Scleral Buckling for Rhegmatogenous Retinal Detachment Associated With Severe Myopia
Francisco J. Rodriguez, M.D., H i l e l Lewis, M.D., A l l a n E, Kreiger, M . D . , Marc O. Yoshizumi, M.D., and Yossi Sidikaro, M . D .
F r o m J a n . 1 , 1980, t o D e c . 3 1 , 1989, w e p e r f o r m e d s c l e r a l b u c k l i n g s u r g e r y o n 48 e y e s o f 46 p a t i e n t s f o r r h e g m a t o g e n o u s r e t i n a l d e tachments associated with severe myopia ( g r e a t e r t h a n 5.00 d i o p t e r s ) . F o r t y e y e s o f 38 patients w e r e o b s e r v e d for at least six m o n t h s , a n d t h e m e a n f o l l o w - u p p e r i o d w a s 46 months. Intraoperative complications oc c u r r e d i n f o u r of 48 e y e s (8%) a n d i n c l u d e d retinal incarceration (two eyes), choroidal hemorrhage (one eye), and choroidal detach m e n t ( o n e e y e ) . T h r e e of t h e 40 e y e s (7.5%) f o l l o w e d u p for m o r e t h a n s i x m o n t h s developed a recurrent retinal detachment and underwent a revision of the scleral buckle. At the last follow-up examination, the retinas of a l l 40 e y e s w e r e t o t a l l y r e a t t a c h e d . F i n a l v i s u al a c u i t y o f 20/40 o r b e t t e r w a s a t t a i n e d i n 26 of 40 e y e s (65%). B e c a u s e o f t h e l o w r a t e of intraoperative complications and the high rate of success, scleral b u c k l i n g is r e c o m m e n d e d for most p a t i e n t s w i t h r h e g m a t o g e nous retinal detachments associated with se vere myopia.
M Y O P I A a c c o u n t s for 1 2 % to 4 2 % o f r h e g m a t o g e n o u s r e t i n a l d e t a c h m e n t s , a n d t h e risk o f retinal d e t a c h m e n t i n c r e a s e s with an i n c r e a s e in r e f r a c t i v e e r r o r . ' ^ B u r t o n ' a n d W i n s l o w a n d Tasman^ f o u n d t h a t t h e r e t i n a w a s s u c c e s s f u l l y r e a t t a c h e d in 81 % to 8 6 % o f e y e s with m y o p i a . T h e u s e o f t h i s t e c h n i q u e in t h e r e p a i r o f r e t i n a l d e t a c h m e n t s in s e v e r e l y m y o p i c e y e s , h o w e v e r , h a s b e e n
Accepted for publication Jan. 25, 1991. From the Department of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, California. This study was supported in part by the Charles Kenneth Feldman Fund (Dr. Lewis) and by Research to Prevent Blindness, Inc. (Drs. Rodriguez and Lewis). Reprint requests to Hilel Lewis, M.D., Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90024-7007.
r e p o r t e d t o b e a s s o c i a t e d w i t h a n i n c r e a s e d risk of intraoperative complications.* T h e s e c o m p l i c a t i o n s , w h i c h m a y l e a d to s e v e r e v i s u a l l o s s or blindness, include choroidal or subretinal hem orrhage, choroidal detachment, retinal incarce ration, retinal break, postoperative anterior segment ischemia, anisometropia, strabismus, macular distortion, cystoid macular edema, and e x t r u s i o n or i n f e c t i o n o f e x t r a s c l e r a l i m p l a n t material.* T h e r e f o r e , p n e u m a t i c r e t i n o p e x y or p r i m a r y v i t r e c t o m y h a v e b e e n s u g g e s t e d as a l t e r n a t i v e s to s c l e r a l b u c k l i n g in t h e m a n a g e ment of rhegmatogenous retinal detachment associated with severe myopia."'" We d e t e r m i n e d t h e r e s u l t s a n d c o m p l i c a t i o n s o f s c l e r a l b u c k l i n g s u r g e r y in a c o n s e c u t i v e series of patients with rhegmatogenous retinal detachments associated with severe myopia. W e a r b i t r a r i l y d e f i n e d s e v e r e m y o p i a as a r e f r a c t i v e e r r o r o f —5.00 d i o p t e r s or g r e a t e r .
Patients and Methods W e p e r f o r m e d s c l e r a l b u c k l i n g o p e r a t i o n s for all p a t i e n t s w i t h r h e g m a t o g e n o u s r e t i n a l d e tachments associated with severe myopia exam i n e d at o u r i n s t i t u t i o n b e t w e e n J a n . 1 , 1 9 8 0 , and D e c . 3 1 , 1989. A total o f 48 eyes o f 46 c o n s e c u t i v e p a t i e n t s w e r e o p e r a t e d o n , a n d all t h e p r o c e d u r e s w e r e p e r f o r m e d at o u r i n s t i t u t i o n b y four o f u s ( H . L . , A . E . K . , M . O . Y . , or Y.S.). Thus, none of the patients with rhegma togenous retinal detachments associated with severe myopia examined during the same peri od o f t i m e w e r e o p e r a t e d o n w i t h a different t e c h n i q u e , s u c h as p n e u m a t i c r e t i n o p e x y or vitrectomy. E x c e p t for e i g h t p a t i e n t s , a l l w e r e f o l l o w e d up for a m i n i m u m o f s i x m o n t h s . O f t h e s e e i g h t patients, two died, and we could not determine t h e i r r e t i n a l s t a t u s at t h e t i m e o f d e a t h . T h e o t h e r six p a t i e n t s h a d m o v e d away a n d c o u l d n o t b e l o c a t e d . O u r a t t e m p t s to o b t a i n o c u l a r
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i n f o r m a t i o n on t h e s e six p a t i e n t s w e r e n o t s u c cessful. T h u s , to a n a l y z e t h e l o n g - t e r m r e s u l t s we i n c l u d e d o n l y t h e 4 0 e y e s o f 3 8 p a t i e n t s t h a t w e r e o b s e r v e d for at l e a s t six m o n t h s ( m e a n , 4 6 months). T h e m e d i c a l a n d o p e r a t i v e r e c o r d s o f all p a tients were reviewed. Drawings and color pho tographs were also reviewed when available. T h e f o l l o w i n g h i s t o r i c a l data w e r e c o l l e c t e d : age; g e n d e r ; r a c e ; p r e v i o u s o c u l a r d i s e a s e ; p r e vious trauma; previous ocular surgery; onset of retinal detachment; and time between the onset of r e t i n a l d e t a c h m e n t a n d s u r g i c a l r e p a i r . O p h t h a l m i c data o b t a i n e d i n c l u d e d t h e f o l l o w i n g : preoperative and postoperative best-corrected v i s u a l a c u i t y ; r e f r a c t i v e e r r o r ; status o f t h e l e n s ; intraocular pressure; presence and extent of retinal detachment; number, type, and location of r e t i n a l b r e a k s ; p r e s e n c e o f p r o l i f e r a t i v e vit reoretinopathy; and presence of peripheral reti n a l a b n o r m a l i t i e s , s u c h as l a t t i c e d e g e n e r a t i o n or c y s t i c r e t i n a l tufts. I n t r a o p e r a t i v e i n f o r m a tion obtained included the following: p r e s e n c e a n d e x t e n t o f s c l e r a l t h i n n i n g , e c t a s i a , or b o t h ; type and extent of the buckling e l e m e n t used; method of chorioretinal adhesion used; need for a n d l o c a t i o n o f d r a i n a g e o f s u b r e t i n a l fluid; u s e o f i n t r a o c u l a r air or g a s ; a n d d e v e l o p m e n t of i n t r a o p e r a t i v e c o m p l i c a t i o n s , s u c h a s i n a d vertent scleral perforation, retinal incarcera t i o n , c h o r o i d a l h e m o r r h a g e , or v i t r e o u s h e m o r rhage. The complete medical and operative r e c o r d s w e r e a v a i l a b l e for all 4 8 e y e s o f 4 6 patients.
Results The study group included 25 males and 21 f e m a l e s . T h e a g e s r a n g e d from 15 to 7 4 y e a r s (mean, 42 years). Thirty-nine patients ( 8 5 % ) w e r e w h i t e , five ( 1 1 % ) w e r e H i s p a n i c , a n d t w o ( 4 % ) were black. T h e refractive error was b e t w e e n - 5 . 0 0 a n d - 8 . 0 0 d i o p t e r s in 2 6 e y e s ( 5 4 % ) , b e t w e e n - 8 . 2 5 a n d - 1 1 . 2 5 d i o p t e r s in 17 e y e s ( 3 5 % ) , b e t w e e n - 1 1 . 5 0 a n d - 1 4 . 7 5 d i o p t e r s in two e y e s ( 4 % ) , a n d g r e a t e r t h a n - 1 5 . 0 0 d i o p t e r s in t h r e e e y e s ( 6 % ) . F o r r e t i n a l b r e a k s w i t h o u t a r e t i n a l d e t a c h m e n t , five e y e s ( 1 0 % ) had previous treatment with laser photo coagulation, one eye ( 2 % ) with cryoretinopexy, and one eye ( 2 % ) with both laser p h o t o c o a g u l a tion and cryoretinopexy. O n e patient had pre v i o u s b l u n t o c u l a r t r a u m a t h a t w a s t h o u g h t to be n o t r e l a t e d to t h e r e t i n a l d e t a c h m e n t .
May, 1991
All the e y e s w e r e p h a k i c , t w o h a d a d i a g n o s i s of chronic recurrent uveitis, and none had m a c u l a r h o l e s . T h e m a c u l a w a s d e t a c h e d in 15 e y e s ( 3 1 % ) . R e t i n a l t e a r s w e r e p r e s e n t in 4 0 e y e s ( 8 3 % ) , r e t i n a l h o l e s in s e v e n e y e s ( 1 5 % ) , a n d n o r e t i n a l b r e a k s c o u l d b e f o u n d in o n e eye ( 2 % ) . L a t t i c e d e g e n e r a t i o n w a s p r e s e n t in 2 4 eyes ( 5 0 % ) , and the association b e t w e e n retinal tears and lattice degeneration of the retina was o b s e r v e d in 17 e y e s ( 3 5 % ) . M i l d p r o l i f e r a t i v e v i t r e o r e t i n o p a t h y w a s p r e s e n t in t w o e y e s ( 4 % ) . T h e i n i t i a l a n d final v i s u a l a c u i t y o f t h e 4 0 e y e s f o l l o w e d up for m o r e t h a n six m o n t h s are s h o w n in t h e F i g u r e . The mean time between diagnosis and scleral b u c k l i n g w a s 41/2 days. T w e n t y - f o u r e y e s ( 5 0 % ) w e r e o p e r a t e d o n in t h e first 2 4 h o u r s after t h e diagnosis was made. Forty eyes were observed from six to 1 0 5 m o n t h s ( m e a n , 4 6 m o n t h s ) , a n d t h e r e m a i n i n g e i g h t e y e s w e r e o b s e r v e d for five m o n t h s ( t w o e y e s ) , four m o n t h s ( o n e e y e ) , t h r e e m o n t h s ( o n e e y e ) , two m o n t h s ( t h r e e e y e s ) , a n d one month (one eye). The technical variations of the scleral buck ling p r o c e d u r e s are l i s t e d in t h e T a b l e . E x t r a s c l e r a l i m p l a n t s w e r e p e r f o r m e d in 3 0 e y e s ( 6 2 . 5 % ) a n d i n t r a s c l e r a l i m p l a n t s in 1 8 e y e s ( 3 7 . 5 % ) ; c r y o t h e r a p y w a s u s e d in 4 3 e y e s ( 9 0 % ) a n d d i a t h e r m y in t h r e e e y e s ( 6 % ) ; a n d e x t e r n a l d r a i n a g e o f s u b r e t i n a l fluid w a s p e r f o r m e d in 3 7 e y e s ( 7 7 % ) . I n t r a o c u l a r air w a s u s e d in four e y e s ( 8 % ) to i n c r e a s e t h e i n t r a o c u l a r p r e s s u r e a n d in two e y e s ( 4 % ) to t a m p o n a d e l a r g e r e t i n a l t e a r s . B a l a n c e d salt s o l u t i o n w a s i n j e c t e d i n t r a v i t r e a l l y in t h r e e e y e s ( 6 % ) to i n c r e a s e t h e i n t r a o c u l a r p r e s s u r e . In s e v e n e y e s ( 1 4 % ) s c l e r al t h i n n i n g w a s n o t e d . I n t r a o p e r a t i v e c o m p l i c a t i o n s o c c u r r e d in four ( 8 % ) of the 4 8 eyes and included retinal incar c e r a t i o n i n t o t h e d r a i n a g e s i t e in two e y e s ( 4 % ) , p a r t i a l c h o r o i d a l h e m o r r h a g e r e l a t e d to t h e d r a i n a g e p r o c e d u r e in o n e e y e ( 2 % ) , a n d s i g n i f i c a n t c h o r o i d a l d e t a c h m e n t in o n e e y e ( 2 % ) . N o t r e a t m e n t w a s p e r f o r m e d for t h e r e t i n a l i n c a r cerations b e c a u s e they were supported by the scleral buckle. T h e choroidal hemorrhage and the significant choroidal d e t a c h m e n t resolved s p o n t a n e o u s l y in t h e p o s t o p e r a t i v e p e r i o d . P o s t o p e r a t i v e c o m p l i c a t i o n s d e v e l o p e d in nine of the 4 0 eyes ( 2 2 . 5 % ) that were observed for at l e a s t six m o n t h s a n d i n c l u d e d r e c u r r e n t r e t i n a l d e t a c h m e n t in t h r e e e y e s ( 7 . 5 % ) , c y s t o i d m a c u l a r e d e m a in t w o e y e s ( 5 % ) , s i g n i f i c a n t c h o r o i d a l d e t a c h m e n t s (different from t h e o n e n o t e d i n t r a o p e r a t i v e l y ) in two e y e s ( 5 % ) , m a c u lar p u c k e r in o n e e y e ( 2 . 5 % ) , a n d e x o t r o p i a in
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Figure (Rodriguez and as sociates). Preoperative and postoperative visual acuity. HM indicates hand motions and CF indicates counting fingers. The letter next to the point indicates how many ob servations for the point: A = 1, Β = 2, C = 3, and F = 6.
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PRE-OPERATIVE VISUAL ACUITY o n e e y e ( 2 . 5 % ) . T h e c a u s e for a n a t o m i c f a i l u r e in t h e e y e s t h a t r e d e t a c h e d w a s t h e d e v e l o p ment of new retinal breaks. T h e two eyes that r e q u i r e d i n j e c t i o n o f air i n t o t h e v i t r e o u s c a v i t y to t a m p o n a d e l a r g e r e t i n a l b r e a k s d e v e l o p e d n e w r e t i n a l b r e a k s , o n e l o c a t e d a d j a c e n t to t h e previous break and the other located 60 degrees from t h e p r e v i o u s r e t i n a l t e a r . A l l t h r e e e y e s underwent revision of the scleral buckle, which w a s s u c c e s s f u l in t w o e y e s . T h e t h i r d e y e r e quired another revision o f the scleral buckle. O f the e i g h t e y e s f o l l o w e d up for l e s s t h a n s i x months, one eye developed cystoid macular edema. At t h e last f o l l o w - u p e x a m i n a t i o n t h e r e t i n a s in all 4 0 e y e s o b s e r v e d for at l e a s t six m o n t h s w e r e t o t a l l y r e a t t a c h e d , a n d final v i s u a l a c u i t y of 2 0 / 4 0 or b e t t e r w a s a t t a i n e d in 2 6 e y e s ( 6 5 % ) . Twenty-five e y e s ( 6 2 . 5 % ) h a d b e t t e r , t e n e y e s ( 2 5 % ) h a d t h e s a m e , a n d five e y e s ( 1 2 . 5 % ) had worse postoperative visual acuity. T h e r e w a s n o c o r r e l a t i o n b e t w e e n t h e s i z e or e x t e n t o f t h e e n c i r c l i n g e l e m e n t a n d final v i s u a l a c u i t y . All five e y e s w i t h w o r s e p o s t o p e r a t i v e v i s u a l
a c u i t y h a d final v i s u a l a c u i t y o f 2 0 / 6 0 or b e t t e r ( F i g u r e ) . O f t h e e i g h t e y e s f o l l o w e d u p for l e s s t h a n six m o n t h s , v i s u a l a c u i t y i m p r o v e d in f o u r e y e s , w a s t h e s a m e in o n e , a n d d e c r e a s e d in three.
Discussion Using data from the N a t i o n a l H e a l t h and Nutrition Examination Survey, Sperduto and a s s o c i a t e s " f o u n d t h a t t h e p r e v a l e n c e of a n y d e g r e e o f m y o p i a in i n d i v i d u a l s b e t w e e n 1 2 a n d 5 4 years o f age was 2 5 % a n d 2 4 . 3 % for the right a n d left e y e s , r e s p e c t i v e l y . In t h e F r a m i n g h a m s t u d y , L e i b o w i t z a n d a s s o c i a t e s ' ^ f o u n d t h a t in people between ages 5 2 and 8 5 years, myopia w a s p r e s e n t in 1 7 . 7 % . Retinal d e t a c h m e n t associated with myopia h a s b e e n f o u n d t o o c c u r m o r e f r e q u e n t l y in middle-aged patients. Cambiaggi" reported that retinal d e t a c h m e n t with myopia occurred m o r e often in patients b e t w e e n the ages o f 4 1
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TABLE TECHNICAL VARIATIONS IN SCLERAL BUCKLING PROCEDURE IN 48 EYES TYPE OF ELEMENT BAND
No No 240 40 240 240 240 240 240 No 240 240 240 240
TIRE
276 No No 220 220 276 280 287 No 276 220 276 280 287
RADIAL (SPONGE)
No Yes No No No No No No Yes Yes Yes Yes Yes No
EXTENT (GRADES) 90
180
2
1
— — —
—
—
5 5 1 1
3 1 1 3
—
— —
1 2 2 2
270
360
— — — — —
— —
2
—
—
—
2 1
— — — 2 7
— — — — — 1
1
—
—
— — —
— — 1
TOTAL (%)
3 (6.2) 1 (2.0) 2(4.1) 1 (2.0) 8(16.6) 8(16.6) 2(4.1) 6(12.5) 7 (14.5) 1 (2.0) 2(4.1) 4 (8.3) 2 (4.1) 1 (2.0)
a n d 7 0 y e a r s . In p a t i e n t s y o u n g e r t h a n 4 1 y e a r s of a g e , m a l e s w e r e m o r e f r e q u e n t l y a f f e c t e d , b u t t h e r e w a s n o s i g n i f i c a n t p r e d i l e c t i o n for e i t h e r s e x in t h e o v e r a l l g r o u p . O f h i s p a t i e n t s , 5 0 % h a d l e s s t h a n — 4 . 0 0 d i o p t e r s o f m y o p i a . In our p a t i e n t s , t h e r e t i n a l d e t a c h m e n t o c c u r r e d m o r e often b e t w e e n t h e a g e s of 3 0 a n d 5 9 y e a r s ( 7 4 % ) , a n d t h e r e w a s a s l i g h t p r e d i l e c t i o n for males (54%). Bilateral retinal detachment associated with m y o p i a h a s b e e n r e p o r t e d . ' ' ' ^ In o n e s t u d y , six of 4 7 p a t i e n t s ( 1 3 % ) d e v e l o p e d a r e t i n a l d e t a c h m e n t in t h e f e l l o w eye d u r i n g 14 y e a r s o f follow-up (unpublished data, M a t t h e w A. T h o m a s , M . D . , N o v . 1 1 , 1 9 8 7 ) . Folk a n d B u r t o n " found a significant association b e t w e e n bilateral retinal detachment and myopia ( — 2 . 5 0 d i o p t e r s or g r e a t e r ) . T h e i n c i d e n c e o f m y o p i a in their patients with bilateral retinal detach m e n t s w a s 5 5 % c o m p a r e d to 3 3 % in p a t i e n t s with u n i l a t e r a l r e t i n a l d e t a c h m e n t , a n d t h e i n c i d e n c e o f b i l a t e r a l r e t i n a l d e t a c h m e n t in t h e m y o p i c g r o u p w a s 2 1 % c o m p a r e d w i t h 1 0 % in the nonmyopic group. The incidence of bilater al r e t i n a l d e t a c h m e n t w a s t h o u g h t to b e r e l a t e d to t h e c o m b i n e d i n f l u e n c e s o f l a t t i c e d e g e n e r a t i o n of t h e r e t i n a a n d r e f r a c t i v e e r r o r a n d r a n g e d from 8 % in t h e n o n m y o p i c g r o u p w i t h out l a t t i c e d e g e n e r a t i o n o f t h e r e t i n a to 2 5 % in the myopic group with lattice degeneration of t h e r e t i n a . In c o n t r a s t , t h e i n c i d e n c e o f b i l a t e r a l r e t i n a l d e t a c h m e n t in our p a t i e n t s w i t h m y o p i a
May, 1991
w a s l o w e r ( 4 % ) , a n d o n l y o n e o f t h e s e two patients had lattice degeneration of the retina. Byer'* r e p o r t e d that m y o p i c e y e s h a v e an i n c r e a s e d i n c i d e n c e o f l a t t i c e d e g e n e r a t i o n of the retina. B e n s o n and Morse'" found that 7 0 % o f r e t i n a l d e t a c h m e n t s c a u s e d b y b r e a k s in a r e a s o f l a t t i c e d e g e n e r a t i o n of t h e r e t i n a w e r e m y o p i c . In our s e r i e s , 5 0 % o f t h e e y e s h a d lattice degeneration of the retina and, of those, 7 1 % had tears associated with the lattice le sions. In t h e s t u d y b y B u r t o n , ' m y o p i c e y e s ( g r e a t e r t h a n - 4 . 0 0 d i o p t e r s ) a c c o u n t e d for 1 2 % o f t h e rhegmatogenous retinal detachments, and a re d u c e d r e t i n a l r e a t t a c h m e n t r a t e w a s f o u n d in myopic eyes ( 8 6 % ) when compared with e m m e tropic eyes ( 9 3 % ) . W i n s l o w a n d Tasman"* f o u n d t h a t m y o p i a w a s t h e c a u s e o f r e t i n a l d e t a c h m e n t in 2 8 e y e s o f 179 children ( 1 5 % ) , and 17 of 21 eyes ( 8 1 % ) f o l l o w e d u p for at l e a s t s i x m o n t h s w e r e r e a t tached. Our results indicate a high anatomic success rate o f s c l e r a l b u c k l i n g in t h e r e p a i r o f r h e g m a togenous retinal detachment associated with s e v e r e m y o p i a . A l l r e t i n a s w e r e r e a t t a c h e d in traoperatively, and the retinas of 37 of the 4 0 e y e s ( 9 2 . 5 % ) o b s e r v e d f o r at l e a s t six m o n t h s were reattached with one operation. With a revision of the scleral buckle, the retinas of two additional eyes were reattached; with a second r e v i s i o n o f the s c l e r a l b u c k l e , t h e r e t i n a o f a third eye was reattached. Final visual acuity of 2 0 / 4 0 or b e t t e r w a s a t t a i n e d in 2 6 o f t h e 4 0 e y e s ( 6 5 % ) f o l l o w e d up for at l e a s t six m o n t h s . We believe that the good visual results obtained may be because of the large n u m b e r of eyes that had retinal d e t a c h m e n t a n d an attached m a c u l a ( 6 9 % ) as w e l l as b e c a u s e o f e a r l y r e p a i r o f t h e r e t i n a l d e t a c h m e n t s ( 5 0 % o f e y e s o p e r a t e d on within 24 hours of diagnosis). A n i m p o r t a n t c o n s i d e r a t i o n in t h e t r e a t m e n t of r e t i n a l d e t a c h m e n t s in m y o p i c e y e s is t h e t e c h n i c a l difficulty e n c o u n t e r e d . In t h i s r e g a r d , t h e r e f r a c t i v e e r r o r i t s e l f is n o t a s i m p o r t a n t a s t h e effect o f m y o p i a o n t h e o c u l a r t i s s u e s , s u c h as e l o n g a t i o n o f t h e g l o b e , s c l e r a l t h i n n i n g , liquefaction of the vitreous, and the c o m p l e x v i t r e o r e t i n a l r e l a t i o n s h i p s t h a t are o f t e n p r e s e n t . T h e s e c h a n g e s p r o d u c e s p e c i a l p r o b l e m s in achieving the goals of scleral buckling.'" B e cause of the a n a t o m i c peculiarities of severely myopic eyes, intraoperative complications may be m o r e frequent. Surgical e x p o s u r e o f large m y o p i c e y e s m a y b e difficult b e c a u s e t h e s i z e o f the globe limits rotation and posterior expo-
Vol. I l l , No. 5
Scleral Buckling for Retinal Detachment
sure. A l s o , r e t i n a l b r e a k s t e n d to b e l a r g e , m u l t i p l e , or p o s t e r i o r a n d m a y b e i m p o s s i b l e to c l o s e w i t h a s c l e r a l b u c k l e b e c a u s e o f t h e diffi c u l t y in e x p o s u r e a n d s c l e r a l t h i n n i n g . B e c a u s e of t h i n n e d a n d p e r h a p s m o r e fragile c h o r o i d a l t i s s u e , d r a i n a g e of s u b r e t i n a l fluid w i t h t h e inevitable rapid ocular d e c o m p r e s s i o n that fol l o w s m a y h a v e a h i g h e r risk o f p r o d u c i n g a choroidal hemorrhage. Similarly, extensive c h o r o i d a l d e t a c h m e n t m a y occur.^ I n t r a s c l e r a l s u t u r e p l a c e m e n t in e y e s w i t h thin s c l e r a or w i t h s t a p h y l o m a t a is difficult, a n d e y e - w a l l p e r f o r a t i o n w i t h a n e e d l e m a y l e a d to hemorrhage, retinal perforation, or inoppor t u n e d e c o m p r e s s i o n o f t h e g l o b e from d r a i n a g e o f v i t r e o u s or s u b r e t i n a l fluid. In o u r s e r i e s o f 46 patients (48 eyes), the frequency of intraop erative c o m p l i c a t i o n s w a s l o w ; h o w e v e r , o n l y 12 of 4 8 e y e s ( 2 5 % ) h a d m y o p i a g r e a t e r t h a n 10.00 diopters. O n e eye ( 2 % ) developed choroi dal h e m o r r h a g e , o n e e y e ( 2 % ) d e v e l o p e d a significant c h o r o i d a l d e t a c h m e n t , a n d in a n o t h er two e y e s ( 4 % ) t h e r e t i n a w a s i n c a r c e r a t e d in the d r a i n a g e s i t e . In t h e p o s t o p e r a t i v e p e r i o d t h r e e e y e s ( 7 . 5 % ) of the 3 8 p a t i e n t s ( 4 0 e y e s ) o b s e r v e d for at l e a s t six m o n t h s d e v e l o p e d a r e c u r r e n t r e t i n a l d e tachment caused by the development of n e w r e t i n a l b r e a k s . Two o f t h e t h r e e e y e s t h a t d e v e l o p e d n e w r e t i n a l b r e a k s h a d air i n j e c t e d i n t o t h e v i t r e o u s c a v i t y at t h e t i m e o f s u r g e r y . Two e y e s u n d e r w e n t a s u c c e s s f u l r e v i s i o n o f t h e scleral buckle, and a third eye required a s e c o n d r e v i s i o n o f t h e s c l e r a l b u c k l e . Two e y e s ( 5 % ) developed significant choroidal d e t a c h m e n t s , but both cases resolved spontaneously. O t h e r postoperative complications included cystoid m a c u l a r e d e m a in two e y e s ( 5 % ) , m a c u l a r p u c k er in o n e e y e ( 2 . 5 % ) , a n d e x o t r o p i a in o n e e y e ( 2 . 5 % ) . E x t r u s i o n , i n t r u s i o n , or i n f e c t i o n o f t h e s c l e r a l b u c k l e m a t e r i a l did n o t o c c u r in any o f our p a t i e n t s . P n e u m a t i c r e t i n o p e x y or p r i m a r y v i t r e c t o m y have b e e n s u g g e s t e d as a l t e r n a t i v e p r o c e d u r e s in t h e t r e a t m e n t o f r e t i n a l d e t a c h m e n t s a s s o c i a t e d w i t h myopia.*"'" T h e m a i n a d v a n t a g e s c i t e d in favor o f t h e s e p r o c e d u r e s as c o m p a r e d to s c l e r a l b u c k l i n g i n c l u d e a p o s s i b l e l o w e r risk o f i n t r a o p e r a t i v e c o m p l i c a t i o n s , a r e d u c t i o n in postoperative discomfort, and avoidance of mo tility p r o b l e m s a n d r e f r a c t i v e c h a n g e s . B e c a u s e of differences in r e p o r t s o f s u r g i c a l e x p e r i e n c e , it is difficult to find c o m p a r a b l e s e r i e s o f patients with severe myopia treated with pneu matic procedures alone. McAllister and associ ates' compared the success rate and c o m
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plications of treating uncomplicated retinal d e t a c h m e n t s w i t h s i n g l e or m u l t i p l e b r e a k s within the superior 2 4 0 degrees of the fundus b y p n e u m a t i c r e t i n o p e x y , L i n c o f f b a l l o o n , or scleral buckle. Although their group included patients with myopia (greater than - 4 . 0 0 diop t e r s ) , t h e y d i d n o t s p e c i f i c a l l y n o t e t h e r e s u l t s in this particular subgroup. Algvere, Hallnás, and Palmqvist* r e p o r t e d 5 8 c o n s e c u t i v e e y e s w i t h rhegmatogenous retinal detachment treated with pneumatic retinopexy. This technique suc cessfully reattached the retina in 18 o f 2 2 ( 8 2 % ) m y o p i c e y e s ( - 3 . 0 0 to - 1 1 . 0 0 d i o p t e r s ) . T h i s is a l o w e r r a t e o f a n a t o m i c s u c c e s s for a s i n g l e intervention when compared with our results, namely 3 7 of 4 0 eyes ( 9 2 . 5 % ) observed longer t h a n six m o n t h s . Van E f f e n t e r r e a n d a s s o c i a t e s * r e p o r t e d t h e a n a t o m i c s u c c e s s in t r e a t i n g r e t i nal d e t a c h m e n t s in 1 2 0 eyes, s o m e o f w h i c h were myopic, by either cryotherapy, vitrec t o m y , a n d g a s i n j e c t i o n or c r y o t h e r a p y a n d g a s injection only. Total retinal r e a t t a c h m e n t with one intervention was 8 2 % and 8 5 % , respective ly, b u t t h e r e s u l t s w e r e n o t r e p o r t e d a c c o r d i n g to t h e r e f r a c t i v e s t a t u s o f t h e e y e . The potential complications of pneumatic r e t i n o p e x y a l s o n e e d to b e c o n s i d e r e d . T h e intraocular gas bubble may increase vitreous traction and cause further tears, mainly 1 8 0 d e g r e e s o p p o s i t e to t h e b u b b l e . " T h e a b s e n c e o f s u p p o r t at t h e v i t r e o u s b a s e m a k e s p o s t o p e r a tive r e t i n a l t e a r s m o r e l i k e l y t o c a u s e a r e c u r rent retinal d e t a c h m e n t . Migration of gas t h r o u g h r e t i n a l b r e a k s to t h e s u b r e t i n a l s p a c e h a s b e e n r e p o r t e d " a n d m a y b e m o r e l i k e l y in severely myopic eyes with large retinal breaks. E n d o p h t h a l m i t i s is r a r e , b u t if it o c c u r s it fre q u e n t l y l e a d s to s e v e r e v i s u a l l o s s . F i n a l l y , t h e r o l e o f v i t r e c t o m y s u r g e r y as a p r i m a r y p r o c e d u r e i n s e v e r e l y m y o p i c e y e s is controversial.''" The main advantages of re p a i r i n g r e t i n a l d e t a c h m e n t s in m y o p i c e y e s w i t h v i t r e c t o m y as c o m p a r e d w i t h s c l e r a l b u c k le i n c l u d e l i t t l e or n o s c l e r a l m a n i p u l a t i o n in patients with extremely thin sclera, complete r e a t t a c h m e n t o f t h e r e t i n a w i t h o u t t h e risk o f gaping of the retinal break over the posterior edge of the scleral b u c k l e , and the technical e a s e w i t h w h i c h fluid-air e x c h a n g e a n d i n t e r n a l d r a i n a g e o f s u b r e t i n a l fluid a c h i e v e s i n t e r n a l t a m p o n a d e in e y e s w i t h m u l t i p l e , l a r g e , or posterior breaks. Conversely, potential disad vantages of vitrectomy a l o n e as the primary procedure include the absence of a scleral buck le to s u p p o r t r e t i n a l b r e a k s a n d offset s o m e d e g r e e o f p e r i r e t i n a l t r a c t i o n or p o s t o p e r a t i v e
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AMERICAN JOURNAL OF OPHTHALMOLOGY
v i t r e o r e t i n a l t r a c t i o n , as w e l l as t h e c o m p l i c a t i o n s o f t h e p r o c e d u r e , s u c h as u v e a l effusion, subretinal infusion, peripheral retinal dialysis, or n e w r e t i n a l t e a r s , l e n s d a m a g e , i n c a r c e r a t i o n of t h e v i t r e o u s or t h e r e t i n a in t h e s c l e r o t o m y site, intraoperative h e m o r r h a g e , e n d o p h t h a l mitis, and sympathetic ophthalmia. Moreover, t h e r e is a h i g h e r risk o f d e v e l o p i n g n u c l e a r cataract.'" N e v e r t h e l e s s , in c e r t a i n e y e s in which the technical problems of scleral buck ling are great ( t h i n s c l e r a , l a r g e , m u l t i p l e , or posterior retinal breaks), vitrectomy may be p r e f e r a b l e to s c l e r a l b u c k l i n g . Although we cannot compare our results us ing s c l e r a l b u c k l i n g w i t h e i t h e r p n e u m a t i c r e t i nopexy or vitrectomy, because neither of these t w o p r o c e d u r e s w e r e p e r f o r m e d in o u r p a t i e n t s with rhegmatogenous retinal d e t a c h m e n t s and severe myopia, the high rate of success and the l o w risk o f s u r g i c a l c o m p l i c a t i o n s s u g g e s t t h a t s c l e r a l b u c k l i n g is an e x c e l l e n t t r e a t m e n t for most patients with retinal detachment associat ed w i t h s e v e r e m y o p i a .
References 1. Burton, T. C : Preoperative factors influencing anatomic success rates following retinal detachment surgery. Trans. Am. Acad. Ophthalmol. Otolaryngol. 83:499, 1977. 2. Schepens, C. L., and Marden, D.: Data on the natural history of retinal detachment. Further char acterization of certain unilateral nontraumatic cases. Am. J. Ophthalmol. 61:213, 1 9 6 6 . 3. Ashrafzadeh, M. T., Schepens, C. L., Elzeneiny, I. I., Moura, R., Morse, P., and Kraushar, M. F.: Aphakic and phakic retinal detachment. I. Preopera tive findings. Arch. Ophthalmol. 89:476, 1 9 7 3 . 4. Winslow, R. L., and Tasman, W.: Juvenile rheg matogenous retinal detachment. Ophthalmology 85:607, 1978. 5. Schepens, C. L.: Retinal Detachment and Allied Diseases, vol. 2. Philadelphia, W. B. Saunders, 1 9 8 3 , pp. 5 8 9 - 5 9 7 .
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6. Algvere, P., Hallnäs, Κ., and Palmqvist, B.-M.: Success and complications of pneumatic retinopexy. Am. J . Ophthalmol. 106:400, 1 9 8 8 . 7. McAllister, I. L., Meyers, S. M., Zegarra, H., Gutman, F. Α., Zakov, Z. N., and Beck, G. J.: Com parison of pneumatic retinopexy with alternative surgical techniques. Ophthalmology 95:877, 1 9 8 8 . 8. Van Effenterre, G., Haut, J . , Larricart, P., AbidRached, J . , and Vachet, J. M.: Gas tamponade as a single technique in the treatment of retinal detach ment. Is vitrectomy needed? A comparative study of 120 cases. Graefes Arch. Clin. Exp. Ophthalmol. 225:254, 1987. 9. Charles, S.: Vitrectomy in high myopia. In Thompson, F. B. (ed.): Myopia Surgery. Anterior and Posterior Segments. New York, Macmillan Publish ing Co., 1990, pp. 2 0 9 - 2 3 8 . 10. Kreiger, A. E.: Retinal detachment. In Thomp son, F. B. (ed.): Myopia Surgery. Anterior and Poster ior Segments. New York, Macmillan Publishing Co., 1990, pp. 2 3 9 - 2 6 6 . 11. Sperduto, R. D., Seigel, D., Roberts, J . , and Rowland, M.: Prevalence of myopia in the United States. Arch. Ophthalmol. 101:405, 1 9 8 3 . 12. Leibowitz, H. M., Krueger, D. E., Maunder, L. R., Milton, R. C , Kini, M. M., Kahn, Η. Α., Nickerson, R. J . , PooL J., Colton, T. L., Ganley, J. P., Lowenstein, J. I., and Dawber, T. R.: The Framingham Eye Study monograph. Surv. Ophthalmol. 24:335, 1980. 13. Cambiaggi, Α.: Myopia and retinal detach ment. Am. J. Ophthalmol. 58:642, 1 9 6 4 . 14. Folk, J. C , and Burton, T. C : Bilateral phakic retinal detachment. Ophthalmology 89:815, 1 9 8 2 . 15. Byer, Ν. Ε.: Clinical study of lattice degenera tion of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 69:1064, 1 9 6 5 . 16. Benson, W. E., and Morse, P. H.: The progno sis of retinal detachment due to lattice degeneration. Ann. Ophthalmol. 10:1197, 1 9 7 8 . 17. Dreyer, R. F.: Sequential retinal tears attribut ed to intraocular gas. Am. J. Ophthalmol. 102:276, 1986. 18. McDonald, H. R., Abrams, G. W., Irvine, A. R., Sipperly, J. O., Boyden, B. S., Fiore, J. V., and Zegarra, H.: The management of subretinal gas fol lowing attempted pneumatic retinopexy. Ophthal mology 94:319, 1 9 8 7 .
Francisco J. Rodriguez, M.D., H i l e l Lewis, M.D., A l l a n E, Kreiger, M . D . , Marc O. Yoshizumi, M.D., and Yossi Sidikaro, M . D .
F r o m J a n . 1 , 1980, t o D e c . 3 1 , 1989, w e p e r f o r m e d s c l e r a l b u c k l i n g s u r g e r y o n 48 e y e s o f 46 p a t i e n t s f o r r h e g m a t o g e n o u s r e t i n a l d e tachments associated with severe myopia ( g r e a t e r t h a n 5.00 d i o p t e r s ) . F o r t y e y e s o f 38 patients w e r e o b s e r v e d for at least six m o n t h s , a n d t h e m e a n f o l l o w - u p p e r i o d w a s 46 months. Intraoperative complications oc c u r r e d i n f o u r of 48 e y e s (8%) a n d i n c l u d e d retinal incarceration (two eyes), choroidal hemorrhage (one eye), and choroidal detach m e n t ( o n e e y e ) . T h r e e of t h e 40 e y e s (7.5%) f o l l o w e d u p for m o r e t h a n s i x m o n t h s developed a recurrent retinal detachment and underwent a revision of the scleral buckle. At the last follow-up examination, the retinas of a l l 40 e y e s w e r e t o t a l l y r e a t t a c h e d . F i n a l v i s u al a c u i t y o f 20/40 o r b e t t e r w a s a t t a i n e d i n 26 of 40 e y e s (65%). B e c a u s e o f t h e l o w r a t e of intraoperative complications and the high rate of success, scleral b u c k l i n g is r e c o m m e n d e d for most p a t i e n t s w i t h r h e g m a t o g e nous retinal detachments associated with se vere myopia.
M Y O P I A a c c o u n t s for 1 2 % to 4 2 % o f r h e g m a t o g e n o u s r e t i n a l d e t a c h m e n t s , a n d t h e risk o f retinal d e t a c h m e n t i n c r e a s e s with an i n c r e a s e in r e f r a c t i v e e r r o r . ' ^ B u r t o n ' a n d W i n s l o w a n d Tasman^ f o u n d t h a t t h e r e t i n a w a s s u c c e s s f u l l y r e a t t a c h e d in 81 % to 8 6 % o f e y e s with m y o p i a . T h e u s e o f t h i s t e c h n i q u e in t h e r e p a i r o f r e t i n a l d e t a c h m e n t s in s e v e r e l y m y o p i c e y e s , h o w e v e r , h a s b e e n
Accepted for publication Jan. 25, 1991. From the Department of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, California. This study was supported in part by the Charles Kenneth Feldman Fund (Dr. Lewis) and by Research to Prevent Blindness, Inc. (Drs. Rodriguez and Lewis). Reprint requests to Hilel Lewis, M.D., Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90024-7007.
r e p o r t e d t o b e a s s o c i a t e d w i t h a n i n c r e a s e d risk of intraoperative complications.* T h e s e c o m p l i c a t i o n s , w h i c h m a y l e a d to s e v e r e v i s u a l l o s s or blindness, include choroidal or subretinal hem orrhage, choroidal detachment, retinal incarce ration, retinal break, postoperative anterior segment ischemia, anisometropia, strabismus, macular distortion, cystoid macular edema, and e x t r u s i o n or i n f e c t i o n o f e x t r a s c l e r a l i m p l a n t material.* T h e r e f o r e , p n e u m a t i c r e t i n o p e x y or p r i m a r y v i t r e c t o m y h a v e b e e n s u g g e s t e d as a l t e r n a t i v e s to s c l e r a l b u c k l i n g in t h e m a n a g e ment of rhegmatogenous retinal detachment associated with severe myopia."'" We d e t e r m i n e d t h e r e s u l t s a n d c o m p l i c a t i o n s o f s c l e r a l b u c k l i n g s u r g e r y in a c o n s e c u t i v e series of patients with rhegmatogenous retinal detachments associated with severe myopia. W e a r b i t r a r i l y d e f i n e d s e v e r e m y o p i a as a r e f r a c t i v e e r r o r o f —5.00 d i o p t e r s or g r e a t e r .
Patients and Methods W e p e r f o r m e d s c l e r a l b u c k l i n g o p e r a t i o n s for all p a t i e n t s w i t h r h e g m a t o g e n o u s r e t i n a l d e tachments associated with severe myopia exam i n e d at o u r i n s t i t u t i o n b e t w e e n J a n . 1 , 1 9 8 0 , and D e c . 3 1 , 1989. A total o f 48 eyes o f 46 c o n s e c u t i v e p a t i e n t s w e r e o p e r a t e d o n , a n d all t h e p r o c e d u r e s w e r e p e r f o r m e d at o u r i n s t i t u t i o n b y four o f u s ( H . L . , A . E . K . , M . O . Y . , or Y.S.). Thus, none of the patients with rhegma togenous retinal detachments associated with severe myopia examined during the same peri od o f t i m e w e r e o p e r a t e d o n w i t h a different t e c h n i q u e , s u c h as p n e u m a t i c r e t i n o p e x y or vitrectomy. E x c e p t for e i g h t p a t i e n t s , a l l w e r e f o l l o w e d up for a m i n i m u m o f s i x m o n t h s . O f t h e s e e i g h t patients, two died, and we could not determine t h e i r r e t i n a l s t a t u s at t h e t i m e o f d e a t h . T h e o t h e r six p a t i e n t s h a d m o v e d away a n d c o u l d n o t b e l o c a t e d . O u r a t t e m p t s to o b t a i n o c u l a r
©AMERICAN JOURNAL OF OPHTHALMOLOGY 1 1 1 : 5 9 5 - 6 0 0 , MAY, 1 9 9 1
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i n f o r m a t i o n on t h e s e six p a t i e n t s w e r e n o t s u c cessful. T h u s , to a n a l y z e t h e l o n g - t e r m r e s u l t s we i n c l u d e d o n l y t h e 4 0 e y e s o f 3 8 p a t i e n t s t h a t w e r e o b s e r v e d for at l e a s t six m o n t h s ( m e a n , 4 6 months). T h e m e d i c a l a n d o p e r a t i v e r e c o r d s o f all p a tients were reviewed. Drawings and color pho tographs were also reviewed when available. T h e f o l l o w i n g h i s t o r i c a l data w e r e c o l l e c t e d : age; g e n d e r ; r a c e ; p r e v i o u s o c u l a r d i s e a s e ; p r e vious trauma; previous ocular surgery; onset of retinal detachment; and time between the onset of r e t i n a l d e t a c h m e n t a n d s u r g i c a l r e p a i r . O p h t h a l m i c data o b t a i n e d i n c l u d e d t h e f o l l o w i n g : preoperative and postoperative best-corrected v i s u a l a c u i t y ; r e f r a c t i v e e r r o r ; status o f t h e l e n s ; intraocular pressure; presence and extent of retinal detachment; number, type, and location of r e t i n a l b r e a k s ; p r e s e n c e o f p r o l i f e r a t i v e vit reoretinopathy; and presence of peripheral reti n a l a b n o r m a l i t i e s , s u c h as l a t t i c e d e g e n e r a t i o n or c y s t i c r e t i n a l tufts. I n t r a o p e r a t i v e i n f o r m a tion obtained included the following: p r e s e n c e a n d e x t e n t o f s c l e r a l t h i n n i n g , e c t a s i a , or b o t h ; type and extent of the buckling e l e m e n t used; method of chorioretinal adhesion used; need for a n d l o c a t i o n o f d r a i n a g e o f s u b r e t i n a l fluid; u s e o f i n t r a o c u l a r air or g a s ; a n d d e v e l o p m e n t of i n t r a o p e r a t i v e c o m p l i c a t i o n s , s u c h a s i n a d vertent scleral perforation, retinal incarcera t i o n , c h o r o i d a l h e m o r r h a g e , or v i t r e o u s h e m o r rhage. The complete medical and operative r e c o r d s w e r e a v a i l a b l e for all 4 8 e y e s o f 4 6 patients.
Results The study group included 25 males and 21 f e m a l e s . T h e a g e s r a n g e d from 15 to 7 4 y e a r s (mean, 42 years). Thirty-nine patients ( 8 5 % ) w e r e w h i t e , five ( 1 1 % ) w e r e H i s p a n i c , a n d t w o ( 4 % ) were black. T h e refractive error was b e t w e e n - 5 . 0 0 a n d - 8 . 0 0 d i o p t e r s in 2 6 e y e s ( 5 4 % ) , b e t w e e n - 8 . 2 5 a n d - 1 1 . 2 5 d i o p t e r s in 17 e y e s ( 3 5 % ) , b e t w e e n - 1 1 . 5 0 a n d - 1 4 . 7 5 d i o p t e r s in two e y e s ( 4 % ) , a n d g r e a t e r t h a n - 1 5 . 0 0 d i o p t e r s in t h r e e e y e s ( 6 % ) . F o r r e t i n a l b r e a k s w i t h o u t a r e t i n a l d e t a c h m e n t , five e y e s ( 1 0 % ) had previous treatment with laser photo coagulation, one eye ( 2 % ) with cryoretinopexy, and one eye ( 2 % ) with both laser p h o t o c o a g u l a tion and cryoretinopexy. O n e patient had pre v i o u s b l u n t o c u l a r t r a u m a t h a t w a s t h o u g h t to be n o t r e l a t e d to t h e r e t i n a l d e t a c h m e n t .
May, 1991
All the e y e s w e r e p h a k i c , t w o h a d a d i a g n o s i s of chronic recurrent uveitis, and none had m a c u l a r h o l e s . T h e m a c u l a w a s d e t a c h e d in 15 e y e s ( 3 1 % ) . R e t i n a l t e a r s w e r e p r e s e n t in 4 0 e y e s ( 8 3 % ) , r e t i n a l h o l e s in s e v e n e y e s ( 1 5 % ) , a n d n o r e t i n a l b r e a k s c o u l d b e f o u n d in o n e eye ( 2 % ) . L a t t i c e d e g e n e r a t i o n w a s p r e s e n t in 2 4 eyes ( 5 0 % ) , and the association b e t w e e n retinal tears and lattice degeneration of the retina was o b s e r v e d in 17 e y e s ( 3 5 % ) . M i l d p r o l i f e r a t i v e v i t r e o r e t i n o p a t h y w a s p r e s e n t in t w o e y e s ( 4 % ) . T h e i n i t i a l a n d final v i s u a l a c u i t y o f t h e 4 0 e y e s f o l l o w e d up for m o r e t h a n six m o n t h s are s h o w n in t h e F i g u r e . The mean time between diagnosis and scleral b u c k l i n g w a s 41/2 days. T w e n t y - f o u r e y e s ( 5 0 % ) w e r e o p e r a t e d o n in t h e first 2 4 h o u r s after t h e diagnosis was made. Forty eyes were observed from six to 1 0 5 m o n t h s ( m e a n , 4 6 m o n t h s ) , a n d t h e r e m a i n i n g e i g h t e y e s w e r e o b s e r v e d for five m o n t h s ( t w o e y e s ) , four m o n t h s ( o n e e y e ) , t h r e e m o n t h s ( o n e e y e ) , two m o n t h s ( t h r e e e y e s ) , a n d one month (one eye). The technical variations of the scleral buck ling p r o c e d u r e s are l i s t e d in t h e T a b l e . E x t r a s c l e r a l i m p l a n t s w e r e p e r f o r m e d in 3 0 e y e s ( 6 2 . 5 % ) a n d i n t r a s c l e r a l i m p l a n t s in 1 8 e y e s ( 3 7 . 5 % ) ; c r y o t h e r a p y w a s u s e d in 4 3 e y e s ( 9 0 % ) a n d d i a t h e r m y in t h r e e e y e s ( 6 % ) ; a n d e x t e r n a l d r a i n a g e o f s u b r e t i n a l fluid w a s p e r f o r m e d in 3 7 e y e s ( 7 7 % ) . I n t r a o c u l a r air w a s u s e d in four e y e s ( 8 % ) to i n c r e a s e t h e i n t r a o c u l a r p r e s s u r e a n d in two e y e s ( 4 % ) to t a m p o n a d e l a r g e r e t i n a l t e a r s . B a l a n c e d salt s o l u t i o n w a s i n j e c t e d i n t r a v i t r e a l l y in t h r e e e y e s ( 6 % ) to i n c r e a s e t h e i n t r a o c u l a r p r e s s u r e . In s e v e n e y e s ( 1 4 % ) s c l e r al t h i n n i n g w a s n o t e d . I n t r a o p e r a t i v e c o m p l i c a t i o n s o c c u r r e d in four ( 8 % ) of the 4 8 eyes and included retinal incar c e r a t i o n i n t o t h e d r a i n a g e s i t e in two e y e s ( 4 % ) , p a r t i a l c h o r o i d a l h e m o r r h a g e r e l a t e d to t h e d r a i n a g e p r o c e d u r e in o n e e y e ( 2 % ) , a n d s i g n i f i c a n t c h o r o i d a l d e t a c h m e n t in o n e e y e ( 2 % ) . N o t r e a t m e n t w a s p e r f o r m e d for t h e r e t i n a l i n c a r cerations b e c a u s e they were supported by the scleral buckle. T h e choroidal hemorrhage and the significant choroidal d e t a c h m e n t resolved s p o n t a n e o u s l y in t h e p o s t o p e r a t i v e p e r i o d . P o s t o p e r a t i v e c o m p l i c a t i o n s d e v e l o p e d in nine of the 4 0 eyes ( 2 2 . 5 % ) that were observed for at l e a s t six m o n t h s a n d i n c l u d e d r e c u r r e n t r e t i n a l d e t a c h m e n t in t h r e e e y e s ( 7 . 5 % ) , c y s t o i d m a c u l a r e d e m a in t w o e y e s ( 5 % ) , s i g n i f i c a n t c h o r o i d a l d e t a c h m e n t s (different from t h e o n e n o t e d i n t r a o p e r a t i v e l y ) in two e y e s ( 5 % ) , m a c u lar p u c k e r in o n e e y e ( 2 . 5 % ) , a n d e x o t r o p i a in
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D
Figure (Rodriguez and as sociates). Preoperative and postoperative visual acuity. HM indicates hand motions and CF indicates counting fingers. The letter next to the point indicates how many ob servations for the point: A = 1, Β = 2, C = 3, and F = 6.
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PRE-OPERATIVE VISUAL ACUITY o n e e y e ( 2 . 5 % ) . T h e c a u s e for a n a t o m i c f a i l u r e in t h e e y e s t h a t r e d e t a c h e d w a s t h e d e v e l o p ment of new retinal breaks. T h e two eyes that r e q u i r e d i n j e c t i o n o f air i n t o t h e v i t r e o u s c a v i t y to t a m p o n a d e l a r g e r e t i n a l b r e a k s d e v e l o p e d n e w r e t i n a l b r e a k s , o n e l o c a t e d a d j a c e n t to t h e previous break and the other located 60 degrees from t h e p r e v i o u s r e t i n a l t e a r . A l l t h r e e e y e s underwent revision of the scleral buckle, which w a s s u c c e s s f u l in t w o e y e s . T h e t h i r d e y e r e quired another revision o f the scleral buckle. O f the e i g h t e y e s f o l l o w e d up for l e s s t h a n s i x months, one eye developed cystoid macular edema. At t h e last f o l l o w - u p e x a m i n a t i o n t h e r e t i n a s in all 4 0 e y e s o b s e r v e d for at l e a s t six m o n t h s w e r e t o t a l l y r e a t t a c h e d , a n d final v i s u a l a c u i t y of 2 0 / 4 0 or b e t t e r w a s a t t a i n e d in 2 6 e y e s ( 6 5 % ) . Twenty-five e y e s ( 6 2 . 5 % ) h a d b e t t e r , t e n e y e s ( 2 5 % ) h a d t h e s a m e , a n d five e y e s ( 1 2 . 5 % ) had worse postoperative visual acuity. T h e r e w a s n o c o r r e l a t i o n b e t w e e n t h e s i z e or e x t e n t o f t h e e n c i r c l i n g e l e m e n t a n d final v i s u a l a c u i t y . All five e y e s w i t h w o r s e p o s t o p e r a t i v e v i s u a l
a c u i t y h a d final v i s u a l a c u i t y o f 2 0 / 6 0 or b e t t e r ( F i g u r e ) . O f t h e e i g h t e y e s f o l l o w e d u p for l e s s t h a n six m o n t h s , v i s u a l a c u i t y i m p r o v e d in f o u r e y e s , w a s t h e s a m e in o n e , a n d d e c r e a s e d in three.
Discussion Using data from the N a t i o n a l H e a l t h and Nutrition Examination Survey, Sperduto and a s s o c i a t e s " f o u n d t h a t t h e p r e v a l e n c e of a n y d e g r e e o f m y o p i a in i n d i v i d u a l s b e t w e e n 1 2 a n d 5 4 years o f age was 2 5 % a n d 2 4 . 3 % for the right a n d left e y e s , r e s p e c t i v e l y . In t h e F r a m i n g h a m s t u d y , L e i b o w i t z a n d a s s o c i a t e s ' ^ f o u n d t h a t in people between ages 5 2 and 8 5 years, myopia w a s p r e s e n t in 1 7 . 7 % . Retinal d e t a c h m e n t associated with myopia h a s b e e n f o u n d t o o c c u r m o r e f r e q u e n t l y in middle-aged patients. Cambiaggi" reported that retinal d e t a c h m e n t with myopia occurred m o r e often in patients b e t w e e n the ages o f 4 1
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TABLE TECHNICAL VARIATIONS IN SCLERAL BUCKLING PROCEDURE IN 48 EYES TYPE OF ELEMENT BAND
No No 240 40 240 240 240 240 240 No 240 240 240 240
TIRE
276 No No 220 220 276 280 287 No 276 220 276 280 287
RADIAL (SPONGE)
No Yes No No No No No No Yes Yes Yes Yes Yes No
EXTENT (GRADES) 90
180
2
1
— — —
—
—
5 5 1 1
3 1 1 3
—
— —
1 2 2 2
270
360
— — — — —
— —
2
—
—
—
2 1
— — — 2 7
— — — — — 1
1
—
—
— — —
— — 1
TOTAL (%)
3 (6.2) 1 (2.0) 2(4.1) 1 (2.0) 8(16.6) 8(16.6) 2(4.1) 6(12.5) 7 (14.5) 1 (2.0) 2(4.1) 4 (8.3) 2 (4.1) 1 (2.0)
a n d 7 0 y e a r s . In p a t i e n t s y o u n g e r t h a n 4 1 y e a r s of a g e , m a l e s w e r e m o r e f r e q u e n t l y a f f e c t e d , b u t t h e r e w a s n o s i g n i f i c a n t p r e d i l e c t i o n for e i t h e r s e x in t h e o v e r a l l g r o u p . O f h i s p a t i e n t s , 5 0 % h a d l e s s t h a n — 4 . 0 0 d i o p t e r s o f m y o p i a . In our p a t i e n t s , t h e r e t i n a l d e t a c h m e n t o c c u r r e d m o r e often b e t w e e n t h e a g e s of 3 0 a n d 5 9 y e a r s ( 7 4 % ) , a n d t h e r e w a s a s l i g h t p r e d i l e c t i o n for males (54%). Bilateral retinal detachment associated with m y o p i a h a s b e e n r e p o r t e d . ' ' ' ^ In o n e s t u d y , six of 4 7 p a t i e n t s ( 1 3 % ) d e v e l o p e d a r e t i n a l d e t a c h m e n t in t h e f e l l o w eye d u r i n g 14 y e a r s o f follow-up (unpublished data, M a t t h e w A. T h o m a s , M . D . , N o v . 1 1 , 1 9 8 7 ) . Folk a n d B u r t o n " found a significant association b e t w e e n bilateral retinal detachment and myopia ( — 2 . 5 0 d i o p t e r s or g r e a t e r ) . T h e i n c i d e n c e o f m y o p i a in their patients with bilateral retinal detach m e n t s w a s 5 5 % c o m p a r e d to 3 3 % in p a t i e n t s with u n i l a t e r a l r e t i n a l d e t a c h m e n t , a n d t h e i n c i d e n c e o f b i l a t e r a l r e t i n a l d e t a c h m e n t in t h e m y o p i c g r o u p w a s 2 1 % c o m p a r e d w i t h 1 0 % in the nonmyopic group. The incidence of bilater al r e t i n a l d e t a c h m e n t w a s t h o u g h t to b e r e l a t e d to t h e c o m b i n e d i n f l u e n c e s o f l a t t i c e d e g e n e r a t i o n of t h e r e t i n a a n d r e f r a c t i v e e r r o r a n d r a n g e d from 8 % in t h e n o n m y o p i c g r o u p w i t h out l a t t i c e d e g e n e r a t i o n o f t h e r e t i n a to 2 5 % in the myopic group with lattice degeneration of t h e r e t i n a . In c o n t r a s t , t h e i n c i d e n c e o f b i l a t e r a l r e t i n a l d e t a c h m e n t in our p a t i e n t s w i t h m y o p i a
May, 1991
w a s l o w e r ( 4 % ) , a n d o n l y o n e o f t h e s e two patients had lattice degeneration of the retina. Byer'* r e p o r t e d that m y o p i c e y e s h a v e an i n c r e a s e d i n c i d e n c e o f l a t t i c e d e g e n e r a t i o n of the retina. B e n s o n and Morse'" found that 7 0 % o f r e t i n a l d e t a c h m e n t s c a u s e d b y b r e a k s in a r e a s o f l a t t i c e d e g e n e r a t i o n of t h e r e t i n a w e r e m y o p i c . In our s e r i e s , 5 0 % o f t h e e y e s h a d lattice degeneration of the retina and, of those, 7 1 % had tears associated with the lattice le sions. In t h e s t u d y b y B u r t o n , ' m y o p i c e y e s ( g r e a t e r t h a n - 4 . 0 0 d i o p t e r s ) a c c o u n t e d for 1 2 % o f t h e rhegmatogenous retinal detachments, and a re d u c e d r e t i n a l r e a t t a c h m e n t r a t e w a s f o u n d in myopic eyes ( 8 6 % ) when compared with e m m e tropic eyes ( 9 3 % ) . W i n s l o w a n d Tasman"* f o u n d t h a t m y o p i a w a s t h e c a u s e o f r e t i n a l d e t a c h m e n t in 2 8 e y e s o f 179 children ( 1 5 % ) , and 17 of 21 eyes ( 8 1 % ) f o l l o w e d u p for at l e a s t s i x m o n t h s w e r e r e a t tached. Our results indicate a high anatomic success rate o f s c l e r a l b u c k l i n g in t h e r e p a i r o f r h e g m a togenous retinal detachment associated with s e v e r e m y o p i a . A l l r e t i n a s w e r e r e a t t a c h e d in traoperatively, and the retinas of 37 of the 4 0 e y e s ( 9 2 . 5 % ) o b s e r v e d f o r at l e a s t six m o n t h s were reattached with one operation. With a revision of the scleral buckle, the retinas of two additional eyes were reattached; with a second r e v i s i o n o f the s c l e r a l b u c k l e , t h e r e t i n a o f a third eye was reattached. Final visual acuity of 2 0 / 4 0 or b e t t e r w a s a t t a i n e d in 2 6 o f t h e 4 0 e y e s ( 6 5 % ) f o l l o w e d up for at l e a s t six m o n t h s . We believe that the good visual results obtained may be because of the large n u m b e r of eyes that had retinal d e t a c h m e n t a n d an attached m a c u l a ( 6 9 % ) as w e l l as b e c a u s e o f e a r l y r e p a i r o f t h e r e t i n a l d e t a c h m e n t s ( 5 0 % o f e y e s o p e r a t e d on within 24 hours of diagnosis). A n i m p o r t a n t c o n s i d e r a t i o n in t h e t r e a t m e n t of r e t i n a l d e t a c h m e n t s in m y o p i c e y e s is t h e t e c h n i c a l difficulty e n c o u n t e r e d . In t h i s r e g a r d , t h e r e f r a c t i v e e r r o r i t s e l f is n o t a s i m p o r t a n t a s t h e effect o f m y o p i a o n t h e o c u l a r t i s s u e s , s u c h as e l o n g a t i o n o f t h e g l o b e , s c l e r a l t h i n n i n g , liquefaction of the vitreous, and the c o m p l e x v i t r e o r e t i n a l r e l a t i o n s h i p s t h a t are o f t e n p r e s e n t . T h e s e c h a n g e s p r o d u c e s p e c i a l p r o b l e m s in achieving the goals of scleral buckling.'" B e cause of the a n a t o m i c peculiarities of severely myopic eyes, intraoperative complications may be m o r e frequent. Surgical e x p o s u r e o f large m y o p i c e y e s m a y b e difficult b e c a u s e t h e s i z e o f the globe limits rotation and posterior expo-
Vol. I l l , No. 5
Scleral Buckling for Retinal Detachment
sure. A l s o , r e t i n a l b r e a k s t e n d to b e l a r g e , m u l t i p l e , or p o s t e r i o r a n d m a y b e i m p o s s i b l e to c l o s e w i t h a s c l e r a l b u c k l e b e c a u s e o f t h e diffi c u l t y in e x p o s u r e a n d s c l e r a l t h i n n i n g . B e c a u s e of t h i n n e d a n d p e r h a p s m o r e fragile c h o r o i d a l t i s s u e , d r a i n a g e of s u b r e t i n a l fluid w i t h t h e inevitable rapid ocular d e c o m p r e s s i o n that fol l o w s m a y h a v e a h i g h e r risk o f p r o d u c i n g a choroidal hemorrhage. Similarly, extensive c h o r o i d a l d e t a c h m e n t m a y occur.^ I n t r a s c l e r a l s u t u r e p l a c e m e n t in e y e s w i t h thin s c l e r a or w i t h s t a p h y l o m a t a is difficult, a n d e y e - w a l l p e r f o r a t i o n w i t h a n e e d l e m a y l e a d to hemorrhage, retinal perforation, or inoppor t u n e d e c o m p r e s s i o n o f t h e g l o b e from d r a i n a g e o f v i t r e o u s or s u b r e t i n a l fluid. In o u r s e r i e s o f 46 patients (48 eyes), the frequency of intraop erative c o m p l i c a t i o n s w a s l o w ; h o w e v e r , o n l y 12 of 4 8 e y e s ( 2 5 % ) h a d m y o p i a g r e a t e r t h a n 10.00 diopters. O n e eye ( 2 % ) developed choroi dal h e m o r r h a g e , o n e e y e ( 2 % ) d e v e l o p e d a significant c h o r o i d a l d e t a c h m e n t , a n d in a n o t h er two e y e s ( 4 % ) t h e r e t i n a w a s i n c a r c e r a t e d in the d r a i n a g e s i t e . In t h e p o s t o p e r a t i v e p e r i o d t h r e e e y e s ( 7 . 5 % ) of the 3 8 p a t i e n t s ( 4 0 e y e s ) o b s e r v e d for at l e a s t six m o n t h s d e v e l o p e d a r e c u r r e n t r e t i n a l d e tachment caused by the development of n e w r e t i n a l b r e a k s . Two o f t h e t h r e e e y e s t h a t d e v e l o p e d n e w r e t i n a l b r e a k s h a d air i n j e c t e d i n t o t h e v i t r e o u s c a v i t y at t h e t i m e o f s u r g e r y . Two e y e s u n d e r w e n t a s u c c e s s f u l r e v i s i o n o f t h e scleral buckle, and a third eye required a s e c o n d r e v i s i o n o f t h e s c l e r a l b u c k l e . Two e y e s ( 5 % ) developed significant choroidal d e t a c h m e n t s , but both cases resolved spontaneously. O t h e r postoperative complications included cystoid m a c u l a r e d e m a in two e y e s ( 5 % ) , m a c u l a r p u c k er in o n e e y e ( 2 . 5 % ) , a n d e x o t r o p i a in o n e e y e ( 2 . 5 % ) . E x t r u s i o n , i n t r u s i o n , or i n f e c t i o n o f t h e s c l e r a l b u c k l e m a t e r i a l did n o t o c c u r in any o f our p a t i e n t s . P n e u m a t i c r e t i n o p e x y or p r i m a r y v i t r e c t o m y have b e e n s u g g e s t e d as a l t e r n a t i v e p r o c e d u r e s in t h e t r e a t m e n t o f r e t i n a l d e t a c h m e n t s a s s o c i a t e d w i t h myopia.*"'" T h e m a i n a d v a n t a g e s c i t e d in favor o f t h e s e p r o c e d u r e s as c o m p a r e d to s c l e r a l b u c k l i n g i n c l u d e a p o s s i b l e l o w e r risk o f i n t r a o p e r a t i v e c o m p l i c a t i o n s , a r e d u c t i o n in postoperative discomfort, and avoidance of mo tility p r o b l e m s a n d r e f r a c t i v e c h a n g e s . B e c a u s e of differences in r e p o r t s o f s u r g i c a l e x p e r i e n c e , it is difficult to find c o m p a r a b l e s e r i e s o f patients with severe myopia treated with pneu matic procedures alone. McAllister and associ ates' compared the success rate and c o m
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plications of treating uncomplicated retinal d e t a c h m e n t s w i t h s i n g l e or m u l t i p l e b r e a k s within the superior 2 4 0 degrees of the fundus b y p n e u m a t i c r e t i n o p e x y , L i n c o f f b a l l o o n , or scleral buckle. Although their group included patients with myopia (greater than - 4 . 0 0 diop t e r s ) , t h e y d i d n o t s p e c i f i c a l l y n o t e t h e r e s u l t s in this particular subgroup. Algvere, Hallnás, and Palmqvist* r e p o r t e d 5 8 c o n s e c u t i v e e y e s w i t h rhegmatogenous retinal detachment treated with pneumatic retinopexy. This technique suc cessfully reattached the retina in 18 o f 2 2 ( 8 2 % ) m y o p i c e y e s ( - 3 . 0 0 to - 1 1 . 0 0 d i o p t e r s ) . T h i s is a l o w e r r a t e o f a n a t o m i c s u c c e s s for a s i n g l e intervention when compared with our results, namely 3 7 of 4 0 eyes ( 9 2 . 5 % ) observed longer t h a n six m o n t h s . Van E f f e n t e r r e a n d a s s o c i a t e s * r e p o r t e d t h e a n a t o m i c s u c c e s s in t r e a t i n g r e t i nal d e t a c h m e n t s in 1 2 0 eyes, s o m e o f w h i c h were myopic, by either cryotherapy, vitrec t o m y , a n d g a s i n j e c t i o n or c r y o t h e r a p y a n d g a s injection only. Total retinal r e a t t a c h m e n t with one intervention was 8 2 % and 8 5 % , respective ly, b u t t h e r e s u l t s w e r e n o t r e p o r t e d a c c o r d i n g to t h e r e f r a c t i v e s t a t u s o f t h e e y e . The potential complications of pneumatic r e t i n o p e x y a l s o n e e d to b e c o n s i d e r e d . T h e intraocular gas bubble may increase vitreous traction and cause further tears, mainly 1 8 0 d e g r e e s o p p o s i t e to t h e b u b b l e . " T h e a b s e n c e o f s u p p o r t at t h e v i t r e o u s b a s e m a k e s p o s t o p e r a tive r e t i n a l t e a r s m o r e l i k e l y t o c a u s e a r e c u r rent retinal d e t a c h m e n t . Migration of gas t h r o u g h r e t i n a l b r e a k s to t h e s u b r e t i n a l s p a c e h a s b e e n r e p o r t e d " a n d m a y b e m o r e l i k e l y in severely myopic eyes with large retinal breaks. E n d o p h t h a l m i t i s is r a r e , b u t if it o c c u r s it fre q u e n t l y l e a d s to s e v e r e v i s u a l l o s s . F i n a l l y , t h e r o l e o f v i t r e c t o m y s u r g e r y as a p r i m a r y p r o c e d u r e i n s e v e r e l y m y o p i c e y e s is controversial.''" The main advantages of re p a i r i n g r e t i n a l d e t a c h m e n t s in m y o p i c e y e s w i t h v i t r e c t o m y as c o m p a r e d w i t h s c l e r a l b u c k le i n c l u d e l i t t l e or n o s c l e r a l m a n i p u l a t i o n in patients with extremely thin sclera, complete r e a t t a c h m e n t o f t h e r e t i n a w i t h o u t t h e risk o f gaping of the retinal break over the posterior edge of the scleral b u c k l e , and the technical e a s e w i t h w h i c h fluid-air e x c h a n g e a n d i n t e r n a l d r a i n a g e o f s u b r e t i n a l fluid a c h i e v e s i n t e r n a l t a m p o n a d e in e y e s w i t h m u l t i p l e , l a r g e , or posterior breaks. Conversely, potential disad vantages of vitrectomy a l o n e as the primary procedure include the absence of a scleral buck le to s u p p o r t r e t i n a l b r e a k s a n d offset s o m e d e g r e e o f p e r i r e t i n a l t r a c t i o n or p o s t o p e r a t i v e
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AMERICAN JOURNAL OF OPHTHALMOLOGY
v i t r e o r e t i n a l t r a c t i o n , as w e l l as t h e c o m p l i c a t i o n s o f t h e p r o c e d u r e , s u c h as u v e a l effusion, subretinal infusion, peripheral retinal dialysis, or n e w r e t i n a l t e a r s , l e n s d a m a g e , i n c a r c e r a t i o n of t h e v i t r e o u s or t h e r e t i n a in t h e s c l e r o t o m y site, intraoperative h e m o r r h a g e , e n d o p h t h a l mitis, and sympathetic ophthalmia. Moreover, t h e r e is a h i g h e r risk o f d e v e l o p i n g n u c l e a r cataract.'" N e v e r t h e l e s s , in c e r t a i n e y e s in which the technical problems of scleral buck ling are great ( t h i n s c l e r a , l a r g e , m u l t i p l e , or posterior retinal breaks), vitrectomy may be p r e f e r a b l e to s c l e r a l b u c k l i n g . Although we cannot compare our results us ing s c l e r a l b u c k l i n g w i t h e i t h e r p n e u m a t i c r e t i nopexy or vitrectomy, because neither of these t w o p r o c e d u r e s w e r e p e r f o r m e d in o u r p a t i e n t s with rhegmatogenous retinal d e t a c h m e n t s and severe myopia, the high rate of success and the l o w risk o f s u r g i c a l c o m p l i c a t i o n s s u g g e s t t h a t s c l e r a l b u c k l i n g is an e x c e l l e n t t r e a t m e n t for most patients with retinal detachment associat ed w i t h s e v e r e m y o p i a .
References 1. Burton, T. C : Preoperative factors influencing anatomic success rates following retinal detachment surgery. Trans. Am. Acad. Ophthalmol. Otolaryngol. 83:499, 1977. 2. Schepens, C. L., and Marden, D.: Data on the natural history of retinal detachment. Further char acterization of certain unilateral nontraumatic cases. Am. J. Ophthalmol. 61:213, 1 9 6 6 . 3. Ashrafzadeh, M. T., Schepens, C. L., Elzeneiny, I. I., Moura, R., Morse, P., and Kraushar, M. F.: Aphakic and phakic retinal detachment. I. Preopera tive findings. Arch. Ophthalmol. 89:476, 1 9 7 3 . 4. Winslow, R. L., and Tasman, W.: Juvenile rheg matogenous retinal detachment. Ophthalmology 85:607, 1978. 5. Schepens, C. L.: Retinal Detachment and Allied Diseases, vol. 2. Philadelphia, W. B. Saunders, 1 9 8 3 , pp. 5 8 9 - 5 9 7 .
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6. Algvere, P., Hallnäs, Κ., and Palmqvist, B.-M.: Success and complications of pneumatic retinopexy. Am. J . Ophthalmol. 106:400, 1 9 8 8 . 7. McAllister, I. L., Meyers, S. M., Zegarra, H., Gutman, F. Α., Zakov, Z. N., and Beck, G. J.: Com parison of pneumatic retinopexy with alternative surgical techniques. Ophthalmology 95:877, 1 9 8 8 . 8. Van Effenterre, G., Haut, J . , Larricart, P., AbidRached, J . , and Vachet, J. M.: Gas tamponade as a single technique in the treatment of retinal detach ment. Is vitrectomy needed? A comparative study of 120 cases. Graefes Arch. Clin. Exp. Ophthalmol. 225:254, 1987. 9. Charles, S.: Vitrectomy in high myopia. In Thompson, F. B. (ed.): Myopia Surgery. Anterior and Posterior Segments. New York, Macmillan Publish ing Co., 1990, pp. 2 0 9 - 2 3 8 . 10. Kreiger, A. E.: Retinal detachment. In Thomp son, F. B. (ed.): Myopia Surgery. Anterior and Poster ior Segments. New York, Macmillan Publishing Co., 1990, pp. 2 3 9 - 2 6 6 . 11. Sperduto, R. D., Seigel, D., Roberts, J . , and Rowland, M.: Prevalence of myopia in the United States. Arch. Ophthalmol. 101:405, 1 9 8 3 . 12. Leibowitz, H. M., Krueger, D. E., Maunder, L. R., Milton, R. C , Kini, M. M., Kahn, Η. Α., Nickerson, R. J . , PooL J., Colton, T. L., Ganley, J. P., Lowenstein, J. I., and Dawber, T. R.: The Framingham Eye Study monograph. Surv. Ophthalmol. 24:335, 1980. 13. Cambiaggi, Α.: Myopia and retinal detach ment. Am. J. Ophthalmol. 58:642, 1 9 6 4 . 14. Folk, J. C , and Burton, T. C : Bilateral phakic retinal detachment. Ophthalmology 89:815, 1 9 8 2 . 15. Byer, Ν. Ε.: Clinical study of lattice degenera tion of the retina. Trans. Am. Acad. Ophthalmol. Otolaryngol. 69:1064, 1 9 6 5 . 16. Benson, W. E., and Morse, P. H.: The progno sis of retinal detachment due to lattice degeneration. Ann. Ophthalmol. 10:1197, 1 9 7 8 . 17. Dreyer, R. F.: Sequential retinal tears attribut ed to intraocular gas. Am. J. Ophthalmol. 102:276, 1986. 18. McDonald, H. R., Abrams, G. W., Irvine, A. R., Sipperly, J. O., Boyden, B. S., Fiore, J. V., and Zegarra, H.: The management of subretinal gas fol lowing attempted pneumatic retinopexy. Ophthal mology 94:319, 1 9 8 7 .
