Issue : 3 | Page : 123-127
Scleral buckling and intravitreal vitreous implants in retinal detachment
TN Ursekar, DG Mody, BT Maskati
Ophthalmic Department, King Edward Memorial Hospital, Bombay, India
|Date of Web Publication||13-Feb-2008|
T N Ursekar
Ophthalmic Department, King Edward Memorial Hospital, Bombay
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ursekar T N, Mody D G, Maskati B T. Scleral buckling and intravitreal vitreous implants in retinal detachment. Indian J Ophthalmol 1964;12:123-7
After 30 years, Jules Gonin's principle in surgery of a simple detachment of retina, that one has to find and close any existing hole in the retina, still remains true today. No modification has been devised to minimise the importance of retinal tears in surgery of detachment.
After the retinal breaks have been found by a patient examination, the next step is to close these by producing an exudative choroiditis at the appropriate site in the choroid so as to seal the retinal breaks and bring about reattachment of the retina. In a simple detachment, drainage of the subretinal fluid ensures settlement of the detached retina over the treated area and a high percentage of success results in these cases. However failures in cases of retinal detachment with complications have demanded modifications and supplementations of the usual diathermy coagulation to achieve a higher percentage of success in such cases. These variations include different means of causing an infolding or inward buckling of the sclera, in whole or in part, pushing the choroid towards the detached retina to promote contact between retina and choroid.
The condition of the vitreous has assumed therefore an importance only next in degree to that of the search for retinal holes. In this, besides direct and indirect ophthalmoscopy, slit-lamp examination of the fundus and vitreous with the help of a Hruby lens or Goldmann's three-mirror lens has offered a most useful form of examination which is essential in every case.
From January 1960 to December 1963 we have treated 41 cases of retinal detachments of all types, from a simple detachment to a funnel shaped total detachment. Each case was examined thoroughly with a direct opthalmoscope, with Goldmann's three mirror lens and Fison's binocular stereoscopic ophthalmoscope, more recently.
Any medical disorder when found was treated prior to eye surgery. Laboratory studies included complete blood cell count, urinanalysis and X-ray examination of the chest.
Preoperative complete bed rest with both eyes bandaged was instituted in all cases while the medical check up was being done. In simple detachments with one or two retinal breaks, this bed rest was very helpful in getting the detached retina to settle. In other more complicated cases this beneficial effect did not result. It may be noted that Schepens prefers to have the patient ambulatory when scleral buckling operation is to be performed. Since this operation necessarily decreases the volume of the eye, a greater amount of subretinal fluid may thus be available for removal at the time of operation.
Excepting a few cases, we performed all the retinal surgery under local anaesthesia and preoperative sedation in the form of a cocktail consisting of Pethidine, Phenergan and Siquil. We could perform even the scleral buckling procedures with this premedication. Only the more nervous patients were required general anaesthesia.
We performed retinal surgery on 41 cases Out of these 15 underwent diathermy coagulation, 12 scleral resection, 12 scleral buckling with a polyethylene tube all round the eye and 2 scleral buckling with a tube embedded in the area of the reaction only. [Table - 1]
In thirty cases, the retina reattached completely and did not show any recurrence of the detachment. These were followed up from 6 months to 3 years.
In eight cases the retina did not reattach; on the contrary the eyes were lost on account of various complications.
The commonest complication, we came across was a haemorrhage in the retina and in the vitreous cavity. The hemorrhage was usually due to a penetrating diathermy needle puncturing a retinal or a choroidal vessel. In two cases the retina detached further after the operation. Its cause could not be ascertained. In two cases, on account of macular changes the vision did not improve. In one case of scleral buckling, the polyethylene tube caused infection in spite of rigid asepsis during operation and the use of broad spectrum antibiotics post-operatively. The eye was lost following an ophthalmitis. This was our second case of scleral buckling wherein we had put the tube all round Since then we have been taking particular care not to handle the polyethylene with bare hands. Secondly we put chloromycetin ointment into the lumen of the tube. Since these precautions, no further case of sepsis has occured.
The most favourable cases were those where the detachment was confined to one quadrant with one or two breaks only and where the detachment subsided quickly on preoperative rest in bed. A simple diathermy coagulation of the breaks was sufficient in these cases. When retinal detachments are complicated by other factors diathermy by itself does not suffice. One of the most obvious complications is the shrinkage of the retina which on ophthalmoscopic examination appears more white than usual, with fixed folds. In some cases star folds are seen; while in other detachments of longer duration of over six months or so, the detached retina looks thicker than usual, shows cystic changes and is less transparent than usual. Associated vitreous changes in the form of vitreous strands can be made out. These vitreous strands were seen in many of our cases of aphakic detachments and were invariably present in cases with previously unsuccessful operations. In these cases, an eye ball shortening operation was particularly indicated. Nine out of twelve cases, where we did scleral resection, the retina reattached. However in two cases, the visual result was poor on account of macular changes. In some of the cases of retinal detachment, especially in aphakic cases, even a scleral resection did not give a good result. On the contrary there was total detachment with marked shrinkage of the retina. Such cases present the most difficult task. Our first such case was that of a male aged 50 years with bilateral detachment of retina in both his aphakic eyes. The left eye had no light perception while the right eye had good projection of light all round. There was total detachment with number of fixed folds. The peripheral fundus was not clearly visible because of the presence of lens cortex in the pupil. In spite of the hopelessness of the case, we did a scleral buckling with implantation of a polyethylene tube all round the circumference of the eye ball.
To our surprise, the retina completely reattached and today after 3 years, he is moving about with 6/36 vision in the eye. This first success gave us the impetus to try the same technique in more complicated cases where more than one operation had been done already. The fourteen cases where we did scleral buckling with a polyethylene tube embedded either all round or partly, in the resected area, were all complicated cases showing either a number of fixed folds, or a large disinsertion or where the detachment was present in the eye for more than 6 months.
In three of these cases, scleral buckling procedures, had failed. The failures in these cases were due to (1) large retinal haemorrhage, (2) infection and panophthalmitis, (3) no ascertainable cause for failure of reattachment.
With experience we have now started employing this technique in more favourable cases. [Table - 3] shows the details of the various cases. Six of the cases were aphakic and reoperation was done in 6 cases. In six cases the operation was done as a primary procedure. The most gratifying result was in a young man of 40 with high myopia in both the eyes. His right eye was lost following vitreous haemorrhage after a retinal detachment surgery and he came to us with a high detachment in the left eye in the upper nasal quadrant with a horse-shoe shaped tear. In order to avoid reoperation, we did a scleral buckling with a tube all around the globe as a primary procedure. The tear areas was lightly diathermised and no barraging was done. Today after three years he enjoys a vision of 6/12 with his glasses.
| Indications of Scleral Buckling|| |
It was thus found that the scleral buckling operation with an encircling tube was useful especially in (1) detachments with fixed folds, (2) with multiple breaks, (3) detachments in aphakic eyes and (4) in high myopia. It was the only operation to which cases of total detachment responded well in our hands. At first we reserved this procedure for very unfavourable cases and reattachments were obtained in patients who were considered incurable by any other operation. The probable reason for such successes as pointed out by Schepens, lies in the fact that this is the only procedure by which a permanent and extensive choroidal elevation reaching a height of 6 mm or even more can be safely obtained in the area treated with diathermy.
The advantages of scleral buckling operations are many. After the usual diathermy or classical scleral resection the sclera becomes weak and is prone to rupture after reoperation. In scleral buckling, the diathermized sclera is buried underneath the poyethylene tube, thus preventing adhesions to Tenon's capsule and minimises accidental rupture during reoperations. Although the scleral buckling operation is a more traumatising operation than the diathermy coagulation or scleral resection, the trauma that is inflicted in the former is more to the sclera itself than to the choroid or the retina, which tissues are more traumatized in the latter operations. The diathermy applications in scleral buckling are restricted to the area of resection and are much less in intensity; while the same are applied over the intact sclera in simple diathermy operation and also in classical scleral resection. The latter requires a higher intensity of the current to be effective and subsequently causes more trauma to the vital tissues, i.e., the choroid and the retina. Secondly, reoperations are found to be much easier following the scleral buckling operation than following the usual diathermy or the classical resection.
| Vitreous Implant|| |
In two of our detachment cases, in spite of diathermy and scleral resection, the detachment recurred, became very high and total. Although the scleral buckling operation was the next choice, it was felt that if the vitreous can be injected in the hyaloid sac, so as to push the retina against the diathermized choroid, reattachment may take place. In both the cases, after doing the scleral buckling operation. the eye was still very soft and so 1 ml. of vitreous was injected into the vitreous. The vitreous was obtained fresh from Sir Duggan Govt. Eye Bank in Bombay. The reattachment took place in both cases regaining useful sight upto finger couting at 6 m to 6/60 for the patient.
It is no doubt that vitreous implant has an important place in detachment surgery. It is not useful in every case of detachment, but it is definitely useful as a mechanical aid to reattach retina in an appreciable percentage of cases. Even if the vitreous implant fails, the eye, as a rule is still operable.
Much more experience is required as to determine the extent to which vitreous implant can be useful in detachment surgery.
| Summary|| |
Experiences in 41 cases of retinal detachment which have been operated by the different techniques indicated have been critically studied. Particular reference is made about the value of scleral buckling and vitreous implant in selected cases.
| Acknowledgment|| |
We are thankful to the Medical Officer in charge of Sir Duggan Government Eye Bank, Byculla, Bombay for supplying fresh vitreous in two of our cases.
| References|| |
Pischel D. K. A method of scleral resection for retinal detachment. In Schepens C. L. ed : Importance of vitreous body in Retina surgery with emphasis on Reoperations. St. Louis C. V. Mosby 1960 pp. 149-156.
Schepens C. L.. Okamura I. D. and Brockhurst R.J. (1957). A.M.A. Arch. Ophth 58: 797.
Okamura I. D., Schepens C. L. and Brockhurst R. J. (1959) A.M.A. Arch. Ophth. 62: 445.
Shafer D. M. Vitreous Implants in Retina Surgery. In Schepens C. L. ed : Importance of Vitreous body in Retina Surgery with emphasis on Reoperations. St. Louis C. V. Mosby 1960; pp. 131;138.
Stallard H. B.. Eye Surgery-3rd edition. John Wright & Sons Ltd.. Bristol --1958.
McAuley F.B. (1961) Transactions O.S. U.K. 80: 521-538.
[Table - 1], [Table - 2], [Table - 3]