Year : 1974 | Volume
: 22 | Issue : 3 | Page : 13--16
Dry detachment surgery
Bijayananda Patnaik, Rajinder Kalsi
Department of Ophthalmolog, Maulana Azad Medical College and Associated Irwin and G.B. Pant Hospital, New Delhi, India
Department of Ophthalmolog, Maulana Azad Medical College and Associated Irwin and G.B. Pant Hospital, New Delhi
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Patnaik B, Kalsi R. Dry detachment surgery.Indian J Ophthalmol 1974;22:13-16
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Patnaik B, Kalsi R. Dry detachment surgery. Indian J Ophthalmol [serial online] 1974 [cited 2021 Jan 25 ];22:13-16
Available from: https://www.ijo.in/text.asp?1974/22/3/13/31362
Custodis , made an interesting observation that it was not necessary to drain the subretinal fluid when a plomb was used on the scleral surface and claimed a success rate of 85 per cent in unselected cases. Since then this technique has been used by other workers ,, with encouraging results. The replacement of polyviol by silicon as an implant material has reduced the incidence of tissue reaction. The replacement of surface diathermy by cryopexy has reduced the chances of scleral infection and necrosis.
Considering the fact that most of the surgical complications occur either during or soon after the drainage of subretinal fluid, this procedure seemed extremely attractive. In this paper we plan to discuss the pre-operative preparation; operative technique, post operative management and results of 40 operations conducted using this technique.
A detailed fundus diagram is drawn using an indirect ophthalmoscope. Extreme retinal periphery is examined by scleral depression. The state of the vitreous, macula and specific areas of interest are examined by a 3 mirror Goldmann's contact lens. Occasionally the ora serrata attachment is also used.
Patients get a binocular patching and bed rest for 2-3 days to observe the effect of rest on retinal flattening. Bed rest was also resorted to when an upper detachment threatens the macula or a high balloon made exact localisation of the retinal breaks difficult.
All cases were operated under general anaesthesia. The conjunctiva with the tenon's was lifted in one flap after an appropriate peritomy and two radial cuts. The tears were accurately localised on the surface of the sclera by scleral depression combined with indirect ophthalmoscopy and surface diathermy applied. Frequent checking ensured adequate diathermy. When semipenetrating electrodes were used the diathermy usually left no marks on the surface of the sclera. The diathermised sclera was marked with a dye. When cryopexy is used the choroid was frozen for 1-2 seconds under direct visual control, through an indirect ophthalmoscope. The marking on the sclera with a dye was necessary, for the cryopencil did not leave a mark on the sclera after thawing.
A buckle was produced either on a full thickness sclera using a silicon implant after the techniques of Custodis or on imbedding silicon or preserved human sclera in a scleral bed created by lamellar scleral resection. The latter procedure gives a more prominent buckle. Silastic sponge rods of different diameters were found to be more suitable material for the full thickness scleral buckling. Whenever possible buckle was placed radially. Most of the single breaks or breaks situated further apart can be satisfactorily covered by radial buckles. The passing of sutures for very posterior buckles is possible only if the buckle is planned to be placed radially. Thus a buckle could be placed 23mm. behind the limbus in one case. The tendency for the development of radial folds or fish-mouthing were best taken care of by a radial buckle.
When a permanent and prominent buckle was desired or when multiple holes were situated more or less equidistant from the limbus, multiple radial buckles under an encircling 'Supramid' thread was found to be a satisfactory method of management. Ideally the intraocular tension should be somewhat higher than normal at the end of the operation. With multiple buckles it can be too high, in which event a paracentesis is done using a cataract knife and the ocular tension is lowered to a level slightly higher than normal.
Post operative course and management
Only one eye was bandaged and the patient was encouraged to take turn or sit up or if possible move around soon after he comes out of anaesthesia. Early mobilisation was done as a part of the post operative management. Conjunctival stitches were removed on the 5th day. Patient was discharged during the second week.
Forty cases were operated during the last 2 years, without drainage of the fluid. There were 31 males and 9 females. Sixteen cases had single retinal breaks including 4 giant tears and one dialysis. Twenty four cases had multiple breaks; of which 3 had giant tears, and one retinal dialysis. Duration of detachment in the cases of this series has been summerised in [Table 1].
The intraocular tension before the operation has been presented in [Table 2]. The cases have been classified according the classification of Jesberg 1968 [Table 3] Results of 40 consecutive cases of retinal detachment operated without drainage have been summarised in [Table 3].
Retina was flat in 36 out of 40 cases following the first operation and the retinal breaks settled on the buckle within 4 days. Complete flattening of the retina was noted as early as 24 hours and as late as 5 months. However, retina settled completely by the end of 4th day in 65% of cases and by 7th day in 72.5% of cases [Table 3]. Fresh cases and cases with traction tears generally settled early. The retina took longer time to settle in cases having circular holes over areas of lattice degeneration. One such case of only 10 days duration did not show any sign of flattening in 4 days and had to be drained.
Out of the 4 cases which did not settle after Ist operation, one settled on drainage of the subretinal fluid on the 4th day and another case settled on closing a missed hole.
Remaining 2 cases were not reoperated. One of them had an immature cataract and visualisation of the fundus was unsatisfactory.
The second case had massive pre-retinal gliosis. It was a detachment of more than 2 years standing. All 4 cases belonged to either to class IV or V.
One case had a recurrence of detachment due to development of a new retinal break and settled on treating it. Four cases had post operative infection at the site of the implant. In all 4 cases diathermy was used for retinopexy. In 2 of them alcohol preserved human sclera was used as a buckling material on lamellar scleral resection. In other two cases silicon rods, solid in one case and sponge in the other were used as external buckles on the full thickness sclera. The infection was controlled in 3 cases by the use of massive dosage (275 mgms intravenously 4 times a day) of Reverin (Rolitetracycline) for 4-6 days followed by oral tetracyclines for another 4 days. One eye was lost due to endophthalmitis following scleral necrosis. On two occasions the cause of theatre infection could be attributed to improper autoclaving of the linen and cotton swabs at the central sterilization plant.
Selection of cases
Retinal detachments of comparatively short duration with limited number of isolated traction tears and the retina around the breaks free from retinal or vitreal bands are suitable cases for a dry detachment operation. Though the mobility of the detached retina has been considered an essential criterion in selection of patients  we have tried this technique also in cases with shallow retinal detachments; retinas showing no demonstrable mobility but no retinal bands of fixed retinal folds near the retinal breaks and in cases with multiple round holes associated with lattice degeneration but a shallow retinal detachment. Giant tears are no contraindication for this operation. However, it has been observed that cases with round holes on degenerated retina (including lattice) do not settle readily. In such cases it may be safer to drain the fluid.
An analysis of 100 consecutive cases of retinal detachment operated by us  reveals that most of the complications of detachment surgery were related to the act of drainage of the subretinal fluid; which include, choroidal haemorrhage leading to subretinal or vitreous haemorrhage, retinal or vitreous incarceration, intraocular infection etc. Similar is the experience of Scott  . As such a procedure not involving this step should be welcomed. Besides, a too low tension following fluid drainage calls for a vitreous injection with multiplying of the above risks.
A slowly settling retina as in this technique is not associated with the development of radial folds so often seen following the drainage of the fluid. It is not clear whether the post operative visual acuity is favourably influenced in this technique. In cases where visualisation remains unsatisfactory we have often used this technique almost as a test to be sure that all holes are taken care of; for in the presence of an undetected hole, retina does not settle. If there is a recurrence one should look for a fresh tear.
The procedure not only saves time for the surgeon on the table but makes immediate mobilisation of the patient possible and radically shortens the post operative stay in the hospital.
An accurate localisation of the retinal breaks on the table by indirect ophthalmoscopy, adequate retinopexy and use of proper sized buckle properly placed without draining of sub-ritenal fluid gave excellent results. Retina settled in 38 out of 40 cases.
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|2||Custodis, E (1960) Importance of the Vitreous body in retina surgery with special reference to reoperation. P, 175 C. V. Mosby Co. St. Louis.|
|3||Jesberg, D. O. (1968), New and Controversial aspects of Retinal detachment-International Symposium. Ed. Mc. Pherson A. P. 158. Harper & Row, New York.|
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