|Year : 1964 | Volume
| Issue : 4 | Page : 135-146
Retinal detachment- Analysis of 160 cases during 1956-58
SK Biswas, KL Sen
Eye Infirmary, Medical College Hospital, Calcutta, India
|Date of Web Publication||13-Feb-2008|
S K Biswas
Eye Infirmary, Medical College Hospital, Calcutta
Source of Support: None, Conflict of Interest: None
|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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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].
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.
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.
(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|| |
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.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11]