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.     

Combined scleral buckle and pars plana vitrectomy as a primary procedure for pseudophakic retinal detachments.

BACKGROUND AND OBJECTIVE: Pseudophakic and aphakic retinal detachments are associated with a lower percentage of successful primary repair with standard scleral buckling surgery, than phakic retinal detachments. The objective of this study was to determine whether a combined scleral buckle and vitrectomy, as a primary procedure, offers any advantage over conventional scleral buckling in primary pseudophakic and aphakic retinal detachments, without proliferative vitreoretinopathy. MATERIALS AND METHODS: This was a prospective, non-randomized clinical study. Ninety-four consecutive pseudophakic and aphakic retinal detachments were included in the study. All patients were operated upon by the same surgeon. Each patient underwent a combined scleral buckle and pars plana vitrectomy with perfluorocarbon injection and air-fluid exchange. Each patient was followed by the operating surgeon for a minimum of 6 months. Patients were followed with respect to anatomic reattachment, visual acuity improvement, and surgical complications. RESULTS: All eyes were anatomically reattached after a single operation. All demonstrated an increase in their visual acuity, and there were no complications attributable to the vitrectomy procedure. CONCLUSIONS: We conclude that such a combined approach to primary pseudophakic and aphakic retinal detachments offers significant benefits to scleral buckling alone. We believe that the improved success rate is a function of vitrectomy contributing to both an improved peripheral visibility, resulting in fewer missed peripheral breaks, and a lower likelihood of proliferative vitreoretinopathy. We recommend this combined surgical approach for all primary pseudophakic and aphakic retinal detachments.     

Combined scleral buckle and vitrectomy as a primary surgery for pseudophakic and aphakic retinal detachments

AIM: To determine whether a combined scleral buckle and pars plana vitrectomy, as a primary surgery, owns any advantage over a single scleral buckling in pseudophakic and aphakic retinal detachments. · METHODS: Thirty consecutive pseudophakic/aphakic retinal detachments were included in this retrospective study. Each patient underwent combined scleral buckle and pars plana vitrectomy, and was followed up for 3 to 14 months. Patients were examined with respect to anatomic reattachment, visual acuity improvement, and surgical complications. · RESULTS: All eyes were anatomically reattached after the first operation. All patients had an increase in their visual acuity, and there were no complications attributable to the vitrectomy procedure. · CONCLUSION: A combined surgery for primary pseudophakic/ aphakic retinal detachments offers significant benefits to scleral buckling alone. The improved success rate is contributing to the function of vitrectomy, which improves peripheral visibility and reduces the occurrence of proliferative vitreoretinopathy (PVR).     

巩膜外硅压联合玻璃体切割术治疗人工晶状体或无晶状体眼视网膜脱离

目的:探讨在治疗人工晶状体或无晶状体眼视网膜脱离中巩膜硅压联合玻璃体切割术比单纯巩膜硅压手术的优越性。方法:回顾性分析30例我院联合手术治疗的人工晶状体或无晶状体眼视网膜脱离患者的临床资料。各位患者均采用巩膜外硅压联合玻璃体切割手术修复脱离的视网膜,术后随诊3～14mo,对手术后的解剖复位、视力提高情况以及并发症进行考察。结果:所有患者(30眼)均1次手术复位成功并有不同程度的视力提高,没有发现任何玻璃体切割手术的并发症。结论:在治疗人工晶状体或无晶状体眼视网膜脱离中,巩膜外硅压联合玻璃体切割术比单纯巩膜硅压手术有明显的优越性,其成功率的提高与玻璃体切割术提高周边视网膜的可见度,以及减少PVR的发生相关。     

Aphakic versus pseudophakic retinal detachments

Aphakic retinal detachments and pseudophakic retinal detachments (i.e., detachments following extracapsular cataract extraction and posterior chamber lens implant surgery) from the last 3 1/2 years were studied retrospectively. In the aphakic group, myopia (mean preoperative refraction -2.60) and intraoperative loss of vitreous (10.3%) were found to be risk factors. In the pseudophakic group, male patients predominated (21/26 = 80.8%); furthermore, myopia (mean preoperative refraction -4.60, mean axial length = 24.98 mm) was also a risk factor. Additional risk factors included intraoperative rupture of the capsule (11.5%) as well as postoperative Neodymium-YAG laser capsulotomy (34.6%). There was no appreciable difference between the two groups with regard to the type of detachment. In more than 50% of the cases, retinal tears occurred in the superior temporal quadrant. In 19.4% of the cases with pseudophakic retinal detachment, no foramen could be found; on the other hand, only in 7.7% of the cases in the aphakic group was no retinal hole seen. Surgery was anatomically successful in 92.3% of the pseudophakia cases. In the group with pseudophakic retinal detachment retinal surgery was only successful in 84.6% of the cases.     

Retinal detachment and pseudophakia

A consecutive series of pseudophakic retinal detachments was statistically compared with a matched group of aphakic retinal detachments. Distribution of breaks, anatomic results, and final visual acuities were tabulated. Success in reattachment was equal in the two groups, but final visual acuities were better in the aphakic group. Emphasis was placed on the intraoperative ophthalmoscopic examination of pseudophakic eyes with compromised peripheral fundus visibility.     

Prophylaxis of retinal detachment

Prophylactic treatment of retinal breaks can only be justified if the risk of complications from treatment is lower than the risk of breaks leading to clinical retinal detachment. Recommendations for prophylaxis should be based on results from valid controlled studies and not merely on traditional high-risk associations between certain risk factors and clinical retinal detachment. Present evidence supports prophylactic treatment of all symptomatic tractional tears; and is suggestive for the treatment of large, symptomatic operculated tears, high-risk fellow eyes of nontraumatic giant retinal breaks, retinal breaks with subclinical retinal detachments threatening progression, and retinal breaks before cataract surgery. Support for prophylactic treatment of asymptomatic retinal breaks in aphakic and pseudophakic eyes with or without an intact posterior capsule is at best, equivocal. Asymptomatic retinal breaks in phakic eyes with lattice degeneration, high myopia, and fellow eye detachments show no significant benefit from prophylaxis and should be followed without treatment.     

Primary vitrectomy alone for repair of retinal detachments following cataract surgery

PURPOSE: To report the visual, anatomic, and refractive results of primary vitrectomy alone for the repair of retinal detachments (RD) following cataract surgery. METHODS: Retrospective review of office charts and operative reports of 83 eyes. RESULTS: A minimum of 4 months' follow-up was achieved for 78 pseudophakic or aphakic eyes that underwent primary vitrectomy, internal drainage of subretinal fluid, retinopexy, and intravitreal gas injection for RD repair. Anatomic reattachment was achieved in 93.6% of cases after one procedure and in 96.2% eventually. Median preoperative Snellen acuity was 20/200 and increased to 20/25 at final examination. For the 45 eyes with macula-off detachments, 80% achieved final acuities greater than or equal to 20/40. The average refractive change following surgery was -0.11 diopters. Transient postoperative ocular hypertension was seen in 17.9% and proliferative vitreoretinopathy with recurrent RD in 5.1%. CONCLUSION: Primary pars plana vitrectomy is a highly effective treatment modality for the repair of RD following cataract surgery, and appears to be refractively neutral.     

Analysis of risk factors for the outcome of primary retinal reattachment surgery in phakic and pseudophakic eyes

BACKGROUND: To compare the preoperative risk profiles of phakic and pseudophakic eyes with primary retinal detachment and to assess their impact on the outcome of primary reattachment surgery. PATIENTS AND METHODS: 220 consecutive patients with primary retinal detachment, 165 phakic and 55 pseudophakic eyes were operated with scleral buckling alone or additional vitrectomy and followed up for 6 months. Pre-, intra- and postoperative risk factors were recorded and their impact on anatomical outcome after primary surgery in phakic and pseudophakic eyes was then compared in a multivariate regression analysis. RESULTS: The cumulative probability of anatomical success 6 months after surgery was similar in phakic (88.5 %) and pseudophakic eyes (86.3 %; log rank = 0.340). The most important risk factor for a different surgical outcome between phakic and pseudophakic eyes was the size of retinal detachment (p = 0.035). In phakic eyes the size of retinal detachment had no significant impact on surgical outcome (1 vs. 4 quadrants; log rank = 0.135); whereas in pseudophakic eyes a significant impairment on surgical outcome was found (1 vs. 4 quadrants; log rank < 0.001). The relative risk for failure of primary surgery due to retinal detachment of at least 3 quadrants was in phakic eyes 1.22 (CI: 0.71 - 1.70), in pseudophakic ones 1.81 (CI: 0.88 - 2.59). CONCLUSIONS: The outcome of primary retinal reattachment surgery in phakic and pseudophakic eyes is similar for retinal detachments up to 3 quadrants. In retinal detachments of more than 9 clock times, the size of retinal detachment impairs the surgical outcome in pseudophakic eyes more than in phakic ones. The combination of extraocular surgery with vitrectomy in pseudophakic eyes with retinal detachment of more than 9 clock times contributes to a better outcome.     

Success of retinal surgery comparing phakic and pseudophakic eyes with reference to preoperative findings and the kind of lens implant]

We analyzed retrospectively 597 eyes over a minimum follow-up of 6 months and compared the results of pseudophakic eyes with phakic eyes. The repair of pseudophakic retinal detachment is more difficult than the surgery in aphakic retinal detachment. Pseudophakic retinal detachment had a more advanced retinal detachment and PVR-stages at the time of diagnosis. Localisation of the tear was more complicated and the surgery was more invasive than in phakic eyes. In 61.2% the repair was for pseudophakic eyes with posterior chamber lens 78%, with anterior chamber lens 81.8% and for iris-fixated IOL's 75%. Compared to this, the anatomic reattachment rate in phakic eyes was 94.8%. The pseudophakic group had less favorable visual results.     

Retinal detachment after cataract surgery

Background: A study of the characteristics and the results obtained in 99 consecutive eyes operated on for rhegmatogenous retinal detachment associated with aphakia or pseudophakia in order to find the predictive factors of poor anatomical and functional results. Methods: The authors retrospectively reviewed the files of 99 consecutive cases of aphakic and pseudophakic retinal detachment operated on by the same surgeon between January 1992 through July 1993 with a minimum follow-up of 6 months. Multivariate and chi square analysis were carried out. Results: Of the pseudophakic eyes, 25 had an anterior chamber lens and 48 had a posterior chamber lens. The posterior capsule was disrupted using a Yag laser in 58% of those with an posterior chamber lens but only 14% of them developed detachment within 6 months. The rate of vitreous loss was 27% with 5% in case of intracapsular extraction, 31% in case of extracapsular extraction and 54% in case of phacoemulsification. PVR was present in 30% of the patients and 51% of detachments occurred more than 24 months as a mean after cataract surgery. The overall anatomic reattachment rate was 88% with no significant difference between the aphakic and the pseudophakic patients, either with an anterior chamber of posterior chamber lens. Visual results were significantly worse in the anterior chamber lens group and in the aphakic eyes (P < 0.02). Negative prognostic indicators for reattachment included poor preoperative vision, extension of the retinal detachment to the macula (P < 0.05) and grades B, C or D proliferative vitreoretinopathy (P < 0.01). In addition to the above factors, eyes with vitreous loss, anterior chamber lens, aphakia and a larger extent of the retinal detachment had a poor visual outcome. Conclusion: Most aphakic or pseudophakic retinal detachment can now be reattached with either scleral or vitreo retinal surgery. The main difficulties are the localisation of the breaks and the treatment of PVR. Indirect ophthalmoscopy associated with vitrectomy does well in cases of an opacified posterior capsule. In cases of severe PVR long term internal tamponade either with C3F8 or silicone oil improves anatomical results but the functional results remain inferior.     

Pseudophakic retinal detachments

Primary scleral buckling procedures were performed for rhegmatogenous retinal detachments in a consecutive series of 179 pseudophakic eyes. Most cases involved eyes in which extracapsular surgery had been combined with iridocapsular implants or posterior chamber lenses or in which iris-fixation IOLs were placed following intracapsular surgery. The characteristics of the detachments were similar, regardless of the type of cataract surgery employed, although there was a trend toward an increased incidence of significant preoperative proliferative vitreoretinopathy in the intracapsular cases. Anatomic success rates were greater than 90% in all groups. There was a trend for lower visual acuities following successful surgery in the eyes in which intracapsular surgery had been performed than in those following extracapsular procedures.     

Pseudophakic retinal detachments. The relationships between retinal tears and the time following cataract surgery at which they occur

The types and locations of retinal tears associated with 268 pseudophakic retinal detachments were studied as a function of the time at which they occurred following cataract surgery. Retinal detachments occurring more than two years following cataract extraction were significantly more likely to have their most posterior retinal break located at the posterior margin of the vitreous base than at or behind the equator. This distribution of tears was not observed in detachments occurring within six months of cataract surgery, with equatorial tears being significantly more common in early onset detachments than in those occurring after two years. The anterior tears which cause most retinal detachments long after cataract extraction are due to persistent chronic traction upon the vitreous base rather than to acute posterior vitreous detachment.     

Retinal detachment following intraocular lens implantation

This report concerns a consecutive series of 154 pseudophakic eyes in which primary scleral buckling procedures were performed for rhegmatogenous retinal detachments. Most cases involved eyes in which extracapsular surgery had been combined with iridocapsular implants or posterior chamber lenses or in which iris-fixation intraocular lenses were placed following intracapsular surgery. The characteristics of the detachments were similar, although there was a trend towards an increased incidence of significant preoperative proliferative vitreoretinopathy in the intracapsular cases. Anatomical success rates were over 90% in all groups. There was a trend for lower visual acuities following successful surgery in the eyes in which intracapsular surgery had been performed than in those following extracapsular procedures.Presented at the 1984 meeting of the Club Jules Gonin in Lausanne, Switzerland     

A comparison of the rate of refractive growth in pediatric aphakic and pseudophakic eyes

OBJECTIVE: To compare the rate of refractive growth in pseudophakic children's eyes to that of aphakic eyes. DESIGN: Multicenter, retrospective observational case series. PARTICIPANTS: 83 patients with pseudophakic eyes (100 eyes) and 74 patients with aphakic eyes (106 eyes), with an age of surgery between 3 months and 10 years and a minimum follow-up time of 3 years or more, depending on the age at surgery. METHODS: A logarithmic model was used to analyze the rate of refractive growth for each eye. MAIN OUTCOME MEASURES: Age at surgery, intraocular lens power, intraocular lens A-constant, initial postoperative refraction, final refraction, and final age. RESULTS: Overall, pseudophakic eyes showed a lesser rate of refractive growth than aphakic eyes (-4.6 diopter vs. -5.7 diopter, P = 0.03). This trend was also present but less significant when the eyes were grouped into those less than 6 months of age at surgery (-3.3 diopter vs. -4.6 diopter, P = 0.09) and older patients (-5.0 diopter vs. -6.1 diopter, P = 0.07). However, the mean quantity of myopic shift was greater in pseudophakic eyes than in aphakic eyes (-5.26 diopter vs. -4.54 diopter), despite shorter follow-up times in the pseudophakic eyes. This is due to the optical effects of a constant intraocular lens power in a growing eye. CONCLUSIONS: Pediatric pseudophakic eyes have a slightly lesser rate of refractive growth than aphakic eyes. The new rate values should be used for predicting future refractions in these eyes.     

Retinal detachment and pseudophakia

Retinal detachments occur in up to 3.6% of pseudophakic patients. The intraocular lens makes it hard to see the peripheral fundus but the small pupil ophthalmoscope is a valuable help. The functional and anatomic success rates after operation are about 5% less than those of patients with aphakic retinal detachments matched for age and sex. I present fifteen cases of pseudophakic detachment. Any manipulation likely to induce contact between lens and cornea such as collapse of the globe after drainage of fluid or gas injections should be avoided. Careful examination of the fundus before and after cataract extraction and careful selection of paients for lens implantation are the only means of reducing the incidence of retinal detachment.     

Retinal injury induced by near-ultraviolet radiation in aphakic and pseudophakic monkey eyes. A preliminary report

The effect of repeated exposures to low-intensity, near-ultraviolet (UV) radiation on the retinas of phakic, aphakic, and pseudophakic monkey eyes was studied. Ten eyes (4 aphakic eyes, 3 pseudophakic eyes, and 3 normal phakic eyes) of five rhesus monkeys were used. The near-UV radiation was generated by a high-pressure mercury vapor lamp with a total radiance of 14.43 mW/cm2/sr. Exposure regimens were 5 minutes a day for 10 days, 15 minutes a day for 5 days, or 60 minutes a day for 5 days. The retinas of aphakic and pseudophakic eyes were exposed to a daily dose of more than 0.97 J/cm2, or a total dose of more than 4.9 J/cm2 in 5 days at a retinal irradiance of more than 1.0 mW/cm2. Three of four aphakic eyes and one of three pseudophakic eyes showed clinical and pathologic retinal lesions after radiation. None of the three phakic eyes was damaged. The retinal lesions showed mild opalescent thickening ophthalmoscopically and retinal pigment epithelial staining by fluorescein angiography. Histopathologically, the retinal pigment epithelium was the site of primary injury by near-UV radiation.     

Comparison of intracapsular and extracapsular cataract surgery. Histopathologic study of eyes obtained postmortem

We examined 201 consecutive aphakic and pseudophakic eyes postmortem. Of these, 146 eyes had undergone intracapsular cataract extraction (ICCE) and 55 eyes had undergone extracapsular cataract extraction (ECCE), either with the posterior capsule preserved intact (ECCE-CI, 30 eyes) or having had a surgical discission performed (ECCE-D, 25 eyes). Wound-related complications were most numerous in the ICCE group, and this probably reflects the relatively recent development of microsurgical techniques. Posterior vitreous detachment was present in 84% of eyes following ICCE, in 76% of eyes following ECCE-D, and in 40% of eyes following ECCE-CI (P less than 0.001). Peripheral retinal holes were found in 8.2% of ICCE eyes, 8.0% after ECCE-D, and 3.3% of eyes after ECCE-CI. Five (3.4%) of ICCE eyes had associated retinal detachments, while no ECCE eyes had detachments. Macular edema, macular holes, and epiretinal membranes occurred in 2.1%, 1.4%, 12.3% of ICCE eyes; 4.0%, 0.0%, and 8.0% of ECCE-D eyes; and 0.0%, 6.7%, and 6.7% of ECCE-CI eyes, respectively.     

Clinical characteristics and surgical outcomes of pseudophakic and aphakic retinal detachments

We retrospectively evaluated the clinical characteristics and surgical outcomes of 20 pseudophakic retinal detachment (RD) patients (20 eyes) and 17 aphakic RD patients (17 eyes). Males were predominated in both groups. The time interval between cataract extraction and RD was 31 months on average in the pseudophakic group, 32 months with intact posterior capsule and 27 months with ruptured posterior capsule, and 148 months in the aphakic group. In 50% of cases with ruptured posterior capsule in the pseudophakic group, RD occurred within 1 year. The anatomic success rate was 95% in the pseudophakic group and 88% in the aphakic group. The most common cause of failure was the development of proliferative vitreoretinopathy. Visual acuities more than 20/40 after RD surgery were found in 13 pseudophakic (65%) and 6 aphakic (36%) eyes. Aphakic patients were more inclined to have silent RD than pseudophakic patients because of their poor visual acuity. Post-operative follow-up is required especially for the first 1 year in cases of damaged posterior capsule due to the high incidence of RD during this period.     

Retinal detachment in pseudophakia. Results apropos of 74 cases

If the pseudophakic retinal detachment presents certain analogies with aphakic detachment; it as however a certain specificity: higher frequency of macular involvement, of proliferative vitreoretinopathy, of detachments without tears. In addition pseudophakic detachments must be analysed according to the mode of extraction and implantation.