R E T I N A L DETACHMENT A F T E R STRABISMUS SURGERY GIRAIR BASMADJIAN, M.D.,
PIERRE LABELLE, M.D.,
AND JEAN DUMAS,
M.D.
Montreal, Quebec
According to McLean, Galin, and Baras, 1 perforation of the globe during muscle sur gery occurs rather frequently but rarely re sults in symptomatic complications. Havener and Kimball,2 however, reported four cases of severe complications. Recently, Gottlieb and Castro3 examined the fundus of 65 chilFrom the Retina Service, Department of Oph thalmology, Maisonneuve-Rosemont Hospital, Mon treal, Quebec. Reprint requests to Jean Dumas, M.D., Maison neuve-Rosemont Hospital, 541S boul. l'Assomption, Montreal, Quebec, Canada.
dren who had undergone corrective surgery for strabismus. In six children they dis covered choroidal or chorioretinal scars in dicating perforation of the globe. In four of these patients the scar did not show any glial proliferation. McLean, Galin, and Baras 1 believed that such scars may be due to perforation of the choroid without per foration of the retina. Gottlieb also reported two cases of retinal detachment after stra bismus surgery. This paper describes three patients in
Fig. 1 (Basmadjian, Labelle, and Dumas). Fundus drawing of the left eye of Case 1 demonstrating the retinal detachment and the chorioretinal scar at 3-o'clock position. Note the preretinal membrane in the macular region. 30S
306
AMERICAN JOURNAL OF OPHTHALMOLOGY
FEBRUARY, 1975
XII XI
Fig. 2 (Basmadjian, Labelle, and Dumas). Fundus drawing of the right eye of Case 2 showing a localized detachment, a scar, and fibrous bands emanating from the scar.
whom surgical correction of strabismus was followed by a retinal detachment after a rela tively long interval. CASE REPORTS Case 1—A 26-year-old man was referred to our Retina Clinic in 1967 because of gradual diminution of his vision in the left eye. Five years previously, the left eye was operated for a con vergent strabismus. After the procedure, the pa tient experienced 'diplopia, which became less and less distressing äs a result of his gradual loss of vision. Examination disclosed a visual acuity corrected to 20/20 with a small hypermétropie cylinder in the right eye and 20/200 in the left. A residual esotropia of 25 diopters was still present in the left. Ophtha'moscopic examination revealed a subclinical detachment at the 3-o'clock meridian, an
terior to the equator (Fig. 1) A chorioretinal scar was visible slightly superior to the long ciliary nerve surrounded by dense fibrous tissue, which radiated into the vitreous exerting an obvious traction on the neighboring retina. A preretinal membrane was visible at the posterior pole with consequent macular pucker. No retinal break could be found. Residue of an old vitreous hemorrhage was seen interiorly. Case 2—A 48-year-old man was referred to the Retina Clinic in 1971 for a massive vitreous hemor rhage in his left eye. This patient had been op erated on in 1964 for an exotropia. The surgical report indicated a bilateral resection of the medial rectus muscles. A second intervention was per formed in 1965, which included a 10-mm recession of his external rectus muscles. According to the patient, his vision was good before the operations. Afterwards, however, he experienced floaters inter mittently for four years until finally, five days prior to our examination, he had complete loss of vision in his left eye.
VOL. 79, NO. 2
307
RETINAL DETACHMENT
Corrected visual acuity was 20/2S in the right eye and hand movements in the left. The fundus examination of the right eye (Fig. 2) showed a small chorioretinal scar at 3 o'clock overlying the ora serrata surrounded by fibrous tissue. A retinal detachment extended from this region posteriorly. No retinal break was visible. Because of a massive vitreous hemorrhage in the left eye there was no retinal examination. Three months later, vision was 20/100. Examination of the fundus showed a fairly large equatorial scar at the 3-o'clock position (Fig. 3). Pearly-white fibrous tissue surrounding the scar extended inferiori}' and posteriorly. A localized peripheral detachment lim ited by a demarcation line was found in the superotemporal quadrant without any visible retinal break. In the inferior part of the fundus, fresh hemor rhage was still visible. Case 3—A 33-year-old man was referred to the Retina Clinic in May 1973 for a retinal detachment in the left eye.
At the age of 25, the patient underwent a 9-mm recession of his lateral rectus muscle for a left exotropia. The patient had no postoperative symp tom to suggest perforation of the globe, and the vision remained unchanged until a few months prior to our examination. The positive findings were 20/400 visual acuity and a 20-diopter residual exotropia in his left eye. On fundus examination, a subtotal retinal de tachment was seen (Fig. 4). Just inferior to the long temporal ciliary nerve, there was a large band of dense fibrous tissue originating from a scarred area near the ora serrata and extending toward the posterior pole. Two retinal breaks were visible adjacent to this vitreous band. During the buckling procedure, a small scierai defect was discovered under the inferior edge of the lateral rectus muscle at its new insertion site, 16 mm from the corneoscleral limbus. With scierai depression, this defect corresponded exactly to the more posterior retinal break.
Demarcation I ine
Fresh b l o o d
Fig. 3 (Basmadjian, Labelle, and Dumas). Drawing of the left fundus of Case 2 demonstrating dense fibrous tissue radiating into the vitreous, a limited retinal detachment, and inferiorly vitreous hemorrhage.
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AMERICAN JOURNAL OF OPHTHALMOLOGY
FEBRUARY, 1975
XII XI
Fig. 4 (Basmadjian, Labelle, and Dumas). Left eye of Case 3. Note the scar and the fibrous band at 3-o'clock meridian. The location of the chorioretinal and vit reous alterations corresponded with the reThe scierai thickness is greatest at the insertions of the muscles operated on. The posterior pole, where it measures approxi proliferation of dense fibrous tissue from mately 1 mm. It gradually decreases toward the chorioretinal scars was similar to that the equator, the thinnest portion lying be seen in cases of perforation of the globe by neath the tendons of the rectus muscles. The either foreign bodies or sharp instruments. 5 choroid in this region is about 0.1 mm in These factors, together with the absence of thickness.4 Consequently, penetration of the any predisposing lesions in nonmyopic eyes, globe by the needle may not be rare during were considered as evidence that the etiologic muscle surgery. factor was perforation of the globe. Addi In none of our cases was there mention tional evidence is presented in the last case of globe perforation. However, it is our where the scierai scar was seen directly impression that the pathogenesis of the and its relation to the retinal break confirmed retinal detachments in the three cases re by scierai depression and indirect ophthalported is related to the retinal perforation moscopy at the time of retinal surgery. during muscle surgery. DISCUSSION
VOL. 79, NO. 2
RETINAL DETACHMENT
Thorough examination of the three de tachments in the first two patients failed to reveal definite retinal breaks. This ob servation is similar to that of retinal detach ments after perforation of the eye by foreign bodies. Accidental perforation of the sclera dur ing muscle surgery may be prevented by keeping the point of the needle in view as it penetrates the superficial layers of the sclera.6 We believe that the routine use of spatula needles in strabismus surgery reduces further the chances of perforation, as sug gested by Gottlieb and Castro.3 In the event perforation of the globe is suspected or actually occurs, pupillary dilata tion for immediate indirect ophthalmoscopy should be done; diathermy or cryoapplication at the site of perforation is strongly suggested. Periodic examination of the fundus periphery is also advisable. SUMMARY
Four nonmyopic eyes in three patients de veloped retinal detachment after strabismus surgery. Certain features common in all four eyes included the presence of a chorioretinal scar corresponding in location to the muscle operated on, proliferating fibrous tissue ad
309
jacent to the scar, and varying degrees of vitreous hemorrhage. These findings were similar to those in retinal detachments after perforation of the eye by foreign bodies. Penetration of the globe by the needle during muscle surgery was considered the etiologic factor. The use of spatula needles to prevent piercing of the globe is suggested, and in case such accident is suspected, dia thermy or cryoapplication over the perfora tion site is advised. REFERENCES
1. McLean, J. M., Galin, M. A., and Baras, I.: Retinal perforation during strabismus surgery. Am. J. Ophthalmol. 50:1167, 1960. 2. Havener, W. H., and Kimball, O. P. : Scierai perforation during strabismus surgery. Am. J. Ophthalmol. 50:807, 1960. 3. Gottlieb, F., and Castro, J. L. : Perforation of the globe during strabismus surgery. Arch. Oph thalmol. 84:151, 1970. 4. Hogan, M. J., and Zimmerman, L. E. : Oph thalmic Pathology. An Atlas and Textbook, 2nd ed. Philadelphia, W. B. Saunders, 1962, p. 336. 5. Labelle, P., Brunet, M., Basmadjian, G., and Dumas, J. : Retinal detachment following intra ocular foreign body. Can. J. Ophthalmol. 9:9, 1974. 6. Berke, R. N. : Principles, technique and com plications of horizontal nonparalytic nonaccommodative strabismus surgery. In Haik, G. M. (ed.) : Strabismus. Symposium of the New Orleans Acad emy of Ophthalmology. St. Louis, C. V. Mosby, 1962, p. 187.
PIERRE LABELLE, M.D.,
AND JEAN DUMAS,
M.D.
Montreal, Quebec
According to McLean, Galin, and Baras, 1 perforation of the globe during muscle sur gery occurs rather frequently but rarely re sults in symptomatic complications. Havener and Kimball,2 however, reported four cases of severe complications. Recently, Gottlieb and Castro3 examined the fundus of 65 chilFrom the Retina Service, Department of Oph thalmology, Maisonneuve-Rosemont Hospital, Mon treal, Quebec. Reprint requests to Jean Dumas, M.D., Maison neuve-Rosemont Hospital, 541S boul. l'Assomption, Montreal, Quebec, Canada.
dren who had undergone corrective surgery for strabismus. In six children they dis covered choroidal or chorioretinal scars in dicating perforation of the globe. In four of these patients the scar did not show any glial proliferation. McLean, Galin, and Baras 1 believed that such scars may be due to perforation of the choroid without per foration of the retina. Gottlieb also reported two cases of retinal detachment after stra bismus surgery. This paper describes three patients in
Fig. 1 (Basmadjian, Labelle, and Dumas). Fundus drawing of the left eye of Case 1 demonstrating the retinal detachment and the chorioretinal scar at 3-o'clock position. Note the preretinal membrane in the macular region. 30S
306
AMERICAN JOURNAL OF OPHTHALMOLOGY
FEBRUARY, 1975
XII XI
Fig. 2 (Basmadjian, Labelle, and Dumas). Fundus drawing of the right eye of Case 2 showing a localized detachment, a scar, and fibrous bands emanating from the scar.
whom surgical correction of strabismus was followed by a retinal detachment after a rela tively long interval. CASE REPORTS Case 1—A 26-year-old man was referred to our Retina Clinic in 1967 because of gradual diminution of his vision in the left eye. Five years previously, the left eye was operated for a con vergent strabismus. After the procedure, the pa tient experienced 'diplopia, which became less and less distressing äs a result of his gradual loss of vision. Examination disclosed a visual acuity corrected to 20/20 with a small hypermétropie cylinder in the right eye and 20/200 in the left. A residual esotropia of 25 diopters was still present in the left. Ophtha'moscopic examination revealed a subclinical detachment at the 3-o'clock meridian, an
terior to the equator (Fig. 1) A chorioretinal scar was visible slightly superior to the long ciliary nerve surrounded by dense fibrous tissue, which radiated into the vitreous exerting an obvious traction on the neighboring retina. A preretinal membrane was visible at the posterior pole with consequent macular pucker. No retinal break could be found. Residue of an old vitreous hemorrhage was seen interiorly. Case 2—A 48-year-old man was referred to the Retina Clinic in 1971 for a massive vitreous hemor rhage in his left eye. This patient had been op erated on in 1964 for an exotropia. The surgical report indicated a bilateral resection of the medial rectus muscles. A second intervention was per formed in 1965, which included a 10-mm recession of his external rectus muscles. According to the patient, his vision was good before the operations. Afterwards, however, he experienced floaters inter mittently for four years until finally, five days prior to our examination, he had complete loss of vision in his left eye.
VOL. 79, NO. 2
307
RETINAL DETACHMENT
Corrected visual acuity was 20/2S in the right eye and hand movements in the left. The fundus examination of the right eye (Fig. 2) showed a small chorioretinal scar at 3 o'clock overlying the ora serrata surrounded by fibrous tissue. A retinal detachment extended from this region posteriorly. No retinal break was visible. Because of a massive vitreous hemorrhage in the left eye there was no retinal examination. Three months later, vision was 20/100. Examination of the fundus showed a fairly large equatorial scar at the 3-o'clock position (Fig. 3). Pearly-white fibrous tissue surrounding the scar extended inferiori}' and posteriorly. A localized peripheral detachment lim ited by a demarcation line was found in the superotemporal quadrant without any visible retinal break. In the inferior part of the fundus, fresh hemor rhage was still visible. Case 3—A 33-year-old man was referred to the Retina Clinic in May 1973 for a retinal detachment in the left eye.
At the age of 25, the patient underwent a 9-mm recession of his lateral rectus muscle for a left exotropia. The patient had no postoperative symp tom to suggest perforation of the globe, and the vision remained unchanged until a few months prior to our examination. The positive findings were 20/400 visual acuity and a 20-diopter residual exotropia in his left eye. On fundus examination, a subtotal retinal de tachment was seen (Fig. 4). Just inferior to the long temporal ciliary nerve, there was a large band of dense fibrous tissue originating from a scarred area near the ora serrata and extending toward the posterior pole. Two retinal breaks were visible adjacent to this vitreous band. During the buckling procedure, a small scierai defect was discovered under the inferior edge of the lateral rectus muscle at its new insertion site, 16 mm from the corneoscleral limbus. With scierai depression, this defect corresponded exactly to the more posterior retinal break.
Demarcation I ine
Fresh b l o o d
Fig. 3 (Basmadjian, Labelle, and Dumas). Drawing of the left fundus of Case 2 demonstrating dense fibrous tissue radiating into the vitreous, a limited retinal detachment, and inferiorly vitreous hemorrhage.
308
AMERICAN JOURNAL OF OPHTHALMOLOGY
FEBRUARY, 1975
XII XI
Fig. 4 (Basmadjian, Labelle, and Dumas). Left eye of Case 3. Note the scar and the fibrous band at 3-o'clock meridian. The location of the chorioretinal and vit reous alterations corresponded with the reThe scierai thickness is greatest at the insertions of the muscles operated on. The posterior pole, where it measures approxi proliferation of dense fibrous tissue from mately 1 mm. It gradually decreases toward the chorioretinal scars was similar to that the equator, the thinnest portion lying be seen in cases of perforation of the globe by neath the tendons of the rectus muscles. The either foreign bodies or sharp instruments. 5 choroid in this region is about 0.1 mm in These factors, together with the absence of thickness.4 Consequently, penetration of the any predisposing lesions in nonmyopic eyes, globe by the needle may not be rare during were considered as evidence that the etiologic muscle surgery. factor was perforation of the globe. Addi In none of our cases was there mention tional evidence is presented in the last case of globe perforation. However, it is our where the scierai scar was seen directly impression that the pathogenesis of the and its relation to the retinal break confirmed retinal detachments in the three cases re by scierai depression and indirect ophthalported is related to the retinal perforation moscopy at the time of retinal surgery. during muscle surgery. DISCUSSION
VOL. 79, NO. 2
RETINAL DETACHMENT
Thorough examination of the three de tachments in the first two patients failed to reveal definite retinal breaks. This ob servation is similar to that of retinal detach ments after perforation of the eye by foreign bodies. Accidental perforation of the sclera dur ing muscle surgery may be prevented by keeping the point of the needle in view as it penetrates the superficial layers of the sclera.6 We believe that the routine use of spatula needles in strabismus surgery reduces further the chances of perforation, as sug gested by Gottlieb and Castro.3 In the event perforation of the globe is suspected or actually occurs, pupillary dilata tion for immediate indirect ophthalmoscopy should be done; diathermy or cryoapplication at the site of perforation is strongly suggested. Periodic examination of the fundus periphery is also advisable. SUMMARY
Four nonmyopic eyes in three patients de veloped retinal detachment after strabismus surgery. Certain features common in all four eyes included the presence of a chorioretinal scar corresponding in location to the muscle operated on, proliferating fibrous tissue ad
309
jacent to the scar, and varying degrees of vitreous hemorrhage. These findings were similar to those in retinal detachments after perforation of the eye by foreign bodies. Penetration of the globe by the needle during muscle surgery was considered the etiologic factor. The use of spatula needles to prevent piercing of the globe is suggested, and in case such accident is suspected, dia thermy or cryoapplication over the perfora tion site is advised. REFERENCES
1. McLean, J. M., Galin, M. A., and Baras, I.: Retinal perforation during strabismus surgery. Am. J. Ophthalmol. 50:1167, 1960. 2. Havener, W. H., and Kimball, O. P. : Scierai perforation during strabismus surgery. Am. J. Ophthalmol. 50:807, 1960. 3. Gottlieb, F., and Castro, J. L. : Perforation of the globe during strabismus surgery. Arch. Oph thalmol. 84:151, 1970. 4. Hogan, M. J., and Zimmerman, L. E. : Oph thalmic Pathology. An Atlas and Textbook, 2nd ed. Philadelphia, W. B. Saunders, 1962, p. 336. 5. Labelle, P., Brunet, M., Basmadjian, G., and Dumas, J. : Retinal detachment following intra ocular foreign body. Can. J. Ophthalmol. 9:9, 1974. 6. Berke, R. N. : Principles, technique and com plications of horizontal nonparalytic nonaccommodative strabismus surgery. In Haik, G. M. (ed.) : Strabismus. Symposium of the New Orleans Acad emy of Ophthalmology. St. Louis, C. V. Mosby, 1962, p. 187.
