Retinal Detachment after Cataract Surgery Surgical Results Akitoshi Yoshida, MD, Hironobu Ogasawara, MD, Alex E. Jalkh, MD, Reginald]. Sanders, MD, ]. Wallace McMeel, MD, Charles L. Schepens, MD

T

he authors studied the results obtained by the Retina Associates in 376 eyes of 361 patients operated on for retinal detachment associated with aphakia or pseu- , dophakia 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. Ophthalmology 1992; 99:460-465

Currently, intraocular lens (IOL) implantation is routinely performed in cataract surgery,l and it is expected therefore that the number of cases of retinal detachment (RD) in pseudophakia will continue to increase with the popularity of this surgical procedure. The characteristics of RD in aphakia and pseudophakia have been described? This article reports the surgical results of RD repair in aphakia and pseudophakia performed by the Retina Associates between 1982 and 1989.

Materials and Methods The series comprises 376 consecutive eyes of 361 patients with aphakic or pseudophakic RD. The eyes were treated, Originally received: April 30, 1991. Revision accepted: November I, 1991 . From the Eye Research Institute and Retina Associates, Boston. Dr. Yoshida was on leave from the Department of Ophthalmology, Asahikawa Medical College, Japan. Reprint requests to Alex E. Jalkh, MD, Eye Research Institute of Retina Foundation, 20 Staniford St, Boston, MA 02114.

460

mainly with scleral buckling, by eight surgeons at Retina Associates. Twenty-one eyes with less than 6 months of postoperative follow-up were completely excluded from the study. Similarly, this series did not include eyes in which the primary operation was performed elsewhere, and eyes with penetrating ocular trauma or with diabetic retinopathy. The preoperative clinical findings have been reported.2 The type of scleral buckling procedure performed has been described elsewhere. 3- 5 Briefly, the location of a lamellar scleral undermining was determined by scleral 10calization marks that indicated the position of the retinal breaks. Diathermy was applied to the thinned scleral bed in a grid pattern. The appropriate soft silicone implant was inserted under mattress sutures placed in the scleral flaps. The size of the scleral bed and the choice of implant depended on the width and height of the buckling effect desired. A c, ircling silicone band was placed around the globe. Subretinal fluid was released in most cases. When retinal breaks could not be detected or when the ora serrata could not be completely visualized, a scleral buckle that extended over the circumference of the retinal detachment was performed. The buckling extended pos-

Yoshida et al . Retinal Detachment after Cataract Surgery teriorly to the region where the retina was visible. For retinal breaks located posterior to the equator, a radial buckle was used under a circumferential band. The injection of air or gas into the vitreous cavity was used when it was difficult to close a large retinal break. A simultaneous injection of air in the anterior chamber was done when a large bubble in the vitreous cavity produced a shallow anterior chamber with risk of endothelial damage by the IOL. Closed vitrectomy was combined with scleral buckling when the retinal detachment was complicated either by severe vitreoretinal traction or by vitreous membranes or hemorrhage that obscured fundus details. Other concomitant procedures occasionally included choroidal tap, repositioning or removal of the IOL, suture reinforcement of the cataract wound, photocoagulation of retinal breaks, and removal of the scleral buckle. Preoperative data2 and details of the surgical technique were analyzed. Information on the use of silicone tires and encircling bands, materials injected into the vitreous cavity (saline, air, or gas) and the anterior chamber (saline or air), and drainage of subretinal fluid was recorded. The operation was considered anatomically successful if the retina was reattached for at least 6 months after surgery. If the retina remained detached or the detachment recurred, the cause was studied. If a reoperation was not performed, the reasons were recorded. Final best corrected visual acuity in anatomically successful cases was noted at the last follow-up visit in each case. To quantitate the preoperative and the postoperative visual acuity of each eye for statistical analysis, the logarithmic transformation of raw Snellen measures was performed using the code of Snyder et al. 6 It provides steps that represent more closely a measure offunctional value. The Snellen visual acuities were graded from one to eight as follows: step 1, 20/40 or better; step 2, 20/40-1 to 20/80; step 3, 20/80-1 to 20/160; step 4,20/160-1 to 20/400; step 5, counting fingers; step 6, hand motions; step 7, light perception; and step 8, no light perception. When using this method of measuring visual acuity, the higher numbers represent the lower degrees of visual acuity. Intraoperative and postoperative complications were noted. The data were analyzed using standard statistical methods. The relationships between categorical variables were examined using Pearson's chi-square technique. Differences were considered significant when the probability of their occurrence by chance was less than 5%.

Results Fifteen of 361 patients had bilateral involvement. In 3 of 15 patients, the 2 eyes were used in different groups and were handled as described previously.2 The total number of eyes, therefore, is 376 (Table 1). Cases were classified into 4 groups: 103 eyes had aphakia, 17 showed an irisfixated IOL, 111 eyes had an anterior chamber (AC) IOL, and 145 eyes showed a posterior chamber (PC) IOL. The mean follow-up period was 21.2 months. Aphakic patients had an insignificantly longer mean follow-up period than patients in the pseudophakic group. The quadrants of the fundus affected by the scleral buckle during the initial operation were similar in the four groups. One hundred fifty-five eyes (41.2%) had I quadrant scleral buckling, 140 eyes (37.2%) had 2 quadrants scleral buckling, and 79 eyes (21.0%) had 3 or more quadrants scleral buckling. Two eyes did not receive a scleral buckle at the initial operation. Drainage of subretinal fluid was not performed in 14 cases (3.7%). Intravitreous injection of air or gas was performed in 149 cases (39.6%), and intravitreous injection of saline was performed in 18 cases (4.8%) without preference for any of the four groups. Closed vitrectomy was performed in only 10 eyes (2.7%). The reasons for this were severe proliferative vitreoretinopathy (8 eyes) or vitreous hemorrhage (2 eyes). The number of scleral buckle operations in each group is shown in Table 2. Two hundred ninety-five cases (78.5%) had only one operation, 58 (15.4%) had two operations, and 23 (6.1 %) had more than 2 operations. The nature of the procedures performed, in addition to the above-mentioned operations, varied and consisted of photocoagulation for retinal break (12 cases), cataract wound reinforcement (5 cases), endophotocoagulation (3 cases), choroidal tap (2 cases), and 1 case each of IOL repositioning, IOL removal, and implant removal. Table 3 shows the anatomic results. After the first operation, results did not differ statistically in the aphakic and pseudophakic groups. The final success rate was 93.4% overall and was about the same in the different groups. In 10 cases (40% of all failures), reoperation was refused. Table 4 represents preoperative visual acuity and Table 5 reports the best corrected final visual acuity in each group. The aphakia group (61 eyes, 62.9%) and the PC group (80 eyes, 59.7%) had a significantly (P < 0.01) higher prevalence of good visual acuity (20/20 to 20/40) than

Table 1. Characteristics of Cases

No. of cases No. of eyes Postoperative follow-up (mos) Mean Range

Aphakia

Iris-fixated

98 (26.9%) 103 (27.4%)

16 (4.4%) 17 (4.5%)

108 (29.7%) 111 (29.5%)

142 (39.0%) 145 (38.6%)

364 (100%) 376 (100%)

29.4 6-84

23.0 6-62

19.1 6-66

16.8 6-84

21.2 6-84

Anterior Chamber

Posterior Chamber

Total

461

Ophthalmology

Volume 99, Number 3, March 1992

Table 2. Number of Scleral Buckle Operations Number of Scleral Buckle Operations

1

2 3

4

Aphakia

Iris-fixated

Anterior Chamber

84 (81.6%) 16 (15.5%) 3 (2.9%)

14 (82.3%) 3(17.7%)

87 (78.4%) 15 (13.5%) 7 (6.3%) 2 (1.8%)

103 (100%)

17 (100%)

5

Total

the AC group (34 eyes, 33.0%). The AC group had the highest incidence of cases (18 eyes, 17.5%) with a final acuity of counting fingers or less, but the difference with other groups was not significant. Seventeen of 18 eyes with a final visual acuity of counting fingers or worse in the AC group were planned intracapsular cataract extractions with AC IOL and only one was an extracapsular cataract extraction. Table 6 shows the mean preoperative and postoperative visual acuities and the improvement scores (preoperative minus postoperative visual acuity readings) obtained from cases with retinal reattachment for each group. The AC group had significantly higher mean preoperative acuity readings and consequently lower preoperative acuities than the aphakia (P < 0.05) or PC groups (P < 0.05). The AC group also had significantly higher mean postoperative acuity readings (worse postoperative acuity) than the aphakia (P < 0.001) or PC groups (P < 0.001). The AC group had a lesser mean visual improvement than the aphakia or PC groups, but the differences were not statistically significant. Eighty-one (21.5%) of 376 eyes had reoperations. The percentages in each group differed insignificantly. Common causes of reoperation were proliferative vitreoretinopathy (34 eyes, 42.0%), new breaks (32 eyes, 39.5%), and failure to close the original break (19 eyes, 23.5%). Intraoperative complications occurred in 11 (2.9%) of 376 eyes, and there was no significant difference in the percentages of these complications among the 4 groups. Postoperative complications occurred in 122 eyes (32.4%), the most common being choroidal detachment (81 eyes, 21.5%). Other complications included: corneal

111 (100%)

Posterior Chamber 110 (75.8%) 24 (16.6%) 8 (5.5%) 1 (0.7%) 2 (1.4%) 145 (100%)

Total 295 (78.5%) 58(15.4%) 18 (4.8%) 3 (0.8%) 2 (0.5%) 376 (100%)

edema (36 eyes, 9.6%), macular pucker (32 eyes, 8.5%), glaucoma (22 eyes, 5.9%), cystoid macular edema (12 eyes, 3.2%), hyphema (10 eyes, 2.7%), IOL displacement (9 eyes, 2.4%), and 51 eyes (13.6%) with other complications. More than one complication occurred in the same eye in 43 cases. The prevalence of these complications was not significantly different between the groups except for corneal edema, which was significantly (P < 0.05) more frequent in the pseudophakic (32 of 273 eyes, 11.7%) than in the aphakic group (4 of 103 eyes, 3.9%). It also was significantly higher (P < 0.01) in the AC group (17 of III eyes, 15.3%) than in the other groups (19 of 265 eyes, 7.1 %). Sixteen of 17 eyes that had corneal edema in the AC group ended up with some degree of corneal opacification. Table 7 lists significant correlations between surgical success and preoperative findings. The success rate of cases with selected characteristics was compared with the success rate of cases without any of these characteristics. The following were considered: preoperative vitreous hemorrhage clearly recorded on large fundus drawing; large retinal breaks (equal to or larger than I clock hour); breaks located posterior to the equator; total RD; macular detachment; or proliferative vitreoretinopathy (grade B, C, or D). Cases with any of these characteristics had a significantly (P < 0.01) lower chance of successful anatomic repair than those without these characteristics. Eyes submitted to closed vitrectomy also had a significantly (P < 0.0 I) lower prevalence of surgical success compared with cases without closed vitrectomy. A number of preoperative findings had no significant effect on the percentages of surgical reattachment. These

Table 3. Anatomic Results Aphakia (n = 103) Success after first operation Final success Failure Inoperable Reoperation declined

462

84 (81.6%) 97 (94.2%) 6 (5.8%) 3 (2.9%) 3 (2.9%)

Iris-fixated (n = 17)

Anterior Chamber (n= 111)

Posterior Chamber (n = 145)

Total (n = 376)

14 (82.4%) 17 (100%) 0(0%)

85 (76.6%) 103 (92.8%) 8 (7.2%)

107 (71.7%) 134 (92.4%) 11 (7.6%)

290 (77.1%) 351 (93.4%) 25 (6.6%)

6 (5.4%) 2 (1.8%)

6 (4.1%) 5 (3.5%)

15 (4.0%) 10 (2.6%)

0(0%) 0(0%)

Yoshida et al . Retinal Detachment after Cataract Surgery Table 4. Preoperative Visual Acuity 20/20-20/40 20/50-20/100 20/200-20/400 CF, HM, LP Total CF

=

Aphakia

Iris-fixated

Anterior Chamber

Posterior Chamber

Total

23 (22.3%) 18(17.5%) 22 (21.4%) 40 (38.8%) 103 (100%)

4 (23.5%) 3 (17.6%) 2 (11.8%) 8 (47.1%) 17 (100%)

16 (14.4%) 17 (15.3%) 19 (17.1%) 59 (53.2%) 111 (100%)

30 (20.7%) 31 (21.4%) 21 (14.5%) 63 (43.4%) 145 (100%)

73 (19.4%) 69 (18.4%) 64 (17.0%) 170 (45.2%) 376 (100%)

counting fingers; HM

hand motions; LP

=

light perception.

=

are the presence of preoperative vitreous herniation into the anterior chamber, mild uveitis, damage to the posterior capsule, incomplete viewing of the ora serrata, inability to see any retinal break, or the number of retinal breaks found. Similarly, the extent of the scleral buckle did not correlate significantly with the success rate.

Discussion Our anatomic success rate of 93.0% for overall pseudophakic RD cases (Table 3) was comparable with that previously reported by Jungschaffer7 (90.2%), Snyder et al6 (96.7%), Hagler8 (91.5%), Ramsay et al 9 (91.5%), and Wilkinson 10 (96.0%). However, these series only included a small number of cases with PC IOL. Namely, no case with PC IOL was included in the first two studies6 •7 or in that reported by Ramsay et al. 9 Only 10 cases with PC IOL were included in Hagler's8 study and 41 cases in Wilkinson's. 10 Our success rate was better than the overall success rate of 88.0% in the recent largest series reported by Cousins et al (600 cases).13 In their report, only 75 cases (12.5%) had a PC IOL. To our knowledge, the present report, which compares surgical results in retinal detachments that affect aphakic eyes and pseudophakic eyes operated on by the same surgeons over the same period of time, covers the largest series of surgical results obtained in pseudophakic eyes with PC IOL (145 cases). In this study, there are no significant differences between the success rates of the different pseudophakic groups. The three groups achieved roughly the same final success rate as the aphakic group (94.2%).

The PC IOL group had a significantly (P < 0.01) greater prevalence of good postoperative visual acuity compared with the AC IOL group, which achieved the worst final visual acuities (Table 5). The AC IOL group had a significantly lower (P < 0.05) mean preoperative visual acuity and also a significantly lower mean postoperative visual acuity (P < 0.001) than the aphakic or PC groups (Table 6). However, there was no significant difference in improvement of visual acuity between the subgroups after the surgical repair of the retina (Table 6). This demonstrates that eyes in the AC IOL group improved almost as much as those with other types of IOLs. This can be attributed to the presence of preoperative complications2 that may be responsible for the disappointing preoperative and postoperative visual acuities in the AC IOL group. The relatively disappointing visual results after surgical treatment ofRD in cases with iris fixation of the IOL6 •1O,11 and in cases of anterior chamber lenses 6 ,12,13 have previously been reported. Significant preoperative anterior segment inflammation observed in these cases6 as well as increased incidence of postoperative complications in cases with anterior chamber lenses l2 ,13 accounted for the poor postoperative visual acuity. The reasons for the poor visual prognosis in the AC IOL group were further investigated in our patient population. The quadrant in which the scleral buckle was performed, the type or frequency of intravitreous injection performed, the frequency of closed vitrectomy, the number of operations performed, or the type of the additional surgical procedures performed, all had no significant influence on the postoperative visual results. Contrary to other reports,12,13 the prevalence of postoperative com-

Table 5. Final Visual Acuity Final visual acuity"

20/20-20/40 20/50-20/100 20/200-20/400 CF,HM, LP

Aphakia

Iris-fixated

Anterior Chamber

Posterior Chamber

Total

97 61 (62.9%) 17 (17.5%) 9 (9.3%) 10 (10.3%)

17 6 (35.3%) 7 (41.2%) 3(17.7%) 1 (5.9%)

103 34 (33.0%) 34 (33.0%) 17 (16.5%) 18 (17.5%)

134 80 (59.7%) 24 (17.9%) 17 (12.7%) 13 (9.7%)

351 181 (51.6%) 82 (23.4%) 46 (13.1%) 42 (11.9%)

• Final visual acuity was recorded exclUSively in cases of retinal reattachment. CF

=

counting fingers; HM

=

hand motions; LP

=

light perception.

463

Ophthalmology

Volume 99, Number 3, March 1992

Table 6. Comparison of Preoperative and Postoperative Visual Acuity Readings* Group

n

Preoperative Acuity

Aphakia Iris-fixated Anterior chamber Posterior chamber Total

97 17 103 134 351

3.5 3.6 4.0 3.5 3.7

± ± ± ± ±

Postoperative Acuity 1.9 2.3 2.7 2.0 2.2

1.9t 2.0 1.8t§ 1.9§ 1.9

± ± ± ± ±

1.511 1.3 1.611 ~ 1.4~

1.5

Improvementt 1.6 1.3 1.4 1.6 1.5

± ± ± ± ±

1.7 2.3 1.8 1.8 1.8

• A logarithmic transformation of raw Snellen measures (mean ± standard deviation) obtained exclusively from cases of retinal reattachment.

t Preoperative acuity minus postoperative acuity. t p < 0.05. § P < 0.05.

liP < 0.001. 11 P < 0.001.

plication was not significantly different between the four groups. However, the postoperative occurrence of corneal edema in the AC IOL group was significantly higher than in the aphakic and PC groups. In 16 of 17 eyes with postoperative corneal edema in the AC group, there was eventually some degree of corneal opacification. Therefore, corneal decompensation is also probably responsible for the lower postoperative visual acuity in the AC IOL group. Cousins et al l3 also pointed out the frequency of corneal edema after the treatment of RD in cases of AC IOL. The AC IOL group had a significantly higher prevalence of preoperative uveitis (defined as inflammatory reaction in the anterior chamber) than the aphakic group? This finding suggested that the AC IOL group had a high occurrence of breakdown of the blood-aqueous barrier before the treatment of RD. Matsuda et al 14 reported that eyes with AC IOL showed significant morphological changes in the corneal endothelium. They speculated that

Table

Vitreous hemorrhage Large break (;2:1 clock hour) Break posterior to equator Total retinal detachment Macula off Proliferative vitreoretinopathy present Closed vitrectomy

7. Preoperative Findings that are Significant for Reattachment Aphakia (n = 103)

Iris-fixated (n = 17)

Anterior Chamber (n = 111)

Posterior Chamber (n = 145)

Total (n = 376)

15/18* (83.3%) 2/5 (40.0%) 7/10 (70.0%) 8/12 (66.7%) 55/61 (90.2%) 11/16 (68.8%) 0/2 (0%)

2/2 (100%)

19/23 (82.6%)

24/30 (80.0%)

60/73 (82.2%)t

0/0

0/1 (0%)

3/4 (75.0%)

5/10 (50.0%)t

0/0

9/10 (90.0%)

8/12 (66.7%)

24/32 (75.0%)t

0/0

16/18 (88.9%)

18/22 (81.8%)

42/52 (80.8%)t

10/10 (100%)

71/78 (91.0%)

72/82 (87.8%)

208/231 (90.0%)t

1/1 (100%) 0/0

17/24 (70.8%) 3/4 (75.0%)

22/29 (75.9%) 2/4 (50.0%)

51/70 (72.9%)t 5/10 (50.0%)t

• Fraction indicates reattachments divided by total cases.

t

P < 0.01 when compared with cases without that characteristic.

464

these changes may be associated with the disruption of the blood-aqueous barrier after AC IOL implantation. IS Therefore, the persistent corneal dysfunction in the presence of an AC IOL may trigger the postoperative corneal edema observed in our cases and may at least partly explain the poor visual prognosis in our AC IOL group. Vitreous gel in the anterior chamber, in front of the IOL, had been believed to be an unfavorable factor. In our study, this was not found to be significant, perhaps because more attention was paid to the repair of the retinal detachment when this factor was present. Incomplete ora serrata view l2 ,13 and inability to find breaks l6 were also believed to be significant factors in predicting ultimate failure, but they were not in the present study. In the PC group, the cause of incomplete ora serrata view was cloudiness of the lens capsule in 78% of the cases, and this was a frequent reason for not finding retinal breaks. 2 When no retinal breaks were found, the scleral

Yoshida et al . Retinal Detachment after Cataract Surgery buckle was extended over the circumference of the retinal detachment. Therefore, if the frequency of complete ora serrata view can be increased, breaks may be detected before an RO develops and the prevalence ofRO itself may be decreased. If an RO is already present and the breaks causing it are visible, it often becomes possible to treat it with a scleral buckle of lesser extent. This may decrease complications that may arise when a scleral buckle is carried over a considerable extent. Our study clearly demonstrates that both anatomic and visual results in pseudophakia with PC IOL are comparable with those noted in aphakia. Thus, the presence of a PC IOL does not seem to create a disadvantage with regard to the anatomic or visual result after treatment ofRO. Acknowledgments. The authors thank H. Mackenzie Freeman, MD, Felipe I. Tolentino, MD, Ronald C. Pruett, MD, Clement L. Trempe, MD, John J. Weiter, MD, and Sheldon M. Buzney, MD, for allowing us to use their patients' data.

References 1. Stark WJ, Sommer A, Smith RE. Changing trends in intra-

ocular lens implantation [editorial]. Arch Ophthalmol1989; 107:1441-4. 2. Yoshida A, Ogasawara H, Jalkh, AE, et a1. Retinal detachment following cataract surgery. I. Predisposing factors. Ophthalmology 1991; 98:. 3. Schepens CL. Scleral buckling procedures. Trans Am Acad OphthalmolOtolaryngol 1958; 62:206-18.

4. Schepens CL. Scleral buckling with circling element. Trans Am Acad Ophthalmol Otolaryngol 1964; 68:959-79. 5. Schepens CL. Retinal Detachment: and Allied Diseases. Vol. 1. Philadelphia: WB Saunders, 1983; 405-35. 6. Snyder WB, Bernstein I, Fuller D, et a1. Retinal detachment and pseudophakia. Ophthalmology 1979; 86:229-38. 7. Jungschaffer OH. Retinal detachments after intraocular lens implants. Arch Ophthalmol 1977; 95: 1203-4. 8. Hagler WS. Pseudophakic retinal detachment. Trans Am Ophthalmol Soc 1982; 80:45-63. 9. Ramsay RC, Cantrill HL, Knobloch WHo Pseudophakic retinal detachment. Can J Ophthalmol 1983; 18:262-5. 10. Wilkinson CPo Pseudophakic retinal detachments. Retina 1985; 5:1-4. 11. Johnston GP, Okun E, Boniuk I, et a1. Pseudophakic retinal detachment. Mod Probl Ophthalmol 1977; 18:499-502. 12. Ho PC, Tolentino FI. Pseudophakic retinal detachment: surgical success rate with various types of IOLs. Ophthalmology 1984; 91:847-52. 13. Cousins S, Boniuk I, Okun E, et a1. Pseudophakic retinal detachments in the presence of various IOL types. Ophthalmology 1986; 93: 1198-208. 14. Matsuda M, Miyake K, lnaba M. Long-term corneal endothelial changes after intraocular lens implantation. Am J Ophthalmol 1988; 105:248-52. 15. Miyake K, Asakura M, Kobayashi H. Effect of intraocular lens fixation on the blood-aqueous barrier. Am J Ophthalmol 1984; 98:451-5. 16. Ashrafzadeh MT, Schepens CL, Elizeneiny II, et aI. Aphakic and phakic retinal detachment. I. Preoperative findings. Arch Ophthalmol 1973; 89:476-83.

465

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 aphak...
610KB Sizes 0 Downloads 0 Views