Comparison of pneumatic retinopexy and scleral buckling in the management of primary rhegmatogenous retinal detachment. Southern Wisconsin Pneumatic Retinopexy Study Group

PURPOSE: To compare pneumatic retinopexy and scleral buckling for repair of primary rhegmatogenous retinal detachment with respect to visual outcome, single-procedure reattachment rate, and development of proliferative vitreoretinopathy. METHODS: A consecutive series of eyes initially treated with pneumatic retinopexy (n = 56) between March 1986 and February 1996 were compared with a selected group of eyes treated with scleral buckling (n = 86) with similar location and distribution of retinal breaks and absence of proliferative vitreoretinopathy. A regression model was developed to adjust for underlying differences between treatment groups, resulting in a cohort of 50 eyes in each group for final comparison. A minimum follow-up of 6 months was obtained. RESULTS: Single-procedure reattachment rate was significantly higher for scleral buckle eyes (42 of 50 eyes, 84%) than for pneumatic retinopexy eyes (31 of 50 eyes, 62%; P < or = .01). Correspondingly, reoperation rate was significantly higher for pneumatic retinopexy eyes (19 of 50 eyes, 38%) than for scleral buckle eyes (7 of 50 eyes, 14%; P < or = .01). Multiple regression analysis evaluating perioperative factors demonstrated that the use of pneumatic retinopexy was the sole factor predictive of retinal detachment after a single procedure (relative odds = 2.20, P = .02). Final reattachment rate, after reoperations, was 98% (49 of 50 eyes) in each group. Except for nonphakic eyes, final visual outcome and rate of postoperative proliferative vitreoretinopathy development did not differ significantly between the two procedures. CONCLUSIONS: In phakic eyes, pneumatic retinopexy was associated with a significantly higher reoperation rate than scleral buckling, but resulted in equivalent final visual outcome and reattachment rate after reoperations. If used, it must be incorporated into a strategy in which patient and physician are prepared for a greater chance of reoperation compared to initial management with scleral buckling.     

A case of retinal detachment in Kniest dysplasia treated with vitreous surgery

We report a case of retinal detachment with Kniest dysplasia for which vitreous surgery was effective. The patient was a 7-year-old female who had the typical ocular and physical findings of this disease. Visual acuity was light perception alone due to a hypermature cataract and bullous retinal detachment. We performed cataract surgery and pars plana vitrectomy, and used silicone oil tamponade. After seven months, the silicone oil was removed, and visual acuity improved to 0.09. We conclude that bullous retinal detachment with Kniest dysplasia can be treated by vitreous surgery in combination with the use of silicone oil tamponade.     

Pneumatic retinopexy as supplemental therapy for persistent retinal detachment after scleral buckling operation

BACKGROUND: Factors associated with the development of basal cell carcinomas (BCCs) are radiation exposure, sunlight, trauma, and burns. OBJECTIVE: We wish to further document the relationship between the development of BCCs and previous diathermic exposure for therapeutical purposes. Moreover, we compared the histological subtypes of BCCs developed in patients with or without previous therapy. METHODS: A retrospective study of 1053 patients with BCCs seen at our dermatologic clinic was performed. RESULTS: Twenty-three patients had histories of diathermic therapy for different osteoarticular problems. The interval of time between the treatments and the appearance of the tumor was 12-31 years. The histologic subtypes involved were the same of other BCCs on the same areas. CONCLUSIONS: Our study supports the association of BCCs and diathermic therapy in the development of the tumor of the previously treated areas. Histological subtypes do not seem to be affected by environmental factors but are a characteristic of the site location of the tumor.     

Primary vitrectomy for rhegmatogenous retinal detachment associated with choroidal detachment

OBJECTIVE: This study aimed to report the success rate of primary vitrectomy, scleral buckling, and oral steroids in eyes with combined rhegmatogenous retinal detachment (RRD) and choroidal detachment (CD) and to compare these results with those reported in the literature for similar cases managed by scleral buckling alone. DESIGN: Consecutive case series. PARTICIPANTS: Twenty-one eyes of 21 consecutive patients with primary RRD associated with CD were examined. INTERVENTION: All patients were treated with systemic corticosteroids before surgery. Pars plana vitrectomy with scleral buckling or encircling or both were performed. MAIN OUTCOME MEASURES: Retinal reattachment rate and resolution of choroidal detachment were measured. RESULTS: At mean follow-up of 11.4 months, retinal reattachment was attained in 19 eyes (90.5%) compared to less than 53% reported in the literature for scleral buckling alone. With preoperative oral steroids, choroidal detachment regressed completely in 13 eyes (61.9%). In the remaining eyes with persistent choroidal detachment, suprachoroidal fluid was drained during vitrectomy. CONCLUSION: Aggressive treatment with oral steroids followed by pars plana vitrectomy and scleral buckling or encircling is recommended instead of scleral buckling alone in the management of combined primary rhegmatogenous retinal detachment and choroidal detachment.     

Crystalline retinopathy associated with chronic retinal detachment

OBJECTIVE: To describe the presence of crystalline opacities located at the level of the inner retina in patients with chronic retinal detachment. METHODS: We reviewed the clinical records, fundus photographs, and fluorescein angiograms of patients with superficial retinal crystals in the presence of a chronic retinal detachment. RESULTS: Eleven eyes in 11 patients with chronic retinal detachment were found to have these peculiar crystalline opacities on the inner retinal surface. In 5 patients, the crystalline opacities were noted on initial assessment prior to surgery and persisted without change in appearance or number after surgical repair. In 6 eyes, the crystals were not appreciated until after surgical repair of the retinal detachment. The crystals appeared similar in all 11 eyes, were highly refractile, and were located in the posterior pole. Eight of the eyes had retinal detachment associated with retinal dialysis and 6 of these had a history of trauma. There was a definite history of vitreous hemorrhage in 2 eyes. The crystals did not seem to be associated with any visual deficit. CONCLUSIONS: Chronic retinal detachment can be associated with crystals on the inner retinal surface. The cause and composition of these crystals are unknown. They seem to be visually inconsequential and unchanging.     

Complex retinal detachment treated with silicone oil or sulfur hexafluoride gas: a randomized clinical trial

BACKGROUND AND OBJECTIVE: To determine if either silicone oil or sulfur hexafluoride gas (SF6) is superior to the other in the treatment of complex retinal detachment after previously failed vitreous surgery. PATIENTS AND METHODS: In this randomized clinical trial, 18 patients received treatment with silicone oil and 16 patients received SF6. The primary outcome was defined as successful anatomic attachment of the retina. Secondary outcomes included the time to retinal detachment, visual acuity, anatomic macular attachment, and any complications of surgery. RESULTS: The odds of successful reattachment with silicone oil were 50% greater than they were with SF6, but this difference was not statistically significant. There were no differences between the two groups in any of the secondary outcomes. CONCLUSIONS: This study did not have enough statistical power to detect a small but clinically important difference between the two treatment groups. Physicians must use their clinical judgment to select a vitreal substitute for complex retinal detachment when clinical trials are inconclusive. Data pooling is one method of overcoming the limitation of clinical trials with small sample sizes.     

Schisis-like rhegmatogenous retinal detachment associated with choroidal colobomas

BACKGROUND: The breaks that cause retinal detachments in colobomatous eyes are often hidden within the lesion and difficult to find. METHOD: To elucidate the pathoanatomy and possible pathomechanism of such detachments, histological sections of eight choroidal colobomas were reviewed. RESULTS: Sections of the margin showed central continuation of the inner neuroblastic layer (the intercalary membrane) and eversion and separation of the outer neuroblastic layer. The opposite direction of continuity of the neuroblastic layers created a schisis-like configuration between the intercalary membrane and the everted outer retina. The zone of duplication was a point of retinal adhesion, but also a locus minoris resistentiae due to vitreous attachments and variable glial support at the margin. CONCLUSION: The subset of coloboma-associated retinal detachments requires both a central break in the inner layer and a break in the outer layer at the margin of the coloboma. The inner layer break may be precipitated by retinovascular ischemia or scleral stretching; that in the outer layer may be caused by vitreous traction on the margin of the coloboma or extension of the formerly isolated detachment through the outer marginal zone of decreased glial support.     

Scleral buckling with Bioplast fibrin in retinal detachment

The study includes a series of 38 patients with retinal detachment of different aetiology. Scleral reduction combined with the intrascleral implantation of absorbable Bioplast fibrin scleral buckling rods was performed and reattachment achieved in 31 cases. The implant material is biocompatible and is eliminated from the eye in the course of a few weeks.     

Failures in the surgical treatment of retinal detachment. An analysis

One hundred sixteen patients underwent operation for renovascular hypertension from 1962 through 1975; 64% had aortorenal reconstruction and 36% had nephrectomy. Sixty-six percent were cured and 19% were improved. Rapid sequence intravenous pyelography, radioisotope renography, and renal arteriography were equal in ability to detect renovascular hypertension. Bilateral renal biopsy specimens had excellent prognostic value when performed in a graded semiquantitative manner. Plasma renin activity was the most consistently useful criterion for prediction of surgical cure if the following requirements were used: (1) elevated peripheral plasma renin activity, (2) elevated renin from the affected kidney, and (3) suppressed renin secretion from the contralateral kidney. An angiotensin II antagonist, saralasin acetate, used in six patients before operation in an attempt to identify those whose hypertension depended on angiotensin II activity, produced a depressor response correlating well with the surgical result.     

Diagnostic ophthalmology. Idiopathic endophthalmitis with secondary retinal detachment

Toxocariasis is a parasitic disease. Larvae of Toxocara canis, as intra-tissular parasites, can survive in human organism for 10 years. Clinical symptoms depend on massiveness of infection, organ localisation and defensive reactions of patients. 74 children were observed (in age from 1 year 8 months to 15 years). 70% of them had intraocular lesions which is the most serious complication of toxocariasis. Larva of T. canis is neurotropic. EEG revealed abnormalities in 73% of patients. The diagnosis of toxocariasis was confirmed by immunoenzymatic reaction ELISA with T. canis antigen. The patients were treated with hetrazan, if intraocular lesions were present prednisone was added. Improvement was achieved in 78% of children with intraocular lesions, in the rest effectiveness of the treatment is questionable.     

Late recurrences after successful surgery for retinal detachment with macular hole

Six myopic eyes affected by retinal detachment with macular hole which had been successfully reattached developed recurrent retinal detachment 7-78 months postoperatively. The mean interval between surgery and the recurrent retinal detachment was 13.4 months in five eyes managed with gas tamponade and no choroidal irritation. In an eye managed by scleral buckling with choroidal irritation, the recurrent retinal detachment occurred 78 months postoperatively. The retina was reattached following reoperation in all eyes. However, an eye successfully reattached without choroidal irritation developed four recurrences during the follow-up period. The pathogenesis of late recurrences after successful surgery for retinal detachment with macular hole remains speculative. A number of clinical findings suggest that vitreous traction plays a decisive role.     

Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment

PURPOSE: This study was designed to elucidate various aspects of the natural history of posterior vitreous detachment (PVD), in particular the relation between symptomatology and prognosis as it relates to management of patients with the earliest symptoms of PVD. METHODS: A prospective study of 350 consecutive patients with PVD was performed, excluding all patients referred from an ophthalmologist, those with symptoms of more than 3 months in duration, and those with a history of ocular trauma, except for cataract surgery. Aphakia was present in 21 eyes, and 50 patients were bilaterally involved. RESULTS: Of 163 patients who had one to two floaters as their presenting symptom, with or without light flashes, a retinal tear developed in 12 (7.3%). Of 31 phakic eyes with secondary retinal tears on initial examination, 9 (29%) had one to two floaters and light flashes as the only symptoms. Of eight phakic eyes that initially, or eventually, had a retinal detachment, three (37%) had an interval of 2 1/2 to 3 weeks before visual field loss, during which they noticed only one to three visual floaters plus light flashes as their only symptoms. This early stage in which symptoms are detectable is crucial in terms of providing an opportunity for early treatment that might prevent retinal detachments. CONCLUSIONS: The prompt and conscientious vitreoretinal examination of each patient older than 45 years of age who experiences vitreous floaters, even though limited to one or two, should be undertaken without delay. This practice, combined with expeditious treatment of any secondary retinal tears, provides the most effective known means of preventing rhegmatogenous retinal detachment, and currently it appears to be neglected. A national public educational effort should be pursued to publicize the importance of these symptoms.     

Vitrectomy in the treatment of simple retinal detachment

PURPOSE: To report the indications and results of vitrectomy in the treatment of uncomplicated retinal detachment. METHODS: This retrospective study covered 103 vitrectomies that were carried out during an 8-year period for the treatment of rhegmatogenous retinal detachment without severe proliferative vitreoretinopathy, macular hole, or giant tear. Mean follow-up time was 20.3 months. RESULTS: The indications for vitrectomy were vitreal opacities in 32 cases, unseen or uncertain retinal breaks despite a good retinal view in 9 cases, a difficult arrangement of breaks in 34 cases, severe vitreal traction in 15 cases, and iatrogenic intraocular bleeding in 13 cases, 6 of them referred. In all, retinal breaks were uncertain or invisible in 49 cases. A buckle was used in 83 cases and an internal tamponade in 93. After vitrectomy, the retina was reattached in 76 cases, and after further surgery in 88 (85.4%). With vitrectomy, we were able to confirm or to detect all breaks in 36 cases. Of the 13 intraoperatively unseen breaks, 10 were responsible for vitrectomy failure. Late recurrence after more than 6 months was observed in 5 cases (4.9%). Secondary cataract was observed in 22 (66.6%) of the 33 phakic cases that had been operated on successfully and without complication. CONCLUSION: Our results indicate that vitrectomy is a useful procedure in the management of certain cases of uncomplicated rhegmatogenous retinal detachment. However, secondary cataract is a problem, and the risk of late recurrence needs further evaluation.     

Silicone oil tamponade in the treatment of retinal detachment with proliferative vitreoretinopathy

Over 2 months in 1995, 235 assault patients attended the accident and emergency department of the Royal Alexandra Hospital, Paisley (2.4% of total new attendances). 80% were male and their mean age was 28 years (range 6-64); men were the assailants in over 90% of attacks. Alcohol had been consumed by 69% of the victims and 9% admitted to taking illicit drugs. The commonest place of assault was the street (44%) but women were more likely to be assaulted in their homes. Penetrating weapons were used in 23% of assaults. 60% of all injuries were to the head and neck. 27% of the victims were admitted to hospital. Paisley has an assault rate similar to that of other UK centres but the use of penetrating weapons is much higher than elsewhere.     

Limits of constriction in the treatment of retinal detachment

A constricting silicone band was added to 13% of local sponge buckle operations in this series. The purpose was to relieve circumferential traction or to maintain a high buckle. The inclusion of a cerclage did not require drainage of subretinal fluid. The rate of reattachment without drainage (42 of 50 detachments) is comparable to what might be expected if the subretinal fluid had been drained. Constriction was controlled and limited to between 10% and 25% of the circumference of the eye. Anterior segment ischemia requiring relaxation of the band occurred in two patients; scleral erosion did not occur.