RETINAL DETACHMENT AFTER PHACOEMULSIFICA TION JAMES B. WISE, MD OKLAHOMA CITY, OKLAHOMA

RETINAL detachment (RD) is the most common serious complication occurring after cataract surgery, and the surgeon choosing a method of cataract surgery must consider what influence that method will have on this complication. I shall discuss the incidence and cure rate of RD after intracapsular cataract extraction (ICCE) and after Kelman phacoemulsification (KPE), with and without implant lenses. The large Academy study supervised by Dr Troutman1 showed no apparent difference in RD incidence between ICCE and KPE (Table 1). Through the courtesy of three very skillful colleagues, 2- 4 some recent figures on the incidence of RD are shown in Table 2. The evidence is that the more intact the posterior capsule, the lower the incidence of RD. An important consideration is the cure rate when RD does occur. In several previous series,3- 5 the cure rate of RD after KPE has been in the range reported for other aphakic RDs (Table 3), but I have not seen a paper comparing the cure rate of RD after ICCE and after KPE. This study concerns 146 consecutive aphakic RDs, including 27 with intraocular lenses. In the five-year period concerned, the only aphakic eyes excluded were those

with posterior penetrating lacerations or with diabetic traction detachments. All surgeries were performed by the author (Table 4). A RD operation was not considered successful until the retina had remained attached for three months. Most of the eyes classified as failures were actually reattached at one month but had developed massive preretinal proliferation by three months. The failure rate in RD after KPE was found to be only half of the failure rate in patients who had had ICCE. Because vitreous traction was so important in all the failures, signs of vitreous traction were tabulated (Table 5). It is seen that traction was worse after ICCE. The giant tear after ICCE was an inoperable 360° tear, while the two 90° tears after KPE were successfully repaired. All three tears had occurred during vitrectomies. On a percentage basis, there were one-third more total RDs, three times as many macular puckers, and twice as many surgical failures in the ICCE group. The inoperable eyes, which are not included in surgical statistics, were more numerous in the ICCE group and were all severely fibrotic. Analysis of the data by x2 for the total RDs and by TABLE 1

DETACHMENTS AFTER CATARACT 8URGERv*

Submitted for publication Oct 26, 1978.

5870 ICCE had 1.4% RD 2592 KPE had 0.97%-2% RD

From the Baptist Medical Center of Oklahoma_ Reprint requests to 5700 Northwest Grand Boulevard, Oklahoma City, OK 73112 (Dr Wise).

*Academy study, 1974

2007

2008

JAMES B. WISE TABLE 2 RETINAL DETACHMENT CAPSULE STATUS NO. CASES

SURGEON

301 2771 1500

JH Sheets 2 RP Kratz 3 JH Little4

Shafer5 Wilkinson 4 Kratz et aP

CASES

12 74 49

%RD

84% intact 80% capsulotomy 94% capsulectomy

1.77

1.3

3.6

or capsulotomy

SUCCESS % SUCCESS

12 67 48

AND

CAPSULE STATUS

TABLE 3 CuRE RATES IN KPE-RD SERIES

OPHTH AAO

92 91 98

Fisher's exact test for the other data gave the probability values shown. Although the values were not low enough to be considered statistically significant, it should be emphasized that all the data pointed the same way. All three of the RD failures after KPE had had vitreous loss, while six of the eight

failed RDs after ICCE had not had vitreous loss but did develop extreme vitreous traction (Table 6). Thus, by several measures, there appears to be more tendency toward early and late vitreous contraction after ICCE than after KPE. An intact peripheral posterior capsule may have definite value in protecting the vitreous base and in reducing vitreous traction. Another possible influence is the size of the incision. Perhaps the fibrosis in the incision releases some material that causes fibrosis of the vitreous. Retinal detachment is, however, only one factor in choosing a cataract operation. Complications related to capsule and cornea must also be considered. 6 •7

TABLE 4 APHAKIC RETINAL DETACHMENTS IN 146 SUCCESSIVE CASES

After ICCE

After KPE

TOTAL

SUCCESS

FAIL

% SUCCESS

83 63

75 60

8 3

90.4

95.2

TABLE 5 SEVERITY OF VITREOUS TRACTION KPE Giant tears Total detachment Macular pucker Failure of surgery Inoperable

2 32% 3.3% 4.8% 1

fCCE

1 42% 10.7% 9.6% 4

P value 0.2 0.1 0.2 0.3

RETINAL DETACHMENT

VOLUME 86 NOVEMBER 1979

Because intraocular lenses are now so commonly used in conjunction with both ICCE and KPE, this group of RDs was analyzed separately (Table 7). There were no failures in 17 cases of implant lenses after KPE. There were two failures, both from vitreous organization six weeks after apparently successful surgery, in ten cases with implant lenses after ICCE. The only Choycetype lens in the series was one of the failures. The RD repair rate in patients with intraocular lenses was about the same as in aphakic patients without implant lenses.

TABLE

After ICCE

After KPE

TOTAL

VL

NO VL

8 3

2 3

6 0

CONCLUSIONS 1. There is a slightly lower inci-

dence of RD after cataract extraction if the posterior capsule is intact or has a central capsulectomy, compared to total capsulectomy or intracapsular extraction.

2. Detachments after phacoemulsification seem to have a higher cure rate than detachments after intracapsular cataract extraction, but the difference is not statistically significant. 3. Vitreous traction appears to be worse after intracapsular extraction than after phacoemulsification. 4. Pupil-supported and capsulesupported intraocular lenses have little effect on the cure rate of RDs after either phacoemulsification or intracapsular extraction. 7

DETACHMENTS BEHIND IOLs IN

Mter ICCE Mter KPE All IOLs

6

VITREOUS Loss (VL) AT CATARACT IN EYES LATER LosT FROM DETACHMENT

Because some colleagues have been frustrated by the difficulties of small pupil detachments, especially with implant lenses,8 •9 I would like to make these suggestions. Do not attempt to find the holes in the office: they can be found by indenting the peripheral retina with the cryoprobe in a pitch black operating room while viewing the retina through a 20 D aspheric lens. Do not use the so-called small pupil lenses: these give too little light and too little magnification to find small holes. Freeze anything that could possibly be a 1i01e. Use an encircling band if possible, and drain the retina flat upon it. Iron out any folds with air bubbles or radial exoplants. If the retina is not absolutely flat by six days, reoperate. TABLE

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27

SuccESSIVE CASES

TOTAL

SUCCESS

FAIL

% SUCCESS

10 17 27

8 17

2 0 2

100 92.6

25

80

2010

JAMES B. WISE

ACKNOWLEDGMENT Statistical analysis was performed by Willis Owne, PhD, Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center.

REFERENCES 1. Troutman RC, Clahane Ac, Emery JM, et al: Cataract survey of the cataractphacoemulsification committee. Trans Am Acad Ophthalmol Otolaryngol 79:0P-1780P-185, 1975. 2. Sheets JH: Personal communication, June 1978. 3. Kratz RP: Personal communication, June 1978.

OPHTH AAO

4. Wilkinson CP, Anderson LS, Little JH: Retinal detachment following phacoemulsification. Ophthalmology 85:151-156, 1978. 5. Shafer DM: Retinal detachment after phacoemulsification. Trans Am Acad Ophthalmol Otolaryngol 78:0P-28-0P-30, 1974. 6. Sugar S, Michelson J, Kraft' M: The effect of phacoemulsification on corneal endothelial cell density. Arch Ophthalmol 96: 446-448, 1978. 7. Irvine AR, Kratz RP, O'Donnell JJ: Endothelial damage with phacoemulsification and intraocular lens implantation. Arch Ophthalmol 96:1023-1026, 1978. 8. Jungschaffer 0: IOL's make retinal exam for detachments difficult. Ophthalmol Times 3:33, 1978. 9. McPherson AR: IOL's pose new retinal detachment problems. Ophthalmol Times 3: 8, 24-25, 1978.

Retinal detachment after phacoemulsification.

RETINAL DETACHMENT AFTER PHACOEMULSIFICA TION JAMES B. WISE, MD OKLAHOMA CITY, OKLAHOMA RETINAL detachment (RD) is the most common serious complicati...
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