JUVENILE RHEGMATOGENOUS RETINAL DETACHMENT RICHARD L. WINSLOW, MD DALLAS, TEXAS WILLIAM TASMAN, MD PHILADELPHIA, PENNSYLVANIA tively. Late diagnosis is a common problem in this age group because of the patient's failure to report symptoms. It is essential that physicians be cognizant of this problem and, when possible, educate high-risk patients about symptoms of retinal detachment and follow them periodically for asymptomatic predetachment lesions. Early diagnosis may prevent severe visual loss.
Between Jan 1, 1966, and June 30, 1974, 179 children, birth through 16 years of age with rhegmatogenous retinal detachments, underwent scleralbuckling procedures at Wills Eye Hospital. The detachments were associated most frequently with trauma (44%), myopia (15%), aphakia (10%), and retinopathy of prematurity (8%). Successful reattachment was achieved in 80% of the cases. Vision of 20/100 or better was present in 22% preoperatively and 58% postoperatively.
INTRODUCTION
JUVENILE rhegmatogenous retinal detachment has been variously reported to account for 3.2%1 to 5.6%2 of all rhegmatogenous retinal detachments. In this paper we have limited our review to 179 patients birth through 16 years of age, ali of whom underwent scleral-buckling procedures in an attempt to repair rhegmatogenous retinal detachments. We have categorized the various etiologies of all 179 patients, but have reported the surgical and visual results in only the 109 patients who were followed for six months or more postoperaSubmitted for publication Oct 5, 1977. From the Ophthalmology Center, Dallas (Dr Winslow) and the Retina Service, Wills Eye Hospital, Philadelphia (Dr Tasman). Presented at the Eighty·second Annual Meeting of the American Academy of Ophthalmology and Otolaryngology, Dallas, Oct 2-6, 1977. Reprint requests to 2811 Lemmon Ave E, Dallas, TX 75204 (Dr Winslow).
MATERIALS AND METHODS
We conducted a retrospective study of rhegmatogenous retinal detachments occurring from birth through 16 years of age. Consecutive charts of the Wills Eye Hospital Retina Service were reviewed for the period Jan 1, 1966, through June 30, 1974. During this period 179 juvenile patients were treated with a total of 216 scleral-buckling procedures. The total number of scleral-buckling operations performed during this same period was 7,435. Juvenile rhegmatogenous detachments therefore accounted for approximately 2.9% of the scleralbuckling procedures performed during this period. The total group of 179 patients (187 eyes) was reviewed concerning the etiology of the detachment, while only those patients followed for six months or more (109 patients representing 117 eyes) were reviewed regarding the type of surgical therapy, the per-
607
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WINSLOW AND TASMAN
cent age of successful anatomic reattachment, and postoperative visual results. A cure is defined as an anatomic reattachment for at least six months following the last surgical procedure. CHARACTERISTICS OF JUVENILE RHEGMATOGENOUS DETACHMENT
Several unique characteristics distinguished juvenile rhegmatogenous detachment from that of the adult. We found a high preponderance of boys in our study (130 boys [73%] and only 49 girls). This is undoubtedly related to a second characteristic of juvenile detachment, the high incidence of traumatic detachments; 82 of the 187 detachments (44%) were trauma related and of these 69 (84%) were in boys. Tasman 1 reported a series of 52 juvenile rhegmatogenous detachments; 15 (28.8%) of these were trauma related and 14 were in boys (93%). Hilton and Norton 2 reported a series of 71 rhegmatogenous detachments in patients 1 to 20 years of age; 30 of the 71 (42%) were trauma related and 58 of the 71 (82%) were boys. Hudson 3 reported 35 rhegmatogenous detachments in patients 1 to 15 years of age; 18 of the 35 (51%) were trauma related with 14 of the 18 (78%) occurring in boys. Arentsen and Welch 4 reported a series of 100 cases including both rhegmatogenous and nonrhegmatogenous detachments in children through age 16. Of these detachments, 33% were related to trauma with an 82% incidence of boys in the trauma group. Cox et al 5 found a prevalence of males (86.7%) in traumatic retinal detachments while Schepens and Marden 6 reported an equal sex distribution in nontraumatic retinal detachments.
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A third feature of juvenile retinal detachment is late diagnosis. Children often fail to report symptoms of a visual field loss or even a decrease in visual acuity. Our study revealed that 38 of the 187 detachments (21.1%) were diagnosed on routine eye examination by a school nurse, an ophthalmologist, or occasionally by the child's parents. In addition, 16 patients (8.9%) were originally misdiagnosed and treated for a lazy eye or some other condition. Clinical evidence of chronic retinal detachment is listed in Table 1. Fifty-five of 187 detachments (29.4%) displayed one or more signs of chronicity. Similarly, four-quadrant detachments were present in 89 of the 187 eyes (48%), while the macula was noted to be detached in an additional 55 eyes (29%) who did not have a four-quadrant detachment. These findings highlight the problem of late diagnosis in this age group and correlate closely with the series of Hilton and Norton 2 who reported four-quadrant detachments in 51% of their patients and macular detachment in 29% of those detachments not involving all four quadrants.
TABLE
1
CLINICAL EVIDENCE OF CHRONIC RETINAL DETACHMENT NO. EYES
Demarcation line Intraretinal macrocyst Subretinal gliosis Fixed folds
27 6 8 20
Total number of eyes with one or more of above 55/187 = 29.4%
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RHEGMATOGENOUS RETINAL DETACHMENT TRAUMA
Table 2 lists the various causes of the rhegmatogenous retinal detachments found in this study. The 71 eyes with blunt trauma and 11 with penetrating trauma accounted for 82 (44%) of the 187 eyes in the study.
609
ately, 30% were detected within one month, 50% within eight months, and 80% within two years. Arentsen and Welch 4 reported 33 cases of juvenile traumatic detachment, and the interval between trauma and diagnosis of the detachment was greater than six months in slightly over 50% of the cases. Hilton and
TABLE 2 ETIOLOGY OF OPERABLE RHEGMATOGENOUS RETINAL DETACHMENT IN CHILDREN NO. PATIENTS
NO. EYES
70
71 11 28 27
Trauma (blunt) Trauma (penetrating) Myopia Unknown' Aphakia plus trauma Aphakia Retrolental fibroplasia (RLF) RLF and aphakia Uveitis Retinoschisis Lattice degeneration Coloboma Vitreous traction associated with Coats' Down's syndrome Congenital glaucoma postgoniotomy
11
23 27 11
7 11
2 5 4 3 2 1 1 1 179
11 8 12 2 5 4 3 2 1 1 1 187
% EYES INVOLVED
38.0 5.9 15.0 14.4 5.9 4.3 6.4 1.1 2.7 2.1 1.6 1.1 0.5 0.5 0.5 100.0
*17 of 27 had a dialysis.
The average interval between blunt trauma and diagnosis of a detachment was 17.3 months in this series, while the average interval between penetrating trauma and diagnosis of a detachment was 14.7 months. In our patients who sustained blunt trauma, 12.5% were detected in the first week, 29.7% in the first month, 54% in the first six months, and 84.4% within two years. Cox et al 5 found that 12% of the detachments following blunt trauma were diagnosed immedi-
Norton 2 reported that 41% of the juvenile traumatic detachments occurred more than 12 months after the injury. The laboratory experiments by Weidenthal and Schepens 7 have indicated that the majority of retinal breaks responsible for traumatic detachments are formed at the time of the injury. These breaks often cannot be identified because of vitreous haze, poor dilation, and lack of patient cooperation. In time,
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WINSLOW AND TASMAN
vitreous degeneration and traction at the site of the retinal break result in a detachment. Tasman 8 conducted a prospective study on 52 patients with ocular trauma to determine if there was late development of tears. Dialysis of the peripheral retina was diagnosed in 9 of the 52 patients within three weeks of the injury, while a tenth was diagnosed four months after injury when the vitreous hemorrhage cleared. In none of the 52 patients did a late dialysis develop during the ensuing two-year followup. Based on our findings and the reports of others, we believe that any patient with severe ocular trauma should have a careful examination of the ora serrata. If for any reason the ora cannot be visualized, the patient should be followed carefully every three to six months for a two-year period to rule out development of a subclinical retinal detachment. This was also the suggestion of Hilton and Norton 2 in their study of juvenile retinal detachments.
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TABLE
3
DISTRIBUTION OF TRAUMATIC DIALYSES· LOCATION
Inferotem porai Inferonasai Superonasai Superotemporai
NO . EYES
37 14 15 11 77
%
48.0 18.2 19.5 14.3 100.0
"59 patients, 18 bilateral cases.
were inferotemporal, 28% superonasal, 20% superotemporal, and 5% inferonasal. However, Hagler and North found that the greater the evidence for trauma, the higher the incidence of superonasal dialyses. Weidenthal and Schepens'7 study on pig eyes concluded that if trauma were near the center of the cornea, a superonasal dialysis was most likely to occur, while trauma near the temporal 'limbus resulted in a temporal retinal dialysis. They concluded that the frequency of retinal dialyses seen clinically in the inferotemporal quadrant resulted from the configuration of the human orbit which provides the least protection to the eye in this quadrant, a concept our findings support.
Dialysis accounted for the retinal detachment following trauma in 59 of 82 eyes (72%). An additional 18 dialyses were noted in the fellow eye unassociated with a detachDialysis accounted for 40.6% of ment. Dialyses were classified as traumatic when historical or clini- the 187 detachments with 59 traucal evidence of trauma was present. matic and 17 nontraumatic diAnalysis of the location of the 77 alyses. This corresponds with the dialyses showed that 48% were results of Hagler and North 9 who located in the inferotemporal quad- reported a 50% incidence of dialysis rant (Table 3). This varies from the in retinal detachments found in report of Cox et al 5 who reported children and young adults. Arent37.8% superonasal, 27.4% infero- sen and Welch 4 reported a 35% temporal, 22% superotemporal, and incidence of dialysis in 100 cases of 21.8% inferonasal, but concurs with rhegmatogenous and nonrhegmaHagler and North 9 who reported togenous retinal detachments in that of their traumatic dialyses 47% children through age 16.
85
RHEGMATOGENOUS RETINAL DETACHMENT 611 1978 TABLE 4 Hagler and North,9 as well as Tasman,8 pointed out that detachPOSTOPERATIVE VISUAL ACUITY IN TRAUMATIC CASES ments associated with dialyses always begin in the periphery and VISUAL ACUITY NO. EYES % progress slowly with the diagnosis often not being made until central 6/6 to 6/15 13 35.1 vision has become affected. This 6/18 to 6/30 8 21.6 reemphasizes the need for examina6/60 or less 16 43.3 tion of the extreme retinal pe37 100.0 riphery in all cases of trauma since it is theoretically possible to prevent macular involvement by careful examination and early surgery. ment rate in traumatic detachHagler and North 9 reported that ments of all types. 52% of patients with detachment due to dialysis had symptoms in MYOPIA excess of one month and 42% had symptoms longer than three months. Myopia was the cause of retinal detachment in 28 eyes. Fifteen of the 26 recorded refractions were The surgical management of trau- greater than -8.00 diopters (Tabl~ matic detachments most often in- 5). Unlike the trauma cases, bIcluded scleral flaps, diathermy, a lateral detachments occurred in 7 silicone implant, and an encircling of the 23 patients, or 30.4%. Five of silicone band. The cure rate was the seven patients with bilateral 77% with 37 successful anatomic detachments had myopia greater reattachments in 48 eyes. This is than -7.00 D, and only five of the comparable to the cure rate re- seven fellow eyes with detachments ported by Cox et al 5 of 82.6%. There were considered operable. In addiwas no significant difference in the tion, cryotherapy was performed. on incidence of cure whether an encir- six fellow eyes with threatenmg cling procedure was used or not. holes. A round hole in lattice or This is different from the results a round hole unassociated with of Cox et al 5 in which the success lattice was the most common type rate with an encircling element was of break. Therefore, 13 of 23 pa83.3%, compared to 37.5% without tients (56.5%) had significant pait. In our series, case selection thology in the fellow eye. favored those cases without encircling procedures since these were TABLE 5 usually less complicated. The averMYOPIA age follow-up in the 47 patients (48 eyes) was 29.9 months. Table 4 DI()PTERS OF MYOPIA NO. EYES % lists the visual acuity results in the 37 eyes in which anatomic reatPlano to -4.00 32.1 9 tachment was successful. The cure 7.1 -4.00 to -8.00 2 rate of the traumatic dialyses was -8.00 to -12.00 17.9 5 80%, while in the dialyses of un35.8 Greater than -12.00 10 known origin, the cure rate was No refraction only 66%. There was a 75% reat7.1 2 recorded tachment rate of all dialyses which 100.0 28 is comparable to the 77% reattachVOLUME JUNE
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WINSLOW AND TASMAN
A scleral-buckling procedure was performed on 28 eyes. Only 21 of the 28 were followed for six months. Surgical results included 17 anatomic reattachments of the 21 eyes for a cure rate of 80.9% with an average follow-up of 23.9 months. The visual results were somewhat better than in the trauma group or in those with unknown etiology (Table 6). This resulted in part from earlier diagnosis in cases of myopia, a fact also noted by Hilton and Norton. 2 TABLE
6
POSTOPERATIVE VISUAL ACUITY IN MYOPIC EYES VISUAL ACUITY
NO. EYES
6/6 to 6/15 6/18 to 6/30 6/60 or less
12 3 2 17
% 70.6 17.6 11.8 100.0
The major clinical implication is that high myopes who have had a detachment in one eye are at significant risk to develop a detachment in the fellow eye. These patients should be alerted to the early symptoms of detachment. We recommend that they be followed every six months, and holes appearing in the fellow eye be treated promptly. UNKNOWN ETIOLOGY
No specific etiology could be assigned to 27 eyes, and this group comprised the third largest in the series. Generally there was no history or other evidence of trauma, no significant myopia, no history of prematurity, and no aphakia. This partially represented inadequate history taking or failure to record refractive error. The most notable characteristic in this group
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was that 17 of the 27 eyes had dialyses. Verdaguer et apa presented good evidence that some nontraumatic retinal dialyses probably have a genetic origin; they demonstrated more than one affected individual in 8 of 24 sibships (33%). It is of interest that in his series the sex incidence was equal with 19 boys and 21 girls affected. Despite this, we believe that many dialyses are probably traumatic in origin even without a history or clinical evidence of trauma. The distribution of our nontraumatic dialyses is shown in Table 7 and is quite similar to the distribution of our traumatic dialyses (Table 3). It is noteworthy that ten nasal dialyses were found in the group of 17 dialyses in which absolutely no history or other objective signs of trauma were found, and 11 of the 17 (65%) were boys. Verdaguer et apa reported that 54% of his patients had bilateral dialyses compared with only 4 of 17 in our series. TABLE
7
NONTRAUMATIC DIALYSES* LOCATION
Inferotemporal Inferonasal Superonasal Superotemporal
NO. EYES
10 5 5 1 21
% 47.6 23.8 23.8 4.8 100.0
*17 cases nontraumatic. 4 cases bilateral.
Scleral-buckling procedures were performed on 27 eyes, 18 of which were followed six months or more postoperatively; 14 of the 18 (78%) were successfully reattached. Postoperative visual acuity was 6/6 to 6/15 in four eyes, 6/18 to 6/30 in three eyes, and 6/60 or less in seven eyes.
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RHEGMATOGENOUS RETINAL DETACHMENT
RETINOPATHY OF PREMATURITY
Retrolental fibroplasia (RLF) accounted for 11 patients (12 eyes) while RLF plus aphakia accounted for two patients (two eyes). Therefore, RLF accounted for 14 eyes (7.5%) of our series. Retrolental fibroplasia accounted for 21% of the detachments in Tasman'sl series a retrospective study also done at Wills Eye Hospital, but during the period 1962 to 1965. It is encouraging that in the ensuing 8 1/2 years the percentage of RLF-related detachments has declined. This condition tended to be bilateral with 3 of the 13 patients having bilateral detachments and 6 of the 13 having retinal holes in the fellow eye, 4 of which were treated with cryotherapy. Similarly, in Tasman'sl series, 3 of 13 had bilateral retinal detachments and an additional 3 had retinal breaks in the fellow eyes. Nine of the 13 patients in our series had birth weights recorded. The average birth weight was 1.35 kg, but ranged from .95 kg to 1.60 kg. These findings correlate with those of Tasman l l in which children with RLF uniformly weighed less than 1.80 kg and had an average weight of 1.51 kg at birth. Since the patients in our series not only had RLF, but also developed retinal detachments, it is not surprising that the average birth weight was less than that reported by Tasman. Myopia was a significant finding in the RLF patients. No refraction was recorded in two patients and two more were aphakic. The refractive error of the remaining nine patients (ten eyes) is listed in Table 8. Seven of the ten' had
TABLE
613
8
DEGREE OF MYOPIA IN RLF PATIENTS WITH DETACHMENTS DIOPTERS OF MYOPIA
Plano to -4.00 -4.00 to -8.00 -8.00 to -12.00 Greater than -12.00 Aphakic Not recorded
NO. EYES
0 3 3 4 2 2 14 (13 patients)
myopia exceeding -8.00 D (70%). This is in agreement with the study of Tasman,l1 in which he found myopia exceeding -8.00 D in over 69% of patients with RLF detachments. The average age of diagnosis of detachment secondary to RLF was 12.4 years which corresponds with the average age of 13.5 in Tasman's series. 11 Those cases of detachment developing in the active phase of RLF are often inoperable; however, the cases described in this series have a much better prognosis since the detachment occurred in the cicatricial phase of the disease. Since these cases are often amenable to therapy, it is important to continue following patients with known RLF for development of new holes and detachments. Since in both our series and Tasman's 3 of 13 patients (23%) had bilateral detachments, we recommend prophylactic treatment of breaks in the fellow eye. The most common type of break was a round hole, but severe vitreous traction was evidenced by two cases of giant retinal tears.
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WINSLOW AND TASMAN
Nine patients (ten eyes) underwent scleral-buckling procedures and were followed for at least six months with eight of the ten resulting in successful anatomic reattachment for a cure rate of 80%. Tasman l l reported successful anatomic reattachment in 15 of 16 eyes (94%). The techniques most frequently used included scleral flaps, diathermy, a silicone implant, and an encircling band. Postoperative visual acuity was 6/6 to 6/15 in two eyes, 6/18 to 6/30 in one eye, and 6/60 or less in five eyes. The average follow-up was 50.9 months which reflects the fact that this disease is frequently bilateral and progressive so that continued observation is essential. Three patients had bilateral retinal detachments. In two of these patients the poorer eye was considered inoperable, while in the third, an unsuccessful scleral buckle was performed. Thus, in all three of the bilateral cases the more involved eye was irreparable. APHAKIA
Eighteen patients were aphakic for the reasons listed in Table 9. Bilateral detachments were present in five patients, four of whom were
TABLE
9
APHAKIA ETIOLOGY OF CATARACTS
Congenital Traumatic Mongolism Bilateral dislocation Unknown
NO. PATIENTS
7 7 1 1 2 18
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bilaterally aphakic. Three of the fellow eyes were considered inoperable and one fellow eye was phakic; therefore, 19 aphakic eyes with rhegmatogenous retinal detachment were managed by a scleralbuckling procedure. . The average interval of time between the extraction of a nontraumatic cataract and the diagnosis of a retinal detachment was 9.8 years. This is considerably less than the average of 33.3 years quoted by Kanski et al,12 or the median of 21 years in the study by Taylor and Tasman,13 since neither of these studies included only juvenile detachments. The average age at the time of cataract extraction was 4 years in our series and 6.2 years in Kanski'sl2 series, compared with a mean age of 6 years in the study by Taylor and Tasman. 13 Retinal breaks were identified in 17 of the 19 eyes in our series, while Kanski et aJ12 reported detectable breaks in only 9 of 34 detachments. Arentsen and Welch 4 reported that breaks were identified in six of nine juvenile detachments following cataract extraction. Kanski'sl2 results included 18 successful reattachments of the 34 eyes treated for a cure rate of 52.9%. In our series, ten aphakic eyes were followed for six months after surgery; eight eyes had successful anatomic reattachment. Our cure rate of 80% reflects the enhanced ability to find the break resulting from the increased use of the indirect ophthalmoscope in the period of our study (1966 to 1974), as compared with the period of Kanski's study (1951 .to 1972). The most frequent procedure included a scleral bed with diathermy, a silicone
85 1978
VOLUME JUNE
RHEGMATOGENOUS RETINAL DETACHMENT
implant, and an encircling band. The average follow-up of this group was 32.4 months. Postoperative visual acuity was 6/6 to 6/15 in three eyes, 6/18 to 6/30 in two eyes, and 6/60 or less in three eyes. ANALYSIS OF OVER-ALL SURGICAL RESULTS
The 109 patients in this group were all followed for a minimum of six months after their last surgical procedure; eight of the cases were bilateraL The etiologies of the detachments are listed in Table 10 with the surgical results summarized in Table 11. Anatomic reattachment of the retina was accomplished in 94 of 117 eyes, or 80.3%. Seventy-seven eyes required only one operation, 15 eyes required two operations, and two eyes required three operations with the average follow-up of the 109 patients 31.2 months.
615
The type of surgery performed and the results obtained are summarized in Table 12. The most frequent mode of therapy consisted of scleral flaps, diathermy, a buried implant, and an encircling band. It was used in 81 of the 117 eyes producing an 80.2% successful anatomic reattachment. The same procedure without an encircling band was used in only 13 eyes with a 92.3% successful anatomic reattachment. These latter cases were localized detachments with a more favorable prognosis. The technique of cryotherapy and sponge explant was used in 15 eyes and resulted in only 60% successful anatomic reattachment. However, of the six eyes which had unsuccessful anatomic reattachment, all had total retinal detachments, fixed folds, or both. Hilton and Norton 2 reported an 89% anatomic reattachment with
TABLE 10 SURGICAL RESULTS SIx-MoNTH POSTOPERATIVE FOLLOW-UP ETIOLOGY
OF
DETACHMENT
Trauma Myopia Unknown RLF RLF and aphakia Aphakia and trauma Aphakia Retinoschisis Uveitis Coloboma Congenital glaucoma postgoniotomy Vitreous traction associated with Coats' Lattice degeneration
NO. PATIENTS
NO. EYES
% EYES
47 16 18 8 1 6 3 3 2 2 1 1 1 109
48 21 18 9 1 6 4 3 2 2 1 1 1 117
41.0 17.9
15.4 7.7 0.9
5.1 3.4 2.5 1.7 1.7 0.9 0.9 ~ 100.0
616
WINSLOW AND TASMAN
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TABLE 11 SURGICAL RESULTS* NO. EYES
% CURED
Anatomic reattachment first operation Anatomic reattachment second operation Anatomic reattachment third operation
77/117 15/19 213
66.0 79.0 66.6
Total anatomic reattachment
94/117
80.0
• Average follow·up of 109 patients, 31.2 mo.
TABLE 12 TYPE AND RESULTS OF SURGERY PERFORMED* TYPE OF SURGERY
OPERATED ON EYES ATIACHED
Scleral flap plus diathermy plus encircling Scleral flap plus diathermy without encircling Cryotherapy plus sponge Scleral flap plus cryotherapy with encircling Scleral flap plus diathermy plus sponge Cryotherapy plus encircling No. 40 band 'Scleral buckle without drainage: 14/117
NOT ATIACHED % CURE
81
65
16
80.2
13 15
12 9
1 6
92.3 60.0
4
4
0
100.0
3
3
0
100.0
1 117
1 94
0 23
100.0
= 12%.
either diathermy or cryotherapy, although they had 62 patients in their diathermy group and only 9 in their cryotherapy group. Their study was conducted between 1954 and 1966 before cryotherapy was widely used. Hudson 3 reported a 75% successful reattachment rate in 35 juvenile rhegmatogenous detachments, but the length of followup was not stated. Johnston et aP4 reported surgical results of 163 juvenile rhegmatogenous retinal detachments. The patients were followed 6 to 57 months postoperatively and 123 (76%) were reattached successfully.
Most of the eyes in our series were managed with drainage of subretinal fluid with only 14 eyes of the 117 (12%) not drained at the primary operation. Encircling procedures were used in 86 (74%) of the 117 eyes. The series of Hilton and N orton2 likewise only reported 11% without drainage and the use of an encircling procedure in 75% of their cases. Prophylactic treatment of the fellow eye was undertaken in 11 eyes (10%). This treatment included ten eyes which had cryotherapy and one eye which was photocoagulated.
RHEGMATOGENOUS RETINAL DETACHMENT
VOLUME 85 JUNE 1978
617
The 23 cases of surgical failure were analyzed to determine factors that might be indicative of poor prognosis. Factors most frequently associated with unsuccessful reattachment were total retinal detachments, fixed folds, massive periretinal proliferation, dialyses greater than 90 0 , multiple holes, posterior holes, failure to identify a break, choroidal coloboma, and giant tears.
Comparison of preoperative vision with postoperative vision shows that 22.3% had vision of 6/30 or better preoperatively, while 58.5% had vision of 6/30 or better postoperatively (Table 13). Hudson 3 reported that 25 of 32 patients (78%) had 6/60 or better postoperative visual acuity. Hilton and Norton 2 reported only 19% with 20/50 or better visual acuity postoperatively, while in our series 37% had 20/50 or better. Table 14 summarizes the surgical results of the five major etiologies and shows that the reattachment rate was similar but that the postoperative visual acuity results varied considerably. In general, poor visual results were associated with etiologies in which macular damage was likely (trauma, RLF, and unknown).
SUMMARY
Review of the records at the Wills Eye Hospital Retina Service disclosed 179 patients with rhegmatogenous retinal detachment in children from birth through 16 years of age. The most common etiologies in order of frequency were trauma,
TABLE
13
COMPARISON OF PREOPERATIVE AND POSTOPERATIVE VISION PREOPERATIVE VISUAL ACUITY
6/6 to 6/15 6/18 to 6/30 6/60 or less No visual acuity recorded
POSTOPERATIVE
NO. PATIENTS
%
NO. PATIENTS
%
13 8 69 4 94
13.8 8.5 73.4
35 20 39 0 94
37.2 21.3 41.5
~
100.0
TABLE
-100.0
14
SURGICAL RESULTS OF FIVE ETIOLOGIES
ETIOLOGY
Trauma Myopia Unknown RLF
Aphakia
AVERAGE FOLLOW-UP (MO)
29.9 23.9 31.7 50.9 32.4
VISUAL ACUITY EYES OPERATED ON
48 21 18 10 10
% 6/30
ATI'ACHED
% CURE
OR BETTER
37 17 14 8 8
77 81 78 80 80
57 88 50 38 63
618
WINSLOW AND TASMAN
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myopia, unknown etiology, retrolental fibroplasia, and aphakia.
2. Hilton GF, Norton EWD: Juvenile retinal detachment. Mod Probl Ophthalmol 8:325-341, 1969.
Surgical results included 94 of 117 (80%) successful anatomic reattachments. The most common surgical techniques included scleral flaps, diathermy, a buried implant, and an encircling band.
3. Hudson JR: Retinal detachments in children. Trans Ophthalmol Soc UK 85:7991, 1965. 4. Arentsen JJ, Welch RB: Retinal detachment in the young individual: A survey of 100 cases seen at the Wilmer Institute. J Pediatr Ophthalmol 11:198-202, 1965.
The management of juvenile reti5. Cox MS, Schepens CL, Freeman HM: nal detachments can be improved Retinal detachment due to ocular contusion. most by earlier diagnosis so that Arch Ophthalmol 76:678-685, 1966. surgical therapy can be employed 6. Schepens CL, Marden D: Data on the prior to extensive irreversible damage to the retina. Education of high- natural history of retinal detachment. Arch Ophthalmol 66:631-642, 1961. risk patients and their parents regarding the threat of detachment 7. Weidenthal DT, Schepens CL: Periphand symptoms of detachment can eral fundus changes associated with contuimprove our results without any sion. Am J Ophthalmol 62:465-477, 1966. change in our present techniques of 8. Tasman W: Peripheral retinal changes examination or therapy. School following blunt trauma. Trans Am OphthalVISIOn screening tests must be mol Soc 70:190-196, 1972. encouraged since approximately 20% 9. Hagler WS, North AW: Retinal diof the diagnoses in our series were and retinal detachment. Arch Ophmade on routine examination. Long- alyses thalmol 79:376-388, 1968. term follow-up of high-risk patients is necessary to enable prophylactic 10. Verdaguer TJ, Rojas B, Lechuga M: treatment of asymptomatic new Genetical studies in nontraumatic retinal retinal breaks and subclinical de- dialyses. Mod Probl Ophthalmol 15:34-39, tachments. Finally, increased aware- 1975. ness of RLF and improved tech11. Tasman W: Vitreoretinal changes in niques for cataract extraction in cicatricial retrolental fibroplasia. Trans Am children may result in reducing the Ophthalmol Soc 68:548-594, 1970. incidence of juvenile retinal detach12. Kanski JJ, Elkington AR, Daniel R: ment from these causes. Retinal detachment after congenital catKey Words: Juvenile; rhegmatogenous retinal detachment; surgical methods; surgical results; visual results; etiology. REFERENCES 1. Tasman W: Retinal detachment in children. Trans Am Acad Ophthalmol Otolaryngol 71:455-459, 1967.
aract surgery. Br J Ophthalmol 58:92-95, 1974.
13. Taylor BC, Tasman WS: Retinal detachment following congenital cataract surgery. Tex Med 70:83-87, 1974. 14. Johnston GP, Okun E, Cibis PA: Retinal detachment in children: Surgical experience. Mod Probl Ophthalmol 8:209220, 1969.
Between Jan 1, 1966, and June 30, 1974, 179 children, birth through 16 years of age with rhegmatogenous retinal detachments, underwent scleralbuckling procedures at Wills Eye Hospital. The detachments were associated most frequently with trauma (44%), myopia (15%), aphakia (10%), and retinopathy of prematurity (8%). Successful reattachment was achieved in 80% of the cases. Vision of 20/100 or better was present in 22% preoperatively and 58% postoperatively.
INTRODUCTION
JUVENILE rhegmatogenous retinal detachment has been variously reported to account for 3.2%1 to 5.6%2 of all rhegmatogenous retinal detachments. In this paper we have limited our review to 179 patients birth through 16 years of age, ali of whom underwent scleral-buckling procedures in an attempt to repair rhegmatogenous retinal detachments. We have categorized the various etiologies of all 179 patients, but have reported the surgical and visual results in only the 109 patients who were followed for six months or more postoperaSubmitted for publication Oct 5, 1977. From the Ophthalmology Center, Dallas (Dr Winslow) and the Retina Service, Wills Eye Hospital, Philadelphia (Dr Tasman). Presented at the Eighty·second Annual Meeting of the American Academy of Ophthalmology and Otolaryngology, Dallas, Oct 2-6, 1977. Reprint requests to 2811 Lemmon Ave E, Dallas, TX 75204 (Dr Winslow).
MATERIALS AND METHODS
We conducted a retrospective study of rhegmatogenous retinal detachments occurring from birth through 16 years of age. Consecutive charts of the Wills Eye Hospital Retina Service were reviewed for the period Jan 1, 1966, through June 30, 1974. During this period 179 juvenile patients were treated with a total of 216 scleral-buckling procedures. The total number of scleral-buckling operations performed during this same period was 7,435. Juvenile rhegmatogenous detachments therefore accounted for approximately 2.9% of the scleralbuckling procedures performed during this period. The total group of 179 patients (187 eyes) was reviewed concerning the etiology of the detachment, while only those patients followed for six months or more (109 patients representing 117 eyes) were reviewed regarding the type of surgical therapy, the per-
607
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WINSLOW AND TASMAN
cent age of successful anatomic reattachment, and postoperative visual results. A cure is defined as an anatomic reattachment for at least six months following the last surgical procedure. CHARACTERISTICS OF JUVENILE RHEGMATOGENOUS DETACHMENT
Several unique characteristics distinguished juvenile rhegmatogenous detachment from that of the adult. We found a high preponderance of boys in our study (130 boys [73%] and only 49 girls). This is undoubtedly related to a second characteristic of juvenile detachment, the high incidence of traumatic detachments; 82 of the 187 detachments (44%) were trauma related and of these 69 (84%) were in boys. Tasman 1 reported a series of 52 juvenile rhegmatogenous detachments; 15 (28.8%) of these were trauma related and 14 were in boys (93%). Hilton and Norton 2 reported a series of 71 rhegmatogenous detachments in patients 1 to 20 years of age; 30 of the 71 (42%) were trauma related and 58 of the 71 (82%) were boys. Hudson 3 reported 35 rhegmatogenous detachments in patients 1 to 15 years of age; 18 of the 35 (51%) were trauma related with 14 of the 18 (78%) occurring in boys. Arentsen and Welch 4 reported a series of 100 cases including both rhegmatogenous and nonrhegmatogenous detachments in children through age 16. Of these detachments, 33% were related to trauma with an 82% incidence of boys in the trauma group. Cox et al 5 found a prevalence of males (86.7%) in traumatic retinal detachments while Schepens and Marden 6 reported an equal sex distribution in nontraumatic retinal detachments.
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A third feature of juvenile retinal detachment is late diagnosis. Children often fail to report symptoms of a visual field loss or even a decrease in visual acuity. Our study revealed that 38 of the 187 detachments (21.1%) were diagnosed on routine eye examination by a school nurse, an ophthalmologist, or occasionally by the child's parents. In addition, 16 patients (8.9%) were originally misdiagnosed and treated for a lazy eye or some other condition. Clinical evidence of chronic retinal detachment is listed in Table 1. Fifty-five of 187 detachments (29.4%) displayed one or more signs of chronicity. Similarly, four-quadrant detachments were present in 89 of the 187 eyes (48%), while the macula was noted to be detached in an additional 55 eyes (29%) who did not have a four-quadrant detachment. These findings highlight the problem of late diagnosis in this age group and correlate closely with the series of Hilton and Norton 2 who reported four-quadrant detachments in 51% of their patients and macular detachment in 29% of those detachments not involving all four quadrants.
TABLE
1
CLINICAL EVIDENCE OF CHRONIC RETINAL DETACHMENT NO. EYES
Demarcation line Intraretinal macrocyst Subretinal gliosis Fixed folds
27 6 8 20
Total number of eyes with one or more of above 55/187 = 29.4%
VOLUME 85 JUNE 1978
RHEGMATOGENOUS RETINAL DETACHMENT TRAUMA
Table 2 lists the various causes of the rhegmatogenous retinal detachments found in this study. The 71 eyes with blunt trauma and 11 with penetrating trauma accounted for 82 (44%) of the 187 eyes in the study.
609
ately, 30% were detected within one month, 50% within eight months, and 80% within two years. Arentsen and Welch 4 reported 33 cases of juvenile traumatic detachment, and the interval between trauma and diagnosis of the detachment was greater than six months in slightly over 50% of the cases. Hilton and
TABLE 2 ETIOLOGY OF OPERABLE RHEGMATOGENOUS RETINAL DETACHMENT IN CHILDREN NO. PATIENTS
NO. EYES
70
71 11 28 27
Trauma (blunt) Trauma (penetrating) Myopia Unknown' Aphakia plus trauma Aphakia Retrolental fibroplasia (RLF) RLF and aphakia Uveitis Retinoschisis Lattice degeneration Coloboma Vitreous traction associated with Coats' Down's syndrome Congenital glaucoma postgoniotomy
11
23 27 11
7 11
2 5 4 3 2 1 1 1 179
11 8 12 2 5 4 3 2 1 1 1 187
% EYES INVOLVED
38.0 5.9 15.0 14.4 5.9 4.3 6.4 1.1 2.7 2.1 1.6 1.1 0.5 0.5 0.5 100.0
*17 of 27 had a dialysis.
The average interval between blunt trauma and diagnosis of a detachment was 17.3 months in this series, while the average interval between penetrating trauma and diagnosis of a detachment was 14.7 months. In our patients who sustained blunt trauma, 12.5% were detected in the first week, 29.7% in the first month, 54% in the first six months, and 84.4% within two years. Cox et al 5 found that 12% of the detachments following blunt trauma were diagnosed immedi-
Norton 2 reported that 41% of the juvenile traumatic detachments occurred more than 12 months after the injury. The laboratory experiments by Weidenthal and Schepens 7 have indicated that the majority of retinal breaks responsible for traumatic detachments are formed at the time of the injury. These breaks often cannot be identified because of vitreous haze, poor dilation, and lack of patient cooperation. In time,
610
WINSLOW AND TASMAN
vitreous degeneration and traction at the site of the retinal break result in a detachment. Tasman 8 conducted a prospective study on 52 patients with ocular trauma to determine if there was late development of tears. Dialysis of the peripheral retina was diagnosed in 9 of the 52 patients within three weeks of the injury, while a tenth was diagnosed four months after injury when the vitreous hemorrhage cleared. In none of the 52 patients did a late dialysis develop during the ensuing two-year followup. Based on our findings and the reports of others, we believe that any patient with severe ocular trauma should have a careful examination of the ora serrata. If for any reason the ora cannot be visualized, the patient should be followed carefully every three to six months for a two-year period to rule out development of a subclinical retinal detachment. This was also the suggestion of Hilton and Norton 2 in their study of juvenile retinal detachments.
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TABLE
3
DISTRIBUTION OF TRAUMATIC DIALYSES· LOCATION
Inferotem porai Inferonasai Superonasai Superotemporai
NO . EYES
37 14 15 11 77
%
48.0 18.2 19.5 14.3 100.0
"59 patients, 18 bilateral cases.
were inferotemporal, 28% superonasal, 20% superotemporal, and 5% inferonasal. However, Hagler and North found that the greater the evidence for trauma, the higher the incidence of superonasal dialyses. Weidenthal and Schepens'7 study on pig eyes concluded that if trauma were near the center of the cornea, a superonasal dialysis was most likely to occur, while trauma near the temporal 'limbus resulted in a temporal retinal dialysis. They concluded that the frequency of retinal dialyses seen clinically in the inferotemporal quadrant resulted from the configuration of the human orbit which provides the least protection to the eye in this quadrant, a concept our findings support.
Dialysis accounted for the retinal detachment following trauma in 59 of 82 eyes (72%). An additional 18 dialyses were noted in the fellow eye unassociated with a detachDialysis accounted for 40.6% of ment. Dialyses were classified as traumatic when historical or clini- the 187 detachments with 59 traucal evidence of trauma was present. matic and 17 nontraumatic diAnalysis of the location of the 77 alyses. This corresponds with the dialyses showed that 48% were results of Hagler and North 9 who located in the inferotemporal quad- reported a 50% incidence of dialysis rant (Table 3). This varies from the in retinal detachments found in report of Cox et al 5 who reported children and young adults. Arent37.8% superonasal, 27.4% infero- sen and Welch 4 reported a 35% temporal, 22% superotemporal, and incidence of dialysis in 100 cases of 21.8% inferonasal, but concurs with rhegmatogenous and nonrhegmaHagler and North 9 who reported togenous retinal detachments in that of their traumatic dialyses 47% children through age 16.
85
RHEGMATOGENOUS RETINAL DETACHMENT 611 1978 TABLE 4 Hagler and North,9 as well as Tasman,8 pointed out that detachPOSTOPERATIVE VISUAL ACUITY IN TRAUMATIC CASES ments associated with dialyses always begin in the periphery and VISUAL ACUITY NO. EYES % progress slowly with the diagnosis often not being made until central 6/6 to 6/15 13 35.1 vision has become affected. This 6/18 to 6/30 8 21.6 reemphasizes the need for examina6/60 or less 16 43.3 tion of the extreme retinal pe37 100.0 riphery in all cases of trauma since it is theoretically possible to prevent macular involvement by careful examination and early surgery. ment rate in traumatic detachHagler and North 9 reported that ments of all types. 52% of patients with detachment due to dialysis had symptoms in MYOPIA excess of one month and 42% had symptoms longer than three months. Myopia was the cause of retinal detachment in 28 eyes. Fifteen of the 26 recorded refractions were The surgical management of trau- greater than -8.00 diopters (Tabl~ matic detachments most often in- 5). Unlike the trauma cases, bIcluded scleral flaps, diathermy, a lateral detachments occurred in 7 silicone implant, and an encircling of the 23 patients, or 30.4%. Five of silicone band. The cure rate was the seven patients with bilateral 77% with 37 successful anatomic detachments had myopia greater reattachments in 48 eyes. This is than -7.00 D, and only five of the comparable to the cure rate re- seven fellow eyes with detachments ported by Cox et al 5 of 82.6%. There were considered operable. In addiwas no significant difference in the tion, cryotherapy was performed. on incidence of cure whether an encir- six fellow eyes with threatenmg cling procedure was used or not. holes. A round hole in lattice or This is different from the results a round hole unassociated with of Cox et al 5 in which the success lattice was the most common type rate with an encircling element was of break. Therefore, 13 of 23 pa83.3%, compared to 37.5% without tients (56.5%) had significant pait. In our series, case selection thology in the fellow eye. favored those cases without encircling procedures since these were TABLE 5 usually less complicated. The averMYOPIA age follow-up in the 47 patients (48 eyes) was 29.9 months. Table 4 DI()PTERS OF MYOPIA NO. EYES % lists the visual acuity results in the 37 eyes in which anatomic reatPlano to -4.00 32.1 9 tachment was successful. The cure 7.1 -4.00 to -8.00 2 rate of the traumatic dialyses was -8.00 to -12.00 17.9 5 80%, while in the dialyses of un35.8 Greater than -12.00 10 known origin, the cure rate was No refraction only 66%. There was a 75% reat7.1 2 recorded tachment rate of all dialyses which 100.0 28 is comparable to the 77% reattachVOLUME JUNE
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WINSLOW AND TASMAN
A scleral-buckling procedure was performed on 28 eyes. Only 21 of the 28 were followed for six months. Surgical results included 17 anatomic reattachments of the 21 eyes for a cure rate of 80.9% with an average follow-up of 23.9 months. The visual results were somewhat better than in the trauma group or in those with unknown etiology (Table 6). This resulted in part from earlier diagnosis in cases of myopia, a fact also noted by Hilton and Norton. 2 TABLE
6
POSTOPERATIVE VISUAL ACUITY IN MYOPIC EYES VISUAL ACUITY
NO. EYES
6/6 to 6/15 6/18 to 6/30 6/60 or less
12 3 2 17
% 70.6 17.6 11.8 100.0
The major clinical implication is that high myopes who have had a detachment in one eye are at significant risk to develop a detachment in the fellow eye. These patients should be alerted to the early symptoms of detachment. We recommend that they be followed every six months, and holes appearing in the fellow eye be treated promptly. UNKNOWN ETIOLOGY
No specific etiology could be assigned to 27 eyes, and this group comprised the third largest in the series. Generally there was no history or other evidence of trauma, no significant myopia, no history of prematurity, and no aphakia. This partially represented inadequate history taking or failure to record refractive error. The most notable characteristic in this group
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was that 17 of the 27 eyes had dialyses. Verdaguer et apa presented good evidence that some nontraumatic retinal dialyses probably have a genetic origin; they demonstrated more than one affected individual in 8 of 24 sibships (33%). It is of interest that in his series the sex incidence was equal with 19 boys and 21 girls affected. Despite this, we believe that many dialyses are probably traumatic in origin even without a history or clinical evidence of trauma. The distribution of our nontraumatic dialyses is shown in Table 7 and is quite similar to the distribution of our traumatic dialyses (Table 3). It is noteworthy that ten nasal dialyses were found in the group of 17 dialyses in which absolutely no history or other objective signs of trauma were found, and 11 of the 17 (65%) were boys. Verdaguer et apa reported that 54% of his patients had bilateral dialyses compared with only 4 of 17 in our series. TABLE
7
NONTRAUMATIC DIALYSES* LOCATION
Inferotemporal Inferonasal Superonasal Superotemporal
NO. EYES
10 5 5 1 21
% 47.6 23.8 23.8 4.8 100.0
*17 cases nontraumatic. 4 cases bilateral.
Scleral-buckling procedures were performed on 27 eyes, 18 of which were followed six months or more postoperatively; 14 of the 18 (78%) were successfully reattached. Postoperative visual acuity was 6/6 to 6/15 in four eyes, 6/18 to 6/30 in three eyes, and 6/60 or less in seven eyes.
VOLUME 85 JUNE 1978
RHEGMATOGENOUS RETINAL DETACHMENT
RETINOPATHY OF PREMATURITY
Retrolental fibroplasia (RLF) accounted for 11 patients (12 eyes) while RLF plus aphakia accounted for two patients (two eyes). Therefore, RLF accounted for 14 eyes (7.5%) of our series. Retrolental fibroplasia accounted for 21% of the detachments in Tasman'sl series a retrospective study also done at Wills Eye Hospital, but during the period 1962 to 1965. It is encouraging that in the ensuing 8 1/2 years the percentage of RLF-related detachments has declined. This condition tended to be bilateral with 3 of the 13 patients having bilateral detachments and 6 of the 13 having retinal holes in the fellow eye, 4 of which were treated with cryotherapy. Similarly, in Tasman'sl series, 3 of 13 had bilateral retinal detachments and an additional 3 had retinal breaks in the fellow eyes. Nine of the 13 patients in our series had birth weights recorded. The average birth weight was 1.35 kg, but ranged from .95 kg to 1.60 kg. These findings correlate with those of Tasman l l in which children with RLF uniformly weighed less than 1.80 kg and had an average weight of 1.51 kg at birth. Since the patients in our series not only had RLF, but also developed retinal detachments, it is not surprising that the average birth weight was less than that reported by Tasman. Myopia was a significant finding in the RLF patients. No refraction was recorded in two patients and two more were aphakic. The refractive error of the remaining nine patients (ten eyes) is listed in Table 8. Seven of the ten' had
TABLE
613
8
DEGREE OF MYOPIA IN RLF PATIENTS WITH DETACHMENTS DIOPTERS OF MYOPIA
Plano to -4.00 -4.00 to -8.00 -8.00 to -12.00 Greater than -12.00 Aphakic Not recorded
NO. EYES
0 3 3 4 2 2 14 (13 patients)
myopia exceeding -8.00 D (70%). This is in agreement with the study of Tasman,l1 in which he found myopia exceeding -8.00 D in over 69% of patients with RLF detachments. The average age of diagnosis of detachment secondary to RLF was 12.4 years which corresponds with the average age of 13.5 in Tasman's series. 11 Those cases of detachment developing in the active phase of RLF are often inoperable; however, the cases described in this series have a much better prognosis since the detachment occurred in the cicatricial phase of the disease. Since these cases are often amenable to therapy, it is important to continue following patients with known RLF for development of new holes and detachments. Since in both our series and Tasman's 3 of 13 patients (23%) had bilateral detachments, we recommend prophylactic treatment of breaks in the fellow eye. The most common type of break was a round hole, but severe vitreous traction was evidenced by two cases of giant retinal tears.
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WINSLOW AND TASMAN
Nine patients (ten eyes) underwent scleral-buckling procedures and were followed for at least six months with eight of the ten resulting in successful anatomic reattachment for a cure rate of 80%. Tasman l l reported successful anatomic reattachment in 15 of 16 eyes (94%). The techniques most frequently used included scleral flaps, diathermy, a silicone implant, and an encircling band. Postoperative visual acuity was 6/6 to 6/15 in two eyes, 6/18 to 6/30 in one eye, and 6/60 or less in five eyes. The average follow-up was 50.9 months which reflects the fact that this disease is frequently bilateral and progressive so that continued observation is essential. Three patients had bilateral retinal detachments. In two of these patients the poorer eye was considered inoperable, while in the third, an unsuccessful scleral buckle was performed. Thus, in all three of the bilateral cases the more involved eye was irreparable. APHAKIA
Eighteen patients were aphakic for the reasons listed in Table 9. Bilateral detachments were present in five patients, four of whom were
TABLE
9
APHAKIA ETIOLOGY OF CATARACTS
Congenital Traumatic Mongolism Bilateral dislocation Unknown
NO. PATIENTS
7 7 1 1 2 18
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bilaterally aphakic. Three of the fellow eyes were considered inoperable and one fellow eye was phakic; therefore, 19 aphakic eyes with rhegmatogenous retinal detachment were managed by a scleralbuckling procedure. . The average interval of time between the extraction of a nontraumatic cataract and the diagnosis of a retinal detachment was 9.8 years. This is considerably less than the average of 33.3 years quoted by Kanski et al,12 or the median of 21 years in the study by Taylor and Tasman,13 since neither of these studies included only juvenile detachments. The average age at the time of cataract extraction was 4 years in our series and 6.2 years in Kanski'sl2 series, compared with a mean age of 6 years in the study by Taylor and Tasman. 13 Retinal breaks were identified in 17 of the 19 eyes in our series, while Kanski et aJ12 reported detectable breaks in only 9 of 34 detachments. Arentsen and Welch 4 reported that breaks were identified in six of nine juvenile detachments following cataract extraction. Kanski'sl2 results included 18 successful reattachments of the 34 eyes treated for a cure rate of 52.9%. In our series, ten aphakic eyes were followed for six months after surgery; eight eyes had successful anatomic reattachment. Our cure rate of 80% reflects the enhanced ability to find the break resulting from the increased use of the indirect ophthalmoscope in the period of our study (1966 to 1974), as compared with the period of Kanski's study (1951 .to 1972). The most frequent procedure included a scleral bed with diathermy, a silicone
85 1978
VOLUME JUNE
RHEGMATOGENOUS RETINAL DETACHMENT
implant, and an encircling band. The average follow-up of this group was 32.4 months. Postoperative visual acuity was 6/6 to 6/15 in three eyes, 6/18 to 6/30 in two eyes, and 6/60 or less in three eyes. ANALYSIS OF OVER-ALL SURGICAL RESULTS
The 109 patients in this group were all followed for a minimum of six months after their last surgical procedure; eight of the cases were bilateraL The etiologies of the detachments are listed in Table 10 with the surgical results summarized in Table 11. Anatomic reattachment of the retina was accomplished in 94 of 117 eyes, or 80.3%. Seventy-seven eyes required only one operation, 15 eyes required two operations, and two eyes required three operations with the average follow-up of the 109 patients 31.2 months.
615
The type of surgery performed and the results obtained are summarized in Table 12. The most frequent mode of therapy consisted of scleral flaps, diathermy, a buried implant, and an encircling band. It was used in 81 of the 117 eyes producing an 80.2% successful anatomic reattachment. The same procedure without an encircling band was used in only 13 eyes with a 92.3% successful anatomic reattachment. These latter cases were localized detachments with a more favorable prognosis. The technique of cryotherapy and sponge explant was used in 15 eyes and resulted in only 60% successful anatomic reattachment. However, of the six eyes which had unsuccessful anatomic reattachment, all had total retinal detachments, fixed folds, or both. Hilton and Norton 2 reported an 89% anatomic reattachment with
TABLE 10 SURGICAL RESULTS SIx-MoNTH POSTOPERATIVE FOLLOW-UP ETIOLOGY
OF
DETACHMENT
Trauma Myopia Unknown RLF RLF and aphakia Aphakia and trauma Aphakia Retinoschisis Uveitis Coloboma Congenital glaucoma postgoniotomy Vitreous traction associated with Coats' Lattice degeneration
NO. PATIENTS
NO. EYES
% EYES
47 16 18 8 1 6 3 3 2 2 1 1 1 109
48 21 18 9 1 6 4 3 2 2 1 1 1 117
41.0 17.9
15.4 7.7 0.9
5.1 3.4 2.5 1.7 1.7 0.9 0.9 ~ 100.0
616
WINSLOW AND TASMAN
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TABLE 11 SURGICAL RESULTS* NO. EYES
% CURED
Anatomic reattachment first operation Anatomic reattachment second operation Anatomic reattachment third operation
77/117 15/19 213
66.0 79.0 66.6
Total anatomic reattachment
94/117
80.0
• Average follow·up of 109 patients, 31.2 mo.
TABLE 12 TYPE AND RESULTS OF SURGERY PERFORMED* TYPE OF SURGERY
OPERATED ON EYES ATIACHED
Scleral flap plus diathermy plus encircling Scleral flap plus diathermy without encircling Cryotherapy plus sponge Scleral flap plus cryotherapy with encircling Scleral flap plus diathermy plus sponge Cryotherapy plus encircling No. 40 band 'Scleral buckle without drainage: 14/117
NOT ATIACHED % CURE
81
65
16
80.2
13 15
12 9
1 6
92.3 60.0
4
4
0
100.0
3
3
0
100.0
1 117
1 94
0 23
100.0
= 12%.
either diathermy or cryotherapy, although they had 62 patients in their diathermy group and only 9 in their cryotherapy group. Their study was conducted between 1954 and 1966 before cryotherapy was widely used. Hudson 3 reported a 75% successful reattachment rate in 35 juvenile rhegmatogenous detachments, but the length of followup was not stated. Johnston et aP4 reported surgical results of 163 juvenile rhegmatogenous retinal detachments. The patients were followed 6 to 57 months postoperatively and 123 (76%) were reattached successfully.
Most of the eyes in our series were managed with drainage of subretinal fluid with only 14 eyes of the 117 (12%) not drained at the primary operation. Encircling procedures were used in 86 (74%) of the 117 eyes. The series of Hilton and N orton2 likewise only reported 11% without drainage and the use of an encircling procedure in 75% of their cases. Prophylactic treatment of the fellow eye was undertaken in 11 eyes (10%). This treatment included ten eyes which had cryotherapy and one eye which was photocoagulated.
RHEGMATOGENOUS RETINAL DETACHMENT
VOLUME 85 JUNE 1978
617
The 23 cases of surgical failure were analyzed to determine factors that might be indicative of poor prognosis. Factors most frequently associated with unsuccessful reattachment were total retinal detachments, fixed folds, massive periretinal proliferation, dialyses greater than 90 0 , multiple holes, posterior holes, failure to identify a break, choroidal coloboma, and giant tears.
Comparison of preoperative vision with postoperative vision shows that 22.3% had vision of 6/30 or better preoperatively, while 58.5% had vision of 6/30 or better postoperatively (Table 13). Hudson 3 reported that 25 of 32 patients (78%) had 6/60 or better postoperative visual acuity. Hilton and Norton 2 reported only 19% with 20/50 or better visual acuity postoperatively, while in our series 37% had 20/50 or better. Table 14 summarizes the surgical results of the five major etiologies and shows that the reattachment rate was similar but that the postoperative visual acuity results varied considerably. In general, poor visual results were associated with etiologies in which macular damage was likely (trauma, RLF, and unknown).
SUMMARY
Review of the records at the Wills Eye Hospital Retina Service disclosed 179 patients with rhegmatogenous retinal detachment in children from birth through 16 years of age. The most common etiologies in order of frequency were trauma,
TABLE
13
COMPARISON OF PREOPERATIVE AND POSTOPERATIVE VISION PREOPERATIVE VISUAL ACUITY
6/6 to 6/15 6/18 to 6/30 6/60 or less No visual acuity recorded
POSTOPERATIVE
NO. PATIENTS
%
NO. PATIENTS
%
13 8 69 4 94
13.8 8.5 73.4
35 20 39 0 94
37.2 21.3 41.5
~
100.0
TABLE
-100.0
14
SURGICAL RESULTS OF FIVE ETIOLOGIES
ETIOLOGY
Trauma Myopia Unknown RLF
Aphakia
AVERAGE FOLLOW-UP (MO)
29.9 23.9 31.7 50.9 32.4
VISUAL ACUITY EYES OPERATED ON
48 21 18 10 10
% 6/30
ATI'ACHED
% CURE
OR BETTER
37 17 14 8 8
77 81 78 80 80
57 88 50 38 63
618
WINSLOW AND TASMAN
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myopia, unknown etiology, retrolental fibroplasia, and aphakia.
2. Hilton GF, Norton EWD: Juvenile retinal detachment. Mod Probl Ophthalmol 8:325-341, 1969.
Surgical results included 94 of 117 (80%) successful anatomic reattachments. The most common surgical techniques included scleral flaps, diathermy, a buried implant, and an encircling band.
3. Hudson JR: Retinal detachments in children. Trans Ophthalmol Soc UK 85:7991, 1965. 4. Arentsen JJ, Welch RB: Retinal detachment in the young individual: A survey of 100 cases seen at the Wilmer Institute. J Pediatr Ophthalmol 11:198-202, 1965.
The management of juvenile reti5. Cox MS, Schepens CL, Freeman HM: nal detachments can be improved Retinal detachment due to ocular contusion. most by earlier diagnosis so that Arch Ophthalmol 76:678-685, 1966. surgical therapy can be employed 6. Schepens CL, Marden D: Data on the prior to extensive irreversible damage to the retina. Education of high- natural history of retinal detachment. Arch Ophthalmol 66:631-642, 1961. risk patients and their parents regarding the threat of detachment 7. Weidenthal DT, Schepens CL: Periphand symptoms of detachment can eral fundus changes associated with contuimprove our results without any sion. Am J Ophthalmol 62:465-477, 1966. change in our present techniques of 8. Tasman W: Peripheral retinal changes examination or therapy. School following blunt trauma. Trans Am OphthalVISIOn screening tests must be mol Soc 70:190-196, 1972. encouraged since approximately 20% 9. Hagler WS, North AW: Retinal diof the diagnoses in our series were and retinal detachment. Arch Ophmade on routine examination. Long- alyses thalmol 79:376-388, 1968. term follow-up of high-risk patients is necessary to enable prophylactic 10. Verdaguer TJ, Rojas B, Lechuga M: treatment of asymptomatic new Genetical studies in nontraumatic retinal retinal breaks and subclinical de- dialyses. Mod Probl Ophthalmol 15:34-39, tachments. Finally, increased aware- 1975. ness of RLF and improved tech11. Tasman W: Vitreoretinal changes in niques for cataract extraction in cicatricial retrolental fibroplasia. Trans Am children may result in reducing the Ophthalmol Soc 68:548-594, 1970. incidence of juvenile retinal detach12. Kanski JJ, Elkington AR, Daniel R: ment from these causes. Retinal detachment after congenital catKey Words: Juvenile; rhegmatogenous retinal detachment; surgical methods; surgical results; visual results; etiology. REFERENCES 1. Tasman W: Retinal detachment in children. Trans Am Acad Ophthalmol Otolaryngol 71:455-459, 1967.
aract surgery. Br J Ophthalmol 58:92-95, 1974.
13. Taylor BC, Tasman WS: Retinal detachment following congenital cataract surgery. Tex Med 70:83-87, 1974. 14. Johnston GP, Okun E, Cibis PA: Retinal detachment in children: Surgical experience. Mod Probl Ophthalmol 8:209220, 1969.
