Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 8214
  • Home
  • Print this page
  • Email this page

   Table of Contents      
ARTICLE
Year : 1964  |  Volume : 12  |  Issue : 4  |  Page : 135-146

Retinal detachment- Analysis of 160 cases during 1956-58


Eye Infirmary, Medical College Hospital, Calcutta, India

Date of Web Publication13-Feb-2008

Correspondence Address:
S K Biswas
Eye Infirmary, Medical College Hospital, Calcutta
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions

How to cite this article:
Biswas S K, Sen K L. Retinal detachment- Analysis of 160 cases during 1956-58. Indian J Ophthalmol 1964;12:135-46

How to cite this URL:
Biswas S K, Sen K L. Retinal detachment- Analysis of 160 cases during 1956-58. Indian J Ophthalmol [serial online] 1964 [cited 2020 Oct 20];12:135-46. Available from: https://www.ijo.in/text.asp?1964/12/4/135/39090

Table 11

Click here to view
Table 11

Click here to view
Table 10

Click here to view
Table 10

Click here to view
Table 9

Click here to view
Table 9

Click here to view
Table 8

Click here to view
Table 8

Click here to view
Table 7

Click here to view
Table 7

Click here to view
Table 6

Click here to view
Table 6

Click here to view
Table 5

Click here to view
Table 5

Click here to view
Table 4

Click here to view
Table 4

Click here to view
Table 3

Click here to view
Table 3

Click here to view
Table 2

Click here to view
Table 2

Click here to view
Table 1

Click here to view
Table 1

Click here to view
Retinal detachment is not an un­common disease in our out patients. In the unit of Prof. Seri the cases were treated and observed at least for 3 months after their discharge from the hospital. We present only 160 cases for our discussion out of a total of 200 operated during the period 1956-1958, because we have not been able to fol­low up closely the remainder.

Age

The primary group shows the inci­dence mostly between the ages of 11 to 60 years. The younger section be­tween 11 to 30 years includes mostly myopic cases whereas the older sec­tion between 50 to 60 years are cases with degeneration and previous inflam­mation. Senility favours the conditions for production of the disease and so it is not infrequent in advanced age. The aphakic cases are mostly in the age group 51 to 60 years. The Secondary group suffers most between the ages of 21 to 40.

Sex :

Males suffer considerably more in both primary and secondary detach­ments. However, allowance must he made for the general reluctance of In­dian females to be treated in a hospital for a prolonged period. No case with detachment in Toxemia of Pregnancy was seen by us during our almost daily examination of fundii of many patients in the eclampsia ward of this College during this study period.

Refractive Condition:

In studying the refractive condition of the primary group, we find that though the incidence is mostly preval­ent among the myopes, in emmetropes it is not small. Among the myopes those between -1D to --5D have the maximum occurrence. Above -10D. cases are few but they are difficult to assess and unsatisfactory for treatment.

Trauma:

The history of trauma over the eye must be considered with suspicion as often a patient replies in the affirma­tive to a leading question. Among the primary cases 18 gave a definite his­tory and nature of trauma either dir­ect or indirect e.g. over the head, pas­sive congestion, heavy weight lifting. sudden jolt etc. The time period be­tween trauma and detachment varies from a few hours to several days. Among this group are two interesting cases with the history of practising "Shirsasan"---a Yogic procedure of standing on the head. Both were myopes of moderate degree.

Direct trauma had affected mostly the emmetropes while indirect the myopes.

Ocular Work:

Excessive accommodation plays a doubtful role in the production of retinal detachment. Of the primary cases 41 were used to near work, 5 were voracious readers and 57 were habituated to ordinary physical and near work.

Eyes

There is almost equal prevalence of the disease in the right and left with slight predilection for the former. We had Bilateral Primary Detachment in 2: Bilateral Detachment in Ret. Pig­mentosa 1 ;

Bilateral Inflammatory Detachment in 1:

Bilateral Aphakic Detachment 1.

Chorio-Retinal Affection:

Myopic, senile or post inflammatory affection of the choroid greatly pre­dispose to the disease. In many cases the affected eye has diffuse patches of choroiditis, but excessive fibrosis pre­vents the disease. Only in one case the patient was treated for disseminated choroiditis 7 years back and detach­ment in the same eye. We have not been able to trace the role of degene­rative conditions like lattice, snail track or peripheral cystoid degenerations in this series. No case of retinoschisis or congenital retinal cyst was detected during this period.

Vitreous:

In the pathogenesis of the disease vitreous is said to play an important role. Degenerated vitreous is very com­mon in long standing detachments, in high myopes and in the aged. So the duration of detachment has some prog­nostic value which will be discussed later. The amount and character of the subretinal fluid depends on this factor and also the intra-ocular tension. In 60 of combined primary and aphakicc cases vitreous floaters were present showing varying degrees of degenera­tion. But our study on this subject with relation to our cases is meagre and incomplete. In the hospital we have hardly used our slit lamp in cases of detachment but have put these in bed till they were operated upon and/ or discharged. Four cases had frank posterior detachment, 1 aphakic and 1 case had anterior shrinkage of vitre­ous. These 2 were not operated. In one the operation has failed and in the other case previously operated outside, a reoperation was successful with res­toration of vision to 6/12 from 6/60.

Tension

Intraocular tension in the affected eye is less than that in the healthy one. Detachments of less than one month's duration of primary type, only occas­sionally show a fall of more than 5 mm of Hs except when there is a huge tear or a dialysis. Longer duration of a detachment with degeneration is more responsible for the low tension. Apha­kic detachments suffer more with hypotony. In all the cases of primary detachment (phakic or aphakic) we have never come across a case either with a history of glaucoma of any type at any time. One wonders whether re­tinal detachment or a tendency towards it acts contrary to a glaucomatous state.

In our series most of the operated cases had tension between 13 to 19 mm of Hg. Cases with tension below 10 mm were rarely operated upon except 1 or 2 where vain attempts were made in bilaterally blind people as a desperate measure (cf. case note Group IV, Case No. 2).

Initial Symptoms:

Most people came with loss of part of the visual field. Probably our pa­tients were not so much conscious about other early symptoms. The loss of field indicates the area of detach­ment but does not point in any way to the localisation of tears. In most cases however, a tear was found in the area of retina first detached as indicat­ed by the history.

Sudden blurring of vision, a gene­ralised haze or a veil hanging some­where in the field are the next common symptoms. Photopsia described by in­telligent patients often gave us clues in the location of tears. Photopsa in con­valescent patients often suggest a new area of detachment or deterioration of the condition.

Location & Shape of Tears:

A. Ant Dialysis: 13 cases:



B. Semilunar, Curved, J shaped etc. 35 cases distributed as in chart on the next page.

C. Some atypical tears and their significance: -

(a) Macular hole: 2 cases Ex­tent of detachment in one case was small: in the other it was associated with peri­pheral tear. (Group IV, Case No. 3). Both were success­fully operated by light dia­thermy coagulation.

(b) Central to equator: 6 cases. Unsuccessful in 2:--one case with huge dialysis hiding the optic disc (Group IV, Case No. 1): the other with two large tears (cf. case note Group III, Case No. 2) which relapsed 2 months after the diathermy coagulation and scleral resection failed.

(c) Very close to big blood ves­sels: 2 cases. (cf. case note Group IV, Case No. 4).

(d) Tear Hidden in folds-- de­tected after operation: 2.

(f) With Operculum : 2.

On quadrantic basis of division, the tears are more situated in the upper than lower and more on the temporal than on the nasal side. More tears are between the ora serrata and equator. Next come the tears at the equator and next those central to the equator.

It is noteworthy to mention here about slit-like tears frequently seen in the retina opposite the area of insertion of extraocular muscles. Some sudden or jerky muscle action may be res­ponsible. Eight were found near the insertion of the superior oblique, 5 at that of the lateral rectus and 3 at that of the superior rectus.

Rest to the eye and body and pos­tural treatment have got a definite value. These help the absorption of fluid, prevent further retinal separation and involvement of macula, bring the retina and choroid close together and thus increase the chances of success. Appearance of tears after rest as seen in the above table definitely shows its value. Most patients dislike it and in summer they do not even hesitate to allow the eye to get blind rather than suffer the discomfort of lying still in bed.

Duration & Prognosis:

The longer the duration the less are the chances of success. 76 cases were operated out of 89 (primary type). The remaining 13 cases were not ope­rated either because of spontaneous cure as in 2 cases, discharged on a risk bond : 5 cases, because of extreme low tension and marked degeneration of the eye in 3 cases or contraindicated by the general condition in 3 cases. Most of the early cases were treated by dia­thermy coagulation, only a few failed ones necessitating scleral resection. Failures after diathermy coagulation in the late cases required a greater num­ber of scleral resection with lower chances of success.

Result

So 87 operations were performed on 76 cases, i.e., some cases of dia­thermy coagulation had to be reoperat­ed by a scleral resection.

Improvement in Vision:

Cases considered cured were those with complete re-attachment of the retina with improved vision or with lo­calisation of detachment with improve­ment in vision, maintained for ap­proximately 4 months after the opera­tion. Sometimes however complete anatomical reattachment did not im­prove vision due to optic atrophy or with marked degeneration of the cen­tral retina. Improvement of vision is shown in the chart above. Improve­ment of vision by 1 metre in cases with vision below 6/60 on admission and by one line in Snellens distant chart in others were taken as improve­ment. Remarkable recovery of vision from 1/60 to 6/9 or 616 or from linger counting to 6/24 or 6/18 in our cases were very satisfying. [Table - 9].

Aphakic Detachments:

Total 25: Operated 16: Tears de­tected in 7. [Table - 10]

Contrary to ordinary belief, the most beautiful intracapsular extraction cases came more frequently with de­tachment than those done extracaplur­ly. Damage to vitreous during opera­tions is shown in the table. Tears are less frequently detected in aphakic cases than in non-aphakic ones. Dia­thermy coagulation is suitable for a few selected cases only the operation of choice being scleral resection or a combined operation.

The results are shown in [Table - 11] below.

Secondary Detachments:

They are due to various pathological processes.

(a) 22 cases of inflammatory detach­ment; 6 developed Retinal strict after a few months. Of these 3 developed tear with detachments and were later treated by operation. Detachments were shallow and flat type and tears were in the degenerated area (cf. case note Group 1, Case No. 1). Three in­flammatory cases had intraocular haemorrhages.

(b) Eale's Disease with detachment: 4: Diathermy coagulation done in 3, successful in 2: failed in 1 which ended in post-operative endophthalmitis.

(c) Inflamatory detachment in apha­kia --2.

(d) Metastatic 1 ; from breast carci­noma. Patient died 11 months after enucleation.

(e) Von Hippel Disease 1.

(f) Retinitis. Pigmentosa--1.

(g) Congenital coloboma of choroid - 1.

(h) Toxoplasma-1.

(i) Renal type-1.

(j) Intraocular foreign body with complete detachment --1 (Eye lost due to endopthalmitis).

(k) Following 'couching' 1 : blind eye with detachment and forma­tion of new vessels in a diabetic patient.

(i) Retrolental Fibroplasia- 1.

Failures & Defects

Even extensive detachments of short duration have got a good prognosis. Old extensive detachments are cases with poor prognosis.

Cases with a balloon detachment were kept at rest in bed to minimise the height of the retina to facilitate the application of surface diathermy. Even after a long period of rest if the retina did not settle other devises were tried, e.g., Safars pin or penetrating diathermy or previous drainage of intra retinal fluid to flatten the detach­ment before diathermy application.

Multiple tears distributed all over the retina requiring opening up of ex­tensive areas cause much post opera­tive reaction and damage. Giant tears require many points but are still diffi­cult to close and the direct contact of vitreous to the choroid causes less fibrosis where recurrences are the rule. Giant dialysis and multiple giant tears require so much destruction of the re­tina that it was not worth our while to attempt their closure.

Thin retina following post coagula­tion scar could not hold the retina, for long and secondary tears developed in the retina. Light coagulation would have done better.

Missed tears can account for some of our failures. In one aphakic case during the 2nd operation. after the operation finished--a tear was detect­ed hidden in the fold of detachment.

Slight haemorrhages in the vicinity of coagulations are of no importance.

We have lost 2 eyes due to frank in­traocular haemorrhage in aphakic de­tachment following scleral resection.

Severe uveitis caused 4 losses in our series and marked hypotony in 2.

Excessive current caused reactionary detachment in 10 cases. Insufficient current failed to produce the necessary coagulation in 6 cases.

Separation of scar adhesion and shrinkage of vitreous caused 7 recur­rences.

During operation certain simple but avoidable mistakes occurred twice e.g. putting the Cole-Marshall Retinal chart in a wrong way to take guidance but they were corrected in time.

The first diathermy point helps very much in reorientating the tear but that may be missed due to cloudiness of the media as in 6 of our cases.

Imperfect drainage of subretinal fluid occurred in 7. It would be more justifiable to use a trephine instead of a perforating diathermy to drain the intraretinal fluid as we had to deal with so many late cases. Character of subretinal fluid varied from watery, albuminous to viscid containing de­finite vitreous body. In two cases - one of Eales disease with detachment and in other of primary type, the intra­retinal fluid looked suspicious and was sent for immediate pathological exami­nation but no definite findings could be reported. Both of these developed severe post-operative endophthalmitis and were lost.

Development of scar atrophy in co­agulated area commonly started be­tween the 13th to the 16th day, earl­iest after 7 days and latest after 23 days.

Hindrance to fundus examination are many. Non-dilatation of pupils even after subconjunctival injection of mydricaine occured in 2; but the pupils dilated just after a retrobulbar and Tenon's capsule block and so we must be ready for final examination in such cases on the operation table.


  Comments & Summary Top


Analysis of 160 cases of Retinal detachment is placed with all the fai­lures and successes. In etiology we lied that not only the myopes but also re­latively large numbers of emmetropes and hypermetropes suffer from this disease. 'Shirashan' (head-stand) should he avoided in the myopes.

Contrary to the usual belief, well operated, uncomplicated intracapsular extractions seem to get detachment more frequently in aphakia.

Though the modern trend is to do scleral resection in most cases, simple diathermy has its value. Scleral resec­tion is definitely indicated in high myopes and aphakic subjects. We have treated our cases by the classical me­thods of diathermy and scleral resec­tion only.

Some typical case-reports are pre­sented on the following pages.


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Comments & Summary
Article Figures
Article Tables

 Article Access Statistics
    Viewed1831    
    Printed42    
    Emailed0    
    PDF Downloaded0    
    Comments [Add]    

Recommend this journal