Year : 1983 | Volume
: 31 | Issue : 7 | Page : 909--911
Retinal detachment surgery
Bijayananda Patnaik, Rajinder Kalsi, Satish Gupta
Retina Associates, New Delhi, India
203, Sethi Bhawan. Retina Associates, 7 Rajendra Place, New Delhi-110008
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Patnaik B, Kalsi R, Gupta S. Retinal detachment surgery.Indian J Ophthalmol 1983;31:909-911
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Patnaik B, Kalsi R, Gupta S. Retinal detachment surgery. Indian J Ophthalmol [serial online] 1983 [cited 2021 Sep 18 ];31:909-911
Available from: https://www.ijo.in/text.asp?1983/31/7/909/29703
Efficient detection and closure of retinal breaks and permanently counteracting the vitreous traction forces by buckling procedures are factors which have dramatically improved the success rate of reattachment surgery. The purpose of this paper is to highlight certain vital surgical steps which to our mind have been responsible for a very high success rate in a series of unselected consecutive cases of retional detachment operated by us.
243 operations were performed for retinal reattachment and 14 for prophylaxis on 241 eyes of 224 patients. Right eye was affected (53.5%) slightly more often than left eye. (76.8%)-172 cases were males. Maximum number of cases (40.6%) were of age groups 46 to 60 years followed by 31-45 years (20.1%) and 16 to 30 years (17.9%). Only 5.8% cases were below 15 years of age.
43.6% eyes were myopic as against 30.7% aphakpics and 25.7% emmetropic and hypermetropic. Of the myopic eyes more than half (56.2%) were high myopes.
The number of patients who reported within 7 days of symptoms (27.6%) was highest. 14.9% reported between 8-15 days of detachment. 7.9% had no symptoms while an equal numberwere not certain of the duration of detachment.
Maximum number of patients had a preoperative visual acuity of just perception of light or hand movements (33.2%) closely followed by those who could count fingers only upto 3 meters (28.6%). Better visual acuity was found in smaller number upto 6/60/(11.6), 6/36 to 6/11-10.8% and better than 6/12 in 15.8%, the last group includes patients operated for prophylaxis.
Majority of the patients had normal intra ocular pressure (79.7%). 16.6% had pressure less than 10 mm. Hg and 3.7% had pressure more than 20 mm Hg.
MATERIAL AND METHOD
241 consecutive cases of retinal detachment seen in Retina Associates Clinic and operated at MCKR Hospital, New Delhi are included in this series. Preoperative investigation in all cases included: Slit Lamp Biomicroscopic examination, fundus examination with binocular indirect ophthalmosope, recording intraocular pressure, test for patency of lacrimal apparatus, conjunctival swab culture an sensitivity and post prandial blood sugar.
Most of the cases were operated under local anaesthesia-Facial and retrobulbar blocks with a mixture of Marcaine 0.5% and Xylocaine 2% in equal quantities. A tent of draping was made over the nose with the help of a tray over the chest-Oxygen was supplied in the tent. General anaesthesia was given in children, very nervous patients and reoperations.
Pupils were dilated with Homatropine 2% and Phenyl epherine 5%. Alround (360 0sub ) peritomy was done. Conjunctiva and tenons were lifted in one flap. Two radial cuts were made at appropriate diagonally opposite points avoiding the anticipated site of buckle placement. Thick whip sutures were passed under each rectus muscle taking care to preserve the muscle sheath.
Cryopexy was done under indirect ophthalmoscopic visualisation of all the retinal breaks and areas of degeneration. The retinal breaks and degenerations were localised and marked on the surface of sclera with gentian violet. The distance of equator from the limbus was determined and marked. Anchoring sutures were passed in sclera at appropriate sites for various circumferential and or radial buckles and for the encircling band.
Sclerotomy was done in a preselected area. With the help of two scleral hooks the lips of sclera were retracted and the choroid punctured with a fine eyeless suture needle (Ethicon 6-0 silk). The subretinal fluid was gradually expressed out by putting pressure and counter pressure with a spatula. When no more fluid was seen coming out, the scleral wound was stitched with 6-0 braided silk suture.
The buckles were placed and the sutures tied. The encircling band was tightened to produce just adequate indentation and ends tied with 4-0 braided silk. Antibiotic was flushed under the various buckles and the encircling band. Stay sutures were cut and eyeball mobilised under the tenons facia. The radial cuts in conjunctiva were sutured by 6-0 braided silk and 3 to 4 anchoring stitches were placed at the limbus.
The retina is said to have successfully reattached when it remains flat after more than 4 weeks of normal mobility.
The vast majority of cases (97.3%) of retinal detacnment were operated with an encircling procedure over localised implants. Silicon tire was used in 133 (51.8%) of cases. Silicon Sponge rods in 49 (19.1%) cases. In 29.1% both were used.
For retinopexy cryo was used in all cases. In addition diathermy was used in 3 cases of peripheral neovascularisation and photocoagulation was used in 9 either for reinforcement or for neovascular lesions.
Subretinal fluid was drained in the majority 66.1%. However, in a sizeable number 33.9%, no attempts were made to drain fluid. Only in 2 cases, the first attempt to drain fluid had failed. The retina settled after first operation in 96% (218) cases. After reoperation 6 more cases settled. Final percentage of anatomical success was 98.6%.
Prophylactice Surgery (14 Cases)
Indications for prophylactive surgery were: traction tears with history of detachment (bad) in the other eye-4, traction tears rapidly leading to detachment innormal looking retina-3, extensive vitreo-retinal degeneration with bad detachment in the fewllow eye-7.
In all cases, encircling silicon bands over local tires or sponge rods have been used. In one case, inspite of a prominent radial buckle over a large traction tear and an encircling element, a total detachment developed with extensive pre-retinal gliosis.
Surgical Complications: included accidental perforation while passing scleral sutures-3, accidental rupture of sclera (cases of reoperation)-2. Choroidal haemorrhage from sclerotorny-4, retinal incarceration at sclerotonry site-3 and vitreous loss through sclerotonry-I. Choroidal haemorrhage from sclerotomy in one case tickled down to macula leading to loss of central vision, Post operative complications included, infection-8, glaucoma14, buckle extrusion-3, hypotony-3. accidental puncture of the globe while giving retrobulbar injection in preparation of photocoagulation1, massive vitreous retraction-4, premacular gliosis-7 and partial conjunctival necrosis-1.
All cases of infection could be controlled with a.i `ibiotics (Garamycin-3, Reverin-2, other oral antibiotics-3).
An overall success rate of 98.6% is heartening. Careful indirect ophthalmoscopy with scleral depression before and during surgery has been the main stay of investigative system. Lifting the conjunctiva and tenons in one flap and stitching them back giving satisfactory 2 layers cover to the buckle is important. The routine use of cryo under direct vision has not only reduced the time needed for retinopexy but also covered the lessions more satisfactorily. Unlike in diathermy, it lowers the intraocular pressure during retinopexy. The scleral damage or devitalisation is minimal. This may be contributing towards lower buckle infection rates.
Our preference for encircling procedure as the primary procedure has a number of advantages. Besides, effectively closing the retinal breaks, it tends to reduce the equatorial diameter of the globe and thereby relax the vitreous traction. These effects are perma nent. It may be noted that the encircling element has never been used alone. Alway appropriate buckles have been placed wire accurate planning. Judicious use of radialbuckles seems very important in taking care of meridional infolding of the retina subsequent to encircling buckling. These buckles also close large traction breaks more surely and securely. Partly to retain the freedom of placements of radial buckles, we have almost uniformly used episcleral buckling. Besides, being satisfacotry, it saves considerable time. Lastly, constant vigilance against theatre infection is a vital point in successful reattachment surgery.
Two hundred and fifty seven operations for retinal detachment were carried out on 241 eyes of 224 patients. Anatomical flattening of the retina was achieved in 98.6%. The investigative and surgical steps used have been discussed.
|1||Patnaik B. and Kalsi R., 1982, XLI All India Ophthalmological Conference, 1982.|