Year : 1983 | Volume
: 31 | Issue : 7 | Page : 966--970
Prognostic value of the retinal breaks
HK Tewari, NK Agarwal, PK Khosla, Rajvardhan Azad
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
H K Tewari
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi
|How to cite this article:|
Tewari H K, Agarwal N K, Khosla P K, Azad R. Prognostic value of the retinal breaks.Indian J Ophthalmol 1983;31:966-970
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Tewari H K, Agarwal N K, Khosla P K, Azad R. Prognostic value of the retinal breaks. Indian J Ophthalmol [serial online] 1983 [cited 2022 Jan 20 ];31:966-970
Available from: https://www.ijo.in/text.asp?1983/31/7/966/29719
GONIN (1929) attributed every primary retinal detachment to the presence of a retinal break and indicated its treatment by sealing. Various types and location of breaks pose different management problems with differing prognosis inspire of tremendous advances in retinal detachment surgery. Studies on prognostic value of retinal breaks are scanty. We Analysed our cases to know the nature of retinal detachment on the basis of preoperative localisation of different types of breaks and the visual outcome after surgery in these cases so that factors responsible for good prognosis can be delineated.
MATERIAL AND METHODS
500 consecutive cases of rhegmatogenous retinal detachement were studied. Retinal breaks (Shape, site) were located and the pattern of retinal detachment (quadrants involved and macular status) were analysed. Cases with history of trauma or with macular holes, irregular tears, giant tears, dialysis or choroidal detachment were excluded form the study. Cases with nearly same preoperative parameters as age and duration of detachement were sorted out and divided in different groups. Best corrected visual acuity before and after surgery were noted.
A. BREAKS IN SINGLE QUADRANT
Group I - Horse shoetear
Group II - Round hole/and round holes
Group III - Tears and round holes
B. BREAKS IN MULTIPLE QUADRANTS
Group IV - Horse shoe tears
Group V - Round holes
Group VI - Tears and holes
Nearly similar surgical procedure was carried out in groups A & B. Anatomic and functional (best corrected central visual acuity more than 6/60 or improvement of two lines from preoperative visual acutiy) success rate were compared to prognosticate the results.
The distribution of retinal breaks is shown in [Table 1]. We could pick up only 20 cases per group for comparison in a bid to match them as far as possible.
Pattern of retinal detachment (number of quadrants involved) was similar in various subgroups of group A if the cases had nearly similar duration of presentation of symptoms [Table 2]. Whenever, the breaks (horse shoe tear and round hole) were present in similar location the comparison was more realistic.
Total retial detachment was not seen with breaks located only in lower nasal quadrant. The pattern (number of quadrants involved) was not so similar in group B as total detachment was noted more in cases with (Groups IV & VI) rather than (Groups V).
Incidence of total detachment was 26.6% in group Awhile it was 56.6% in group B [Table 3]. Total retinal detachment was seen in 78.5% when the breaks were located at/or between one hour of clock of 12 O'clock position. Some of the cases (21.5%) who had gone in for total detachment may still be in the intermediate stage (subtotal detachment) due to reporting to surgeon with lesser duration of symptoms. However, all total retinal detachments were not due to breaks at 12 O'clock position and these breaks were responsible for only 44% of all total detachments meaning there by that 56% were due to breaks elsewhere and this was more evident in group B.
Macular involvement was more common (88.3%) in group B than with Group A (61.6%) although overall rate was 75%. The anatomical and functional success rate are shown in [Table 4].
In this series, majority (75%) of the primary retinal detachments were due to horse shoe tears present either in single or multiple quadrants which indicates that factors leading to caustion of retinal detachment from horse shoe tears are more prevalent than round holes.
Our results indicate that the extent of retinal detachmenet usually dependent on gravitational factors, is not similar in group A [Table 2], and it was more extensive in Groups I and III in Group II i.e. more in cases with horse shoe tear than round hole alone. When the extent was compared in similar situations taking into consideration the duration, the impression was that same extent of retinal detachment is produced in longer time in round holes as compared to horse shoe tears confirming the belief that horse shoe tears lead to more rapid retinal detachment probably due to presence of vitreous traction.
It is usually believed that in cases of total retinal detachments one must look at 12 O'clock meridian as a break is usually found at this site in all cases. It was interesting to note in this context that all the cases with tear at 12 O'clock position in Group III led to total retinal detachment. There was no difference in incidence of total retinal detachment with nasal or temporal break, when present within 1 clock hour from 12 O'clock meridian.
However, quadrantic or subtotal retinal detachments were also seen with break around 12 O'clock meridian in shorter duration group which indicates that these were in the intermediate stage and would have progressed to total retinal detachment if it is neglected by the patient. Tears at the other places also give rise to total retinal detachment as the number of total retinal detachments 12 `O'clock breaks did not coincide so we feel that single tear at 120' clock position is dangerous although tears at other places do also lead to total retinal detachment so conversely a break at 12 O' clock may not be there in all cases of total retinal detachment.
Breaks with symptoms always report early hence cases with tears come early while those with holes may and probably do delay their visit to the doctor. The first symptom in tears is mostly a flash of light or floaters which was not be very evident in all the cases, while inholes it is quadrantic cloudiness which again is not given importance till central vision is affected. It is, therefore, contended that duration of symptoms in cases of retinal detachment may be fallacious as detachment around the tear or hole must have started before the presentation although we can take into consideration only the symptom put forward by the patient.
As the detachment is a creeping phenomenon in cases of holes rather than in tears, it is presumed that in cases of holes the duration may still be more fallacious. Temporal breaks are considered more dangerous as they cause macular detachment but we feel that they are blessing in disguise as they bringthe patient earlier to the doctor due to dimunition of central vision and there cases do not necessarily go in for total retinal detachment
Analysing Group B cases it was found that the pattern of retinal detachment (quadrants involoved) was the same whether due to tear or hole but again the extent was more in cases with tears with same dura tion. Breaks in the upper half gave rise to total retinal detachment in more cases and earlier as compared to breaks in lower: half. Both anatomical and functional success were less in Group B as compared to Group A. Total retinal detachment was present in all the groups although to a variable extent. Total retinal detachments in Group B was more (56.6%) as compared to Group A (26.6%). It was evident that it was quite frequent within Group B even with shorter duration. It is thus indicated that extent of retinal detachment is more related to duration and needs more urgent treatment.
Anatomical success was less in the Group I as compared to Group II but not different from Group III indicating that success rate is related to presence of tear i.e. vitreous traction factors. It is interesting to note that nasal breaks led to lesser anatomical success than temporal breaks which was not easily explainable as surgical techniques and other factors were the same. The anatomical success in various groups could be prognosticated better on the basis of extent of retinal detachment Functional success was not totally related to presence of macular detachment
Analysis of 500 consecutive cases of rhegmatogenous retinal detachment is presented comparing pattern of retinal detachment and prognosis in cases with different types of retinal breaks. It was observed that pattern of detachment was similar with both (horse shoe tear and round hole in similar circoumstances) although it was more extensive in the former with similar duration. Anatomical success rate was not related to extent of retinal detachment only while maculalt detachment did not totally control functional success.