Aphakic and phakic retinal detachment. I. Preoperative findings

Phacoemulsification after retinal detachment surgery

PURPOSE

Previous studies have documented a 3% to 15.5% risk of retinal redetachment in eyes with prior scleral buckling procedures that later undergo intracapsular or extracapsular cataract extraction. The authors reviewed the records of patients with a history of retinal detachment (RD) surgery and subsequent phacoemulsification to assess the risk of retinal redetachment and the visual outcomes.

METHODS

Forty-seven eyes of 44 patients with a history of scleral buckling surgery who subsequently underwent phacoemulsification were identified. Features found before, during, and after surgery were reviewed.

RESULTS

No retinal redetachments occurred on a mean follow-up of 2.3 years. Eyes with RD repair were more myopic than fellow eyes (P=<0.001), had longer axial lengths (P=0.001), had steeper keratometry readings (P=0.03), and had larger differences in K readings between principal meridians (P=0.01). Postoperative visual acuity was 20/40 or better in 72.3% of eyes and 20/80 or worse in 6.4% of eyes. Preexisting macular pathology was responsible for poor outcomes.

CONCLUSION

The risk of redetachment after phacoemulsification in eyes with previous RD surgery is low. Despite retinal and cataract surgery, these eyes can achieve useful vision.

Retinal detachment after cataract surgery. Surgical results

The authors studied the results obtained by the Retina Associates in 376 eyes of 361 patients operated on for retinal detachment associated with aphakia or pseudophakia with a postoperative follow-up of at least 6 months. All eyes underwent scleral buckling. The series included 103 eyes with aphakia, 17 eyes with iris-fixated intraocular lens, 111 eyes with anterior chamber (AC) IOL, and 145 eyes with posterior chamber (PC) IOL. The overall success rate for retinal detachment was 93%, without significant difference among the different groups. The aphakia and PC IOL groups had significantly higher prevalence (63% and 60%, respectively) of visual acuity equal to or better than 20/40 compared with the AC IOL group (33%). The prevalence of postoperative corneal edema in the AC IOL group was significantly higher than in the aphakia and PC IOL groups. Preoperative vitreous hemorrhage, large retinal breaks, posterior retinal breaks, total retinal detachment, proliferative vitreoretinopathy, and the need for performing a closed vitrectomy were significant factors in predicting ultimate failure.

Retinal detachment after cataract surgery. Predisposing factors

The authors studied the characteristics of 376 eyes of 361 patients with primary retinal detachment (RD) and surgical aphakia (103 eyes) or pseudophakia (273 eyes). Of the pseudophakic eyes, 17 had an iris-fixated intraocular lens (IOL), 111 had an anterior chamber (AC) IOL, and 145 had a posterior chamber (PC) IOL. Of the PC IOL cases, 48 (33%) had undergone YAG capsulotomy, and 46% of them developed RD within 6 months after capsulotomy. The frequency of no breaks found in pseudophakic RD (15%) was significantly higher than in RD with simple aphakia (5%). The most frequent reasons were incomplete fundus view due to a small pupil in the iris-fixated (83%) and the AC (44%) groups, and cloudiness of capsular remnants in the PC group (78%). In pseudophakic RD, sizable single tears, located more posteriorly than in RD with simple aphakia, were frequent. The authors speculate that in pseudophakic RD the retinal breaks may resemble those noted in phakic RD.

Scleral buckling for rhegmatogenous retinal detachment associated with severe myopia

From Jan. 1, 1980, to Dec. 31, 1989, we performed scleral buckling surgery on 48 eyes of 46 patients for rhegmatogenous retinal detachments associated with severe myopia (greater than 5.00 diopters). Forty eyes of 38 patients were observed for at least six months, and the mean follow-up period was 46 months. Intraoperative complications occurred in four of 48 eyes (8%) and included retinal incarceration (two eyes), choroidal hemorrhage (one eye), and choroidal detachment (one eye). Three of the 40 eyes (7.5%) followed up for more than six months developed a recurrent retinal detachment and underwent a revision of the scleral buckle. At the last follow-up examination, the retinas of all 40 eyes were totally reattached. Final visual acuity of 20/40 or better was attained in 26 of 40 eyes (65%). Because of the low rate of intraoperative complications and the high rate of success, scleral buckling is recommended for most patients with rhegmatogenous retinal detachments associated with severe myopia.

Retinal detachment following intracapsular cataract extraction

A retrospective investigation of aphakic retinal detachments following intracapsular cataract extraction during a 12-year period was performed. A total of 8350 eyes had intracapsular cataract extraction in the study period and 118 eyes developed aphakic retinal detachment. The occurrence of retinal detachment is related to age, sex, intraoperative complications, myopia, hyperopia, and pseudophakia. Age and myopia were significantly associated with aphakic retinal detachment. Previous aphakic retinal detachment in the one eye was a strong predictor for the other eye.

Retinal detachment following YAG laser capsulotomy

A retrospective study of 12 patients with rhegmatogenous retinal detachment following YAG posterior capsulotomy is reported. Eleven out of these 12 were at increased risk of detachment. Three had lattice degeneration, three had previous detachment and five had axial myopia. Only 50% of the holes were typical "aphakic" post-oral breaks.

Retrospective study of retinal detachment following neodymium:YAG laser posterior capsulotomy

A retrospective study of 1,000 cases that had Nd:YAG laser posterior capsulotomy after cataract surgery is presented. We analyzed the correlation of the patient's age, axial length of the eye, method of cataract surgery, and laser parameters (exposures, energy, and burst mode) with the incidence of retinal detachment (1.6% overall). The highest risk for retinal detachment (12.3%) was in patients with an axial eye length of 26.1 mm to 28.0 mm. The average age of patients with retinal detachments was 60.6 years, ten years younger than the collective average age. Laser parameters, such as energy, exposures, and burst mode, and the method of cataract surgery (extracapsular or phacoemulsification) did not correlate with the incidence of retinal detachment. After surgical treatment of the 16 retinal detachments, a good postoperative visual acuity (better than 20/40) was achieved in most cases.

Retinal detachment and its relation to cataract surgery

In Western Australia during the period 1 January 1976 to 31 December 1987 1089 eyes of 1044 patients in hospital were operated upon for primary rhegmatogenous retinal detachment due to causes other than penetrating trauma. Of these eyes 295 (27%) were aphakic or pseudophakic. During this period the annual number of cataract operations in the State increased by a factor of 245%, while aphakic and pseudophakic retinal detachment operations rose by only 55%. The declining risk of retinal detachment following cataract surgery is attributed to improvements in microsurgical techniques. In 1983 and 1984 the incidence of aphakic and pseudophakic retinal detachments dropped significantly (p less than 0.05). At about this time extracapsular cataract surgery became widespread in the State, and this may explain the observed fall in retinal detachment operations. Since 1984 the incidence has risen owing to the rapidly increasing prevalence of pseudophakia in the resident population.

Retinal tears and detachments after extracapsular cataract surgery

A review of 3,120 consecutive cases of extracapsular cataract extraction revealed a retinal detachment incidence of 0.8% and a retinal tear incidence of 0.9%. Approximately 85% of all tears and detachments occurred within the first three years of cataract surgery. Analysis of the retinal detachment group identified several risk factors. These included young age, male sex, axial length greater than 25 mm, primary posterior capsulotomy, and previous retinal surgery in the fellow eye. In the retinal tear group, the risk factors were young age and previous retinal surgery in the fellow eye. Visual results were excellent with an average of one line of acuity lost after successful macula-on and macula-off detachment surgery and no significant change after retinal tear repair. Despite multiple surgeries, the retinas in two detachments were lost to proliferative vitreoretinopathy.

Surgery of aphakic retinal detachment

In a prospective study 84 patients with aphakic retinal detachment were treated either by local scleral buckling alone or combined with an encirclement. The rate of surgical reattachment of the retina was found to be similar with either technique over a minimum follow-up period of one year. Simplicity and a low incidence of serious complications of the local procedure merit its application as the initial method of repairing aphakic detachments.

Expanded indications for pneumatic retinopexy

The Collaborative Pneumatic Retinopexy Study evaluated retinal detachments (RDs) secondary to one break or group of breaks no larger than 1 clock hour located within the superior 8 clock hours of the fundus. Eyes with prominent proliferative vitreoretinopathy (PVR) were excluded. Forty eyes which exceed these criteria and were treated with pneumatic retinopexy have been retrospectively evaluated to determine what preoperative conditions limit the application of pneumatic retinopexy. Multiple breaks in multiple quadrants, large tears up to 2.5 clock hours in size, and RDs associated with a moderate degree of PVR were successfully managed with pneumatic retinopexy. The greatest number of failures were due to inferior breaks. The overall success rate for pneumatic retinopexy was 75%. New breaks occurred in 12.5% of eyes, but all of these were successfully managed.

Epidemiology of aphakic retinal detachment following intracapsular cataract extraction: a follow-up study with an analysis of risk factors

We reviewed 604 eyes in 521 patients who had intracapsular cataract extraction. The follow-up period averaged 39 months. The incidence of rhegmatogenous aphakic retinal detachment (ARD) was 1.3% in the whole group. The ARD incidence was 1.0% in eyes without surgical complications and 5.4% in myopic eyes (myopia defined as an aphakic refraction less than or equal to +9.0 diopters). The log-rank test was used to estimate the statistical significance of various ARD predictors. Significant predictors were age at surgery below 70 years (P = .0004) and myopia (P = .001). Our results indicate that the high risk of ARD is concentrated in a small group of myopic patients operated on at a relatively early age. During the follow-up period, 128 patients died. Compared with the mortality rate of the entire Danish population, this was not an above average mortality rate. Thus, our results do not support the hypothesis that senile cataracts reflect general systemic deterioration rather than local eye disease.

Pseudophakic and aphakic retinal detachment mimicking cystoid macular edema

Seventeen eyes of patients who were being followed by their ophthalmologists for aphakic (8 eyes) or pseudophakic (9 eyes) cystoid macular edema (CME) were examined on referral. All eyes showed retinal detachment (RD), and eight eyes had CME with RD. Most RDs were inferior and shallow. Proliferative vitreoretinopathy (PVR) was noted in 15 eyes (88.2%). There was history of vitreous loss during the last intraocular surgery in 88.2% eyes. Visual acuity ranged from 20/40 to hand movements. Fundus view was hazy in most eyes, and indirect ophthalmoscopy was most useful in detecting RD. Retinal reattachment with scleral buckling and/or vitrectomy was achieved in 16 eyes (94.1%). Postoperative visual recovery was jeopardized due to longstanding macular detachment of greater than 1 month in 11 eyes (64.7%). Eight eyes (47%) achieved 20/50 vision whereas 25% did not improve to better than 20/400. Factors leading to failure in making the correct diagnosis and their prevention are discussed.

Clear lens extraction for axial myopia. An appraisal

Optional surgery requires a higher degree of safety than that performed for medical necessity. This ethical principle is particularly applicable to axial myopes, who have higher-than-normal rates of operative and postoperative complications if they undergo lens extraction. Moreover, several noninvasive, extraocular, and reversible techniques now exist for the correction of myopia. Currently, it would appear that the possible optical benefits of clear lens extraction in axial myopia are usually outweighed by the severity of the risks and by the availability of safer alternatives.

Retinal detachment after extracapsular cataract extraction with posterior chamber intraocular lens

The authors reviewed 3065 consecutive cases of extracapsular cataract extraction with posterior chamber lens implant (ECCE-PC IOL) and found the incidence of retinal detachment to be 1.4% overall (44/3065) and 1.7% in a group of eyes followed for at least 1 year (40/2330). Retrospective analysis of the retinal detachment (RD) group (n = 44) showed the patients to be significantly younger than the overall group (n = 3065) (P less than 0.0001). Comparison with an age-matched group of 302 eyes without RD showed higher rates of RD in males (P = 0.0013) and in eyes with axial eye length (AEL) greater than 25 mm (P less than 0.0001). No significant correlation was found between RD and PC IOL manufacturer, phacoemulsification (PKE), or primary discission. Sixty-four percent of RDs occurred within 1 year of cataract operation. Only 10% occurred more than 2 years later. Visual results in eyes with ultimate anatomic success of RD repair (43 of 44 eyes, averaging 15 months follow-up) are substantially better than previously reported in series with other types of IOLs (96% greater than or equal to 20/40 if the macula was not involved, 75% greater than or equal to 20/40 if the macula was involved).

Retinal detachment. A study of a population-based patient material in Sweden 1971-1981. I. Epidemiology

A population-based series of retinal detachments (RD) collected during a 10-year period (538 patients, 590 'cases', i.e. diseased eyes including new RD after 6 months in the same eye) is reported. The annual incidence was 10.6 per 100,000 population. Bilaterality was observed in 11.2%. In this material preponderance of the right eye was found. In non-traumatic RD there was a small sex difference, with a higher incidence among females. Older persons were at high risk of sustaining RD, as were myopes. In myopic males the risk increased with the degree of myopia and with increasing age. In myopic females the greatest risk was found in the age group 30-59 years. Myopic eyes are probably also more vulnerable to traumatic RD. Lattice degeneration was more common in middle-aged than in older patients and was also more common in myopic eyes than in eyes with other phakic RD. High myopia (greater than -5D) was more frequent in patients with lattice degeneration than in those without. Aphakia was found to be an important predisposing factor for RD. A classification taking into account the above-mentioned factors is proposed.

Retinal detachment. A study of a population-based patient material in Sweden 1971-1981. II. Pre-operative findings

In a population-based material of patients with retinal detachment (RD), the pre-operative findings in different subgroups were studied. In traumatic cases flap tears and round holes were found in at least as high a frequency as oral dialysis, or even higher. In aphakic cases subtotal or total RD was often observed on admission for surgery. A high proportion of aphakic eyes without lattice degeneration exhibited no breaks. RD in myopic eyes was usually large, and round holes were frequently found. Full-thickness fixed retinal folds were more seldom seen pre-operatively en myopic than in non-myopic eyes. Lattice degeneration was usually observed in myopic RD patients of ages less than 30 years, but mainly in hyperopic or emmetropic eyes in patients over 60. In RD with lattice, multiple breaks were frequently found. A comparatively large group of RD cases without lattice were non-traumatic, phakic and non-myopic (40%). Most of these patients were 60 years and older. Flap tears were often seen, and the detachment was seldom large in this group.

Epidemiology of retinal detachment in childhood and adolescence

The prevalence of retinal detachment during childhood and adolescence was studied in 45,000 recruits aged 17 to 19 years. History of retinal detachment was found in 13 cases (0.028%); 61.5% of these had traumatic retinal detachment, and 23.1% had high myopia without history of trauma. The age-related annual incidence of retinal detachment in patients aged ten to 19 years was calculated to be 2.9 per 100,000. The prevalence among the males was 3.7 per 10,000 and among the females 1.6 per 10,000. The difference between the sexes was not statistically significant.

Retinal detachment after intraocular lens implantation

Between August 1982 and July 1985, 19 eyes were operated for pseudophakic retinal detachment (PRD) (Anterior chamber lens in 13 eyes, posterior chamber lens in 3 eyes and iris supported lens in 3 eyes). The characteristics of these pseudophakic retinal detachments were very similar to those following intracapsular cataract extractions. Retina was re-attached in 18 eyes (95%), in 14 eyes, after one buckling procedure. In 4 eyes, altogether 12 surgical procedures were needed to re-attach the retina. Problems to visualize the peripheral retina, made it necessary to remove the IOL in 3 eyes (2 iris fixated and one in the anterior chamber).

The fellow eye in patients with unilateral retinal detachment: findings and prophylactic treatment

During a 4-year period, 1978-1981, 312 patients were operated on for unilateral rhegmatogenous detachment of the retina. Of the fellow eyes, 11% showed moderate (VA 0.15-0.4) and 5% severe (VA less than or equal to 0.1) visual impairment. Of the fellow eyes 49% were myopic (- 1.0 D. or more), and aphakia was present in 14%. Details of the peripheral fundus were adequately recordable for 260 fellow eyes. Degenerations considered to predispose to retinal detachment were found in 98 eyes (38%): lattice degeneration in 54 (21%), granular tuft in 17 (7%), retinal tear(s) in 12 (5%), and retinoschisis in 15 (6%). Prophylactic treatment of predisposing degenerations was performed in 91 of the 98 eyes using cryo- or photocoagulation (argon laser). No intra- or permanent post-operative complications were noticed. One of the treated fellow eyes (1.1%) detached 10 months after prophylactic treatment due to new tears. In the untreated group, 6 of the 221 eyes detached (2.7%). The difference was not statistically significant, but the groups were not comparable because 93% of the eyes showing predisposing degenerations were treated. None of the eyes treated for retinal breaks or lattice degeneration has detached. In these cases prophylactic treatment of the fellow eye is recommended. In most eyes cryocoagulation seems to be preferable to photocoagulation.

Aphakic retinal detachment

A study of 132 cases of aphakic retinal detachment (ARD) following mainly intracapsular cataract surgery has been made. Forty-nine cases (37%) were found to have vitreous incarcerated into the cataract section out of a total of 54 (41%) cases who had suffered a vitreous complication during cataract surgery. A study of the characteristics of ARD reveals that those cases having had a vitreous complication in the management of their cataracts are more likely to develop detachment within three months than those not suffering from such a complication. The occurrence of these early post-extraction retinal detachments is not influenced by the presence of underlying axial myopia. When we compared ARD in patients whose cataract extractions had been complicated by vitreous incarceration with those ARDs following uncomplicated cataract surgery, we found that the characteristics of the detachments were very similar. Thus distribution of underlying myopia, extent of detachment, length of time of detachment, and multiplicity and type of retinal holes were generally similar. However, ARD following complicated cataract surgery is more likely to suffer from periretinal fibrosis. The findings confirmed the risk of ARD following complicated intracapsular cataract surgery and support the tendency to perform the extracapsular operation.

Shifting subretinal fluid in rhegmatogenous retinal detachment

In a consecutive series of 470 cases of rhegmatogenous retinal detachment 25 (5%) were found to have shifting subretinal fluid (SRF) at the preoperative examination. The study showed that the association between SRF and rhegmatogenous retinal detachment is unusual but not rare. Shifting SRF was most often associated with aphakic and longstanding retinal detachment, and found in cases in which the retinal holes were small.

Proliferative vitreoretinopathy after intraocular lens implantation

The first 3 patients with pseudophakic retinal detachment referred to the Helsinki University Eye Hospital are presented. All had undergone extracapsular cataract extraction with implantation of an iris-supported IOL in one case and a posterior chamber lens in two cases. All showed proliferative vitreoretinopathy (PVR) varying from Grade C2 to D1 when first examined for retinal detachment 6 to 16 weeks after cataract surgery. The retina was primarily re-attached in all cases, but re-detachment occurred in 2 of the 3 due to progressing PVR. Until now our incidence of pseudophakic retinal detachment is 0.3%.

Retinal complications following YAG laser capsulotomy

Eighteen patients (19 eyes) developed retinal complications following YAG laser capsulotomy. Complications included one retinal flap tear, two macular holes, six eyes with cystoid macular edema, and ten retinal detachments. The retinal complications resulted from opening the capsule and were not a specific complication of the YAG laser.

Characteristics of rhegmatogenous retinal detachment

Characteristics of rhegmatogenous retinal detachment and its predisposing factors were studied in a consecutive series of 342 patients operated on for retinal detachment (RD) at the University Eye Hospital in Helsinki in 1978-1981. On these, 234 were pre-operatively examined and operated on by the senior author. The mean age of the patients was 52.8 +/- 1.0 (range 5.7 to 83.0) years, 49.1% were males, 50.9% females. Bilateral RD occurred in 9.9%, and another 4.7% had been treated for retinal breaks in the fellow eye. Of the main predisposing factors, myopia (greater than or equal to -1.0 D) was found in 50.6% of the phakic eyes, 23.0% of the eyes were aphakic, and lattice degeneration was found in 15.1% and trauma in 11.9% of the whole series. In the nontraumatic phakic group, lattice degeneration was present in 31.3%. In the aphakic group, 25.9% had underlying myopia and 8.1% showed lattice degeneration. The relative importance of these factors varied with age. Total RD was found in 60 eyes (17.0%), most commonly in aphakic eyes (32.1%). Macula was detached in 56.5%. Two or more retinal breaks were found in 40.9%. The type of breaks varied with age and refraction. Oral dialysis was common before the age of 20 in non-myopic phakic eyes. Between 20 and 39 years, tears and holes were equally common, and after 40 years of age tears predominated. Tears outnumbered holes both in nonmyopic and myopic eyes, most round holes were found in myopic eyes. In 11.6% of the eyes no sure retinal breaks were detected. Relation of retinal breaks to peripheral retinal degenerations was studied.

Complications of intraocular lenses. A historical and histopathological review

Recent improvements in intraocular lens (IOL) design, manufacturing techniques, and surgical techniques have greatly reduced the incidence of complications following implantation, and many authors now consider IOL implantation to be among the most safe and effective major surgical procedures. However, adverse reactions are still seen--some as late sequelae of earlier IOL designs and implantation techniques and some as sequelae of more recent implantations using "state-of-the-art" lenses and surgical techniques. Complications may be due to various factors, including surgical technique, IOL design, or the inability of some eyes with preexisting disease to tolerate an implant. The authors trace the evolution of IOLs since Ridley's first implant, summarizing the modifications in lenses and surgical techniques that were made as complications were recognized. They then review the clinical and histopathological features of selected cases from more than 200 IOLs and/or globes removed due to IOL-related complications and studied in the University of Utah Ocular Pathology Laboratory. It is hoped that this review will provide insights into the pathogenesis of IOL complications, enhancing the current success of implant procedures and stimulating further basic and clinical research in this area.

Posterior capsulotomy and retinal detachment following extracapsular lens surgery

A retrospective analysis of the results of extracapsular cataract surgery with and without implant is presented. Surgery was performed by a group of consultants and registrars from 1975 to 1982, and minimum patient follow-up was 12 months (mean 26.2 months). The incidence of postoperative capsulotomy was 14.3%, but the need for this procedure declines, becoming negligible after 3.5 years. Of 242 eligible eyes, aphakic retinal detachment occurred in only one.

Pars plana vitrectomy in aphakic retinal detachments

Thirty-three cases of aphakic retinal detachment have been treated by pars plana vitrectomy and retinopexy. This procedure allowed us to lower the incidence of postoperative massive periretinal proliferation from 15,4%, in a series that was performed by a classical method, to 6% in the pars plana treated group.

Prophylactic argon laser photocoagulation in retinal detachment fellow eyes

Over a two-year period (1975-76) 329 patients were operated for rhegmatogenous retinal detachment. 301 patients had unilateral detachment and in 62 of these prophylactic photocoagulation with argon laser in the fellow eye was performed. During the observation time one of these (1.6%) and 7 untreated (2.9%) fellow eyes developed retinal detachment. The indication for prophylactic photocoagulation of fellow eyes and the results are discussed.

Bilateral phakic retinal detachment

Ninety-nine (11.6%) of 850 phakic retinal detachment patients had bilateral detachments. The incidence of bilaterality was greater in nontraumatic detachments (13.4%) than traumatic detachments (3.8%). Patients were divided into two refractive classes: (1) myopic, containing refractive errors of -2.50 diopters or more, and (2) nonmyopic, containing all other refractive errors. The rate of bilaterality in nontraumatic detachments varied with refractive class and lattice degeneration: nonmyopic without lattice (8.1%), nonmyopic with lattice (14.2%), myopic without lattice (16.3%), and myopic with lattice (24.6%). Mean age in years at onset of the initial detachment varied with refractive class and lattice degeneration: nonmyopic without lattice (59.1), nonmyopic with lattice (55.8), myopic without lattice (49.2), and myopic with lattice (28.2). Lattice degeneration reduced the interval between detachments. Annual risks of fellow eye detachments were calculated for four groups: nonmyopic without lattice (0.12%), nonmyopic with lattice (0.95%), myopic without lattice (1.3%), and myopic with lattice (0.98%).

Prognosis for central vision and anatomic reattachment in rhegmatogenous retinal detachment with macula detached

We analyzed a total of 473 eyes with rhegmatogenous retinal detachment and macular involvement for significant factors relating to anatomic success and a favorable visual outcome of 6/15 (20/50) or better. The overall success rate was 90% (427 of 473 eyes). Visual acuities of 6/15 (20/50) or better postoperatively were present in 37% (174 of 470 eyes). Important factors related to both anatomic success and favorable functional results were preoperative visual acuities of 6/15 (20/50) or better, retinal detachments that were less than total, detachments with tears located at or anterior to the equator, absence of giant retinal tears, absence of either preoperative ocular hypotony (tension less than 5 mm Hg) or ocular hypertension (intraocular pressure greater than 20 mm Hg), detachments managed by nondrainage techniques, a single operation with less than 50 cryoapplications, and noncircumferential buckling. Among the other factors related to favorable visual results were detachments lasting less than one month, a shallowly rather than highly detached macula, the absence of fixed retinal folds, a patient age of less than 60 years, and the absence of postoperative choroidal detachments sufficient to cause glaucoma. We found no statistical relationship between either anatomic success or functional result and the presence of aphakia, demarcation lines, vitreous hemorrhage, detachments of the pars plana epithelium, or predetachment glaucoma being treated.

Management of the fellow eyes of patients with rhegmatogenous retinal detachment

The experience of the senior author over the past 18 years in the management of fellow eyes of 3,036 patients with rhegmatogenous detachment is reported. The study group is composed of 2,221 patients with no history of detachment surgery or prophylactic treatment in the functional fellow eye. Of 816 eyes with retinal breaks, lattice degeneration, or retinoschisis-the types of pathology most conducive to detachment-70% were treated with xenon-arc photocoagulation or cryoapplication. Detachment occurred subsequently in 5.4% of the eyes treated with photocoagulation, 2% of the eyes treated with cryoapplications, and 8.2% of the eyes with major pathology that were not treated. Essentially normal fellow eyes with no major pathology and, consequently no treatment, had a subsequent detachment rate of 5.3%. The authors conclude that prophylactic treatment via transconjunctival cryoapplication is safe and effective and recommend treatment of all fellow eyes with lattice degeneration and breaks.

Retinal detachments following intraocular lens implantation

Pseudophakic retinal detachments are more difficult to manage than the phakic variety, primarily because of increased difficulties in visualizing the peripheral retina. A review of the characteristics of 70 pseudophakic retinal detachments revealed that they were similar to those following routine cataract extraction, although we noted a mild tendency for periretinal membrane formation to be more commonly associated with the former group. Despite problems in viewing pseudophakic detachments, our data suggest that their repair rate closely approximates that for aphakic eyes, assuming allowances are made for the number of cases with significant periretinal membranes that are accepted for surgery. Visual results following successful surgery may be somewhat lower than those in comparable aphakic eyes.

Surgical management of retinal detachment without cryopexy

A clinical study of eyes with rhegmatogenous retinal detachment compared the reattachment rate in two groups of eyes: in the control group, cryopexy was applied over the retinal breaks during surgery; in the test group, cryopexy was not applied. There was a similar rate of retinal reattachment in the two groups in the immediate postoperative period. However, during the long follow-up period (36 months) there was a considerable difference in the two groups. Eyes that had undergone cryopexy had a lower rate of redetachment than eyes that had not. The rate of operative and postoperative complications was low in both groups, except for periretinal proliferation, which was more frequent in the test group. These results suggest that cryopexy may lower the incidence of redetachment after retinal detachment surgery.

Cystoid macular edema after retinal detachment surgery

One hundred eyes in 98 patients were studied by fluorescein angiography and stereo color photography six weeks after successful scleral buckling surgery. Twenty-five percent of 67 phakic eyes and 40% of 33 aphakic eyes demonstrated cystoid macular edema. Older phakic patients were at significantly greater risk to develop cystoid macular edema than younger phakic patients. Seventeen percent of successfully repaired eyes demonstrated distortion of the macula by preretinal membranes; 16 of these 17 eyes showed leakage of fluorescein dye into the surrounding retina sometimes also causing cystoid edema. Either cystoid macular edema or macular distortion was present in 38% of the phakic eyes and 64% of the phakic eyes after successful retinal detachment surgery.

Rhegmatogenous retinal detachment without macular involvement treated with scleral buckling

Among 173 patients who had rhegmatogenous retinal detachment with spared maculas, high percentage achieved anatomic and functional success. We reattached 171 (99%) of the retinas; 150 (76%) of the eyes had final visual acuities of 6/15 (20/50) or better. Eighteen eyes (10%) had final postoperative visual acuities reduced more than two lines from the preoperative level. This reduced visual acuity was primarily related to postoperative changes occurring in the macula. The prognosis both for anatomic reattachment and visual acuity after scleral buckling for rhegmatogenous retinal detachment is significantly better when the macula is spared than when it is not. Large numbers of cryoapplications were not associated with macular complications.

Correlation of aphakic retinal detachment and refractive error with gender

I analyzed the aphakic refractive errors of men and women separately in a statistical study of patients with aphakic retinal detachments. I compared the distribution of aphakic refractive errors in a population of 81 adult patients with nontraumatic aphakic retinal detachment with that of a randomly selected control population of 93 adult patients with aphakia. As a group, women who developed aphakic retinal detachments were significantly more myopic than female controls (11.41 vs 12.37 diopters of spherical equivalent; P = .004). In contrast, the refractive error in men did not differ between the aphakic retinal detachment and control groups (11.31 vs 11.68 diopters; P = .156). A significantly higher percentage of patients with bilateral (87%) aphakic retinal detachments were men (P = .017). In men other risk factors for aphakic retinal detachment, including cardiovascular disease, may overshadow the influence of axial myopia.

Vitreous base classification of retinal tears: clinical application

The abundant data about retinal tears has shown that they are prevalent in the general population and that the vast majority of retinal tears do not lead to retinal detachment. What remains to be clarified are the criteria for identifying the few retinal breaks which require prophylactic surgery to prevent their progression to retinal detachment. Numerous reports have identified clinical features which correlate with the risk the retinal detachment. These correlative data offer at best only a suggestion about the need for treatment of any specific retinal break. This paper-demonstrates how the categorization of a retinal tear on the basis of vitreoretinal anatomic detail may be used clinically to make an objective and nonstatistical judgment about the prognosis of any specific retinal break. The application of this new categorization offers an advance in the care of patients with retinal tears.

Five years' follow-up in the surgical management of cataracts in high myopia treated with the Kelman phacoemulsification technique

With the advent of phacoemulsification, much interest has again been rekindled in extracapsular cataract surgery and its effects on the vitreoretinopathies associated in high myopia. Since 1972, 278 patients with high myopia greater than --7.50 D, as as determined by axial length echography, have been operated on by the author. The five-year follow-up with statistical analysis of these cases is presented. Comments as to the merits of extracapsular versus intracapsular surgery in high myopia will be set forth.

Retinal detachment after phacoemulsification

We reviewed the characteristics of 100 retinal detachments after phacoemulsification. The characteristics of retinal breaks and the configurations of the detachments were similar to cases of retinal detachments after intracapsular surgery. Evidence indicates that detachments occurring within six months of cataract surgery appeared to be statistically different from those occurring more than one year after phacoemulsification. Those detachments occurring within six months after cataract surgery tended to be more phakic in nature than those occurring relatively late. The surgical reattachment rates in these eyes compared favorably to previously published figures on the repair of retinal detachment after intracapsular surgery.