Horseshoe Tears Research Articles

National audit of the outcome of primary surgery for rhegmatogenous retinal detachment. I. Sample and methods.

This national study was designed to audit anatomical outcome and complications relating to primary surgery for rhegmatogenous retinal detachments. This paper presents survey methods, characteristics of participating consultants and the demographic and clinical characteristics of the patient sample. Two surveys were undertaken. The first identified consultants who at the time performed retinal detachment surgery in the National Health Service. These surgeons formed the sampling frame for a nationwide cross-sectional clinical study that audited the outcomes of primary surgery for rhegmatogenous retinal detachments. Consultants selected patients according to the study eligibility criteria and data were collected by self-administered postal questionnaires. A validation exercise was carried out to examine selection bias and reporting accuracy. Only 256/671 (38%) of UK consultants, who responded to the first survey, indicated that they performed retinal detachment surgery on NHS patients. Annual activity varied between 0 and 400 primary procedures for rhegmatogenous retinal detachments. Seven hundred and sixty-eight eligible patients from 167 consultants were recruited for the clinical study. Twenty per cent of patients had a single retinal break with less than one quadrant of associated detachment and 45% had single or multiple breaks within the same quadrant and/or less than two quadrants of associated retinal detachment. Over 50% patients had single or multiple horseshoe tears. Validation studies suggested that there was no significant bias from the selection of patients or inaccuracy in reporting outcomes. This large unselected group of primary rhegmatogenous retinal detachments provides a representative sample for considering variations in re-attachment rates.

National audit of the outcome of primary surgery for rhegmatogenous retinal detachment. II. Clinical outcomes.

This national study was designed to audit anatomical outcome and complications relating to primary surgery for rhegmatogenous retinal detachments. This paper presents success and complication rates, and examines variations in outcome. Sampling and recruitment details of this nationwide cross-sectional survey of 768 patients of 167 consultant ophthalmologists having their first operation for rhegmatogenous retinal detachment have been described. The main clinical outcomes detailed here are anatomical reattachment at 3 months after surgery and complications related to surgery. Consultants with a declared special interest in retinal surgery and able to perform pars plana vitrectomy were designated specialists for the analyses. Overall reattachment rate with a single procedure was 77% (95% CI 73.9-80.2). There were significant differences in reattachment rates between specialists and non-specialists. Without allowing for case-mix, specialists had a reattachment rate of 82% (95% CI 77.9-85.7) with a single procedure and non-specialists 71% (95% CI 65.9-76.0). Allowing for case-mix, there was a significant difference between specialists and non-specialists for grade 2 detachments of 87% and 70% respectively (P < 0.0001). Analysing detachments by break type, the largest difference between specialists and non-specialists was observed for retinal detachments secondary to horseshoe tears, 80% and 68% respectively (P < 0.003). Specialists met the standards set for primary reattachment rates, while non-specialists did not. Over a third of patients had at least one complication reported at some point during the audit period. Significant differences were seen in reattachment rates between specialists and non-specialists, overall and for specific subgroups of patients. This study provides relevant, robust and valid standards to enable all surgeons to audit their own surgical outcomes for primary retinal detachment repair in rhegmatogenous retinal detachments, identify common categories of failure and aim to improve results.

Two Cases of Retinal Detachment following Laser In Situ Keratomileusis Repaired by Scleral Buckling Surgery

As laser in situ keratomileusis (LASIK) becomes the treatment of choice in the field of refractive surgery, postoperative rhegmatogenous retinal detachment has also begun to occur. However, since it has not been reported yet here in Japan, we report two cases of retinal detachment following LASIK with suggestions based on our experience. A 34-year-old male(Case 1) and a 26-year-old male(Case 2) suffered from retinal detachment one month and eight months after LASIK, respectively. Contributing retinal breaks were a horseshoe tear in Case 1 and atrophic holes in the lattice degeneration in Case 2. Each patient underwent partial scleral buckling with no intraoperative complication, resulting in successful retinal reattachment. Postoperatively, myopic changes developed and persisted one month in Case 1 and several months in Case 2. Great attention should be paid to the possibility of postoperative myopia after a repair of retinal detachment following LASIK. Thus, we stress the necessity of close cooperation between LASIK surgeons and vitreoretinal surgeons to settle the matter.

Pediatric rhegmatogenous retinal detachment.

To review the clinical features and surgical and visual outcomes of pediatric rhegmatogenous retinal detachment (RRD) as seen in a tertiary referral center. Retrospective case series spanning 6 years from January 1, 1991 to January 1, 1997. Exclusionary criteria were trauma disrupting the globe and acute retinopathy of prematurity. The authors reviewed a series of 29 eyes in 27 pediatric patients (birth to 18 years of age) with RRD. Seventy percent of the patients were male. The mean patient age was 9.6 years. Bilateral RRD was present in 22% of patients; 89% of patients had some form of bilateral ocular pathology at initial presentation. The two most common etiologies (34% each) were myopia and eyes that had undergone surgery for another ocular disorder with subsequent development of RRD. The most common presentation was decreased vision, with a mean duration of 52 days. At presentation, 75% of the affected eyes and 48% of the fellow eyes had visual acuity worse than 20/800. The most common type of retinal break was a horseshoe tear. Late diagnosis was a common problem, evidenced by the frequency of macular detachment (79%) and proliferative vitreoretinopathy (45%) at initial presentation. The most common primary repair was a scleral buckle. Anatomic reattachment was ultimately accomplished in 72% of cases with a mean of 2.2 surgeries per eye. Average postoperative follow-up time was 21.4 months (range 4 to 61 months). At final follow-up, 41% of the affected eyes had visual acuity 20/800 or better. Thirty-eight percent of the affected eyes had a final visual acuity better than or equal to the fellow eye. In this series, pediatric RRD occurred most commonly in association with myopia (Stickler's syndrome and adolescent retinopathy of prematurity) and prior intraocular surgery. Most eyes were anatomically reattached after multiple surgeries. Forty-one percent of eyes retained vision of 20/800 or better. Preserving vision in children with RRD is of great importance, particularly given the 89% frequency of vision-threatening abnormalities in fellow eyes.

Simultaneous choroidal melanoma and rhegmatogenous retinal detachment

A case is reported of a 30-year-old man who presented with the unusual combination of a unilateral inferonasal choroidal melanoma and an unassociated rhegmatogenous retinal detachment attributable to a large horseshoe tear in the superotemporal quadrant. Over 20 cases of simultaneous occurrence of these two phenomena have now been reported but this patient appears to be the youngest. The reports of this uncommon association are reviewed.

Retinal Detachment Following Laser in situ Keratomileusis.

■ OBJECTIVE: To report the clinical characteristics, surgical management and outcome of retinal detachment following laser in situ keratomileusis (LASIK) in myopic patients. ■ PATIENTS AND METHODS: Retrospective review of 10 eyes of 10 myopic patients with retinal detachment who had previously undergone LASIK surgery were analyzed. Included in the study were 7 males and 3 females, aged 22 to 68 years (35.2±2.8). ■ RESULTS: Mean spherical equivalent refraction was -10.51±3.90 D (ranging from -6.37 D to -17.00 D) before surgery. The time interval between the LASIK procedure and the development of retinal detachment varied from two months to nine months (5.2±2.78 months). The number of retinal breaks was one in 7 patients, two in 2 patients and three in 1 patient. The type of retinal breaks included 7 patients with horse shoe tears, 1 patient with a retinal hole, 1 patient with a giant retinal tear, and 1 patient with retinal dialysis. Retinal breaks were located anterior to the equator in 9 patients and posterior to the equator in 1 patient. Retinal reattachment was achieved with one operation in 8 eyes (80%) and the remaining 2 eyes required a second surgery for the reattachment of the retina. ■ CONCLUSION: This study suggests the possible association between retinal detachment and LASIK procedure in patients with myopia. Clinicians should be aware of retinal pathology predisposing to retinal detachment in patients undergoing LASIK.

Retinal Detachment Following Laser In Situ Keratomileusis

To report the clinical characteristics, surgical management and outcome of retinal detachment following laser in situ keratomileusis (LASIK) in myopic patients. Retrospective review of 10 eyes of 10 myopic patients with retinal detachment who had previously undergone LASIK surgery were analyzed. Included in the study were 7 males and 3 females, aged 22 to 68 years (35.2+/-2.8). Mean spherical equivalent refraction was -10.51+/-3.90 D (ranging from -6.37 D to -17.00 D) before surgery. The time interval between the LASIK procedure and the development of retinal detachment varied from two months to nine months (5.2 +/- 2.78 months). The number of retinal breaks was one in 7 patients, two in 2 patients and three in 1 patient. The type of retinal breaks included 7 patients with horse shoe tears, 1 patient with a retinal hole, 1 patient with a giant retinal tear, and 1 patient with retinal dialysis. Retinal breaks were located anterior to the equator in 9 patients and posterior to the equator in 1 patient. Retinal reattachment was achieved with one operation in 8 eyes (80%) and the remaining 2 eyes required a second surgery for the reattachment of the retina. This study suggests the possible association between retinal detachment and LASIK procedure in patients with myopia. Clinicians should be aware of retinal pathology predisposing to retinal detachment in patients undergoing LASIK.

The posterior vitreous detachment clinic: do new retinal breaks develop in the six weeks following an isolated symptomatic posterior vitreous detachment?

Symptomatic posterior vitreous detachment (PVD) is sometimes associated with sight-threatening retinal tears or retinal detachment. Patients are usually reviewed twice because it is believed that retinal breaks may develop within 6 weeks of a PVD and as such the management of a PVD consumes significant resources. The aim of this study was to find the frequency of retinal breaks developing within 6 weeks of an isolated PVD using the same experienced examiner at both visits. Patients presenting to the eye casualty with symptomatic PVD were examined by the casualty staff. Those with a retinal break or retinal detachment were referred directly for treatment and those with only a PVD were seen within 8 days in the PVD clinic. They were examined by a vitreo-retinal Fellow using indirect ophthalmoscopy and a 20 D lens with scleral indentation. The position and nature of any retinal abnormalities were noted and compared with those described in the casualty notes. Those with sight-threatening breaks were referred for treatment and the remainder were reviewed 5 weeks later when the presence of any new breaks was noted. One hundred and seven patients were referred to the PVD clinic over a 6-month period, of whom 2 did not have a PVD. At the first visit to the PVD clinic 6 patients had round holes anterior to the equator, 2 had equatorial horseshoe tears and 1 had lattice with holes. At the second visit, 2 additional patients had round holes anterior to the equator but in both the retina had been obscured by vitreous haemorrhage at the first visit. No patient in whom a full examination was possible at the first visit developed further retinal pathology. These results demonstrate the need to perform a full examination of the peripheral retina with scleral indentation at the time of presentation and emphasise the importance of finding a vitreous haemorrhage following a symptomatic PVD. If no retinal breaks are detected by thorough examination at presentation, further reviews, in the absence of increasing symptoms, may not be necessary.

Retinal detachment surgery in Marfan's syndrome.

Retinal detachment is a known complication of Marfan's syndrome. The literature is scarce on the results of surgery in these cases. To determine the functional and anatomic outcome of retinal detachment surgery in Marfan's syndrome. Retrospective review of charts of Marfan's syndrome patients who had retinal detachment surgery at King Khaled Eye Specialist Hospital between 1983 and 1995. Fourteen patients with 16 surgically treated eyes were identified. Retinal detachment was bilateral in 9/13 (69%) patients. The lens was ectopic in all eyes. Retinal breaks were small horseshoe tears or holes located anterior to the equator in 11/16 (69%) eyes. The retina of 12/16 (75%) eyes remained successfully reattached after a follow-up ranging from 4 to 132 months. All 12 eyes had visual acuity of 20/300 or better (range, 20/30-20/300). Eight of these eyes had visual acuity of 20/125 or better. The cause of failure in the remaining four eyes was proliferative vitreoretinopathy. Results of surgical repair of retinal detachment in Marfan's syndrome were better than previously thought. Bilaterality of detachment is extremely high, which justifies considering prophylactic treatment of the fellow eye in these patients.

Cryopexy in primary rhegmatogenous retinal detachment: a risk factor for postoperative proliferative vitreoretinopathy?

To evaluate the role of cryopexy in the stimulation of postoperative proliferative vitreoretinopathy (PVR) in primary rhegmatogenous retinal detachment. A series of 595 eyes of 554 patients with primary rhegmatogenous retinal detachment, referred before any failed surgery, were prospectively evaluated. Univariate and multivariate statistical analyses of the data were conducted. The incidence of postoperative PVR in relation to the methods used for retinopexy was dependent on the types and anatomy of retinal breaks associated with retinal detachment. The incidence of postoperative PVR was nil in retinal detachments due to atrophic holes in lattice, oral dialyses, and macular holes, regardless of the retinopexy methods. Postoperative PVR occurred solely in retinal detachments due to horseshoe tears (incidence 4.42%), paravascular tears of the postequatorial region (18.18%), and giant tears (24.6%) (P < 0.00001). The incidence of postoperative PVR was 0.5% in eyes with horseshoe tears with mobile posterior edges vs 9.72% in eyes with horseshoe tears with curled posterior edges, regardless of the retinopexy methods (P < 0.00001). In retinal detachments due to horseshoe tears with mobile posterior edges the incidence of postoperative PVR (0.5%) was not influenced by the retinopexy methods. In contrast, in retinal detachments due to horseshoe tears with curled posterior edges the incidence of postoperative PVR was higher in eyes managed with cryopexy (14.77%) than in eyes managed with laser retinopexy (1.78%) (P < 0.02). In retinal detachments due to giant tears the incidence of postoperative PVR was not statistically significantly greater in eyes managed with cryopexy (33.3%) than in eyes managed with laser retinopexy (15.6%). In tears 180 degrees and over in size, however, the incidence of postoperative PVR was significantly higher in eyes managed with cryopexy (9/11 eyes) than in eyes managed with laser retinopexy (5/17 eyes) (P = 0.006). Cryopexy is not a stimulating factor for postoperative PVR in primary rhegmatogenous retinal detachments due to atrophic holes in lattice, oral dialyses, macular holes, or horseshoe tears with mobile posterior edges. In contrast, cryopexy probably is a stimulating factor for postoperative PVR in retinal detachments due to horseshoe tears with curled posterior edges or to retinal tears 180 degrees and over.

Simultaneous bilateral rhegmatogenous retinal detachment

Rhegmatogenous retinal detachment (RD) has a strong bilateral tendency. It results from a chronic degenerative process, wherein both eyes are involved. However, simultaneous RD of both eyes is a rare finding. In a retrospective study we investigated the clinical course as well as risk factors in this kind of manifestation. From 1989 to 1994, 931 patients underwent operation because of RD in our ophthalmologic department. Eleven of these patients presented a simultaneous bilateral RD exceeding one hour. We excluded patients with consecutive retinal detachments and retinal detachments deriving from intraocular surgery, trauma, tractive hole formation or heredodegeneration. Seven out of 11 patients with simultaneous bilateral retinal detachment were under 35 years of age. All of these presented multiple round holes (3-19). Horse-shoe tears were causative in 6 eyes; these patients all were over 50 years of age. There was a preponderance of males (73%) in our study. Nine patients were myopic with diopters ranging from -0.5 to -11.25. Retinal reattachment by a single intervention was achieved in 21 eyes, whereas 3 eyes had to undergo a second operation for a redetachment. Simultaneous bilateral RD, the most severe type of a retinal resp. vitreoretinal degenerative process, occurs predominantly in patients under the age of 35 with multiple bilateral round holes. We therefore conclude that multiple round holes in this group of patients are not to be regarded as a benign form of degeneration.

Retinal Break Type and Proliferative Vitreoretinopathy in Nontraumatic Retinal Detachment

In a retrospective study of 1180 consecutive eyes operated for retinal detachment, vitreous traction on the rent was the determining factor for the development of proliferative vitreoretinopathy (PVR). Round, multiple, small holes in equatorial degeneration (retinogenic) and macular holes in which no vitreous traction on the rent was found did not complicate with PVR. Retinal detachment caused by horseshoe or crescent-shaped tears with evidence of vitreous traction (vitreogenic) developed PVR to a variable degree: in 171 (25.8%) senile myopic, 19 (44.2%) senile-myopic aphakic, 23 (20.2%) typical aphakic, and 32 (78.1%) patients with giant tears. We also found that retinogenic retinal detachments affected younger age groups more than did vitreogenic retinal detachments.

Retinal break type and proliferative vitreoretinopathy in nontraumatic retinal detachment

In a retrospective study of 1180 consecutive eyes operated for retinal detachment, vitreous traction on the rent was the determining factor for the development of proliferative vitreoretinopathy (PVR). Round, multiple, small holes in equatorial degeneration (retinogenic) and macular holes in which no vitreous traction on the rent was found did not complicate with PVR. Retinal detachment caused by horseshoe or crescent-shaped tears with evidence of vitreous traction (vitreogenic) developed PVR to a variable degree: in 171 (25.8%) senile myopic, 19 (44.2%) senile-myopic aphakic, 23 (20.2%) typical aphakic, and 32 (78.1%) patients with giant tears. We also found that retinogenic retinal detachments affected younger age groups more than did vitreogenic retinal detachments.

Retinal detachment following neodymium YAG laser capsulotomy in aphakic and pseudo-aphakic eyes

A retrospective study of 20 eyes with retinal detachment following Nd: YAG-laser capsulotomy was performed. Time intervals between cataract extraction and capsulotomy ranged from 1 to 50 years with a median of 22 months. Time intervals between capsulotomy and diagnosis of detachment ranged from 2 days to 15 months with an average interval of 4.42 months. Fifteen eyes had one or more horseshoe tears and one had a peripapillary tear. In one eye no tear was found. No relationship could be established to the size of the capsulotomy, the total energy applied or the number of laser effects. Three characteristic features were identified: average myopia before cataract extraction was -8.37 diopters with an average axial length of 26.65 mm. Lattice degeneration in the affected eye was found in 13 eyes. In 15 eyes the anterior hyaloid face was ruptured. Eleven cases were successfully reattached with one, 7 cases with two, and two cases with three operations. The retina was ultimately reattached in all cases. The high number of reoperations indicates a higher rate of proliferative vitreoretinopathy.

2 new possibilities for using balloon occlusion in relation to the indentation effect

Two new applications of the balloon are described which exploit its variable indentation: in the first case, the volume is reduced by withdrawal of fluid; in the second it is increased by additional injection. In both cases the procedure consists in two steps performed in subconjunctival anesthesia. In the first case the balloon provides intraocular space prior to gas injection (giant tear detachment). In the first step the balloon is inserted into the parabulbar space. After one to two hours this results in a deep indentation of the globe. In the second step the balloon indentation is used to compensate for the rise in IOP induced by the gas injection. With this "balloongasprocedure", a kind of fluid-gas-exchange is performed by injecting 1.0 ml of an expanding perfluorocarbon gas without prior drainage or pars plana vitrectomy. In the second case, the balloon is used in cases of detachment to interrupt retinal circulation prior to occlusion of a recurrently hemorrhaging vessel using the laser. In the first step, the tear is tamponaded by the parabulbar balloon and with this, the artery crossing the horseshoe tear is attached as well. In the second step, by increasing the balloon volume, retinal circulation is interrupted prior to occlusion of the artery by laser with reduced risk of hemorrhage. In both applications of the balloon a relatively complex detachment operation is divided into two smaller principle of less risky procedures on the surgery in small steps.

Acute Multifocal Hemorrhagic Retinal Vasculitis

The authors present a series of seven patients with acute visual loss associated with mild anterior uveitis, multifocal retinal vasculitis, retinal capillary nonperfusion, retinal hemorrhage, disc swelling, and vitreitis. Oral prednisone was of some benefit in these patients and oral acyclovir was generally ineffective. Neovascular complications including retinal, disc, choroidal, and iris new vessels were common, requiring photocoagulation in five patients. Horseshoe tears developed in two patients in zones of uninvolved retina but retinal detachment did not occur. The etiology remains unknown, although it may represent either a localized ocular form of Behçet's disease or other systemic syndrome, infection with a herpes group virus other than zoster varicella virus, or a manifestation of an undefined infectious agent.

Netzhautablösung nach Implantation einer Hinterkammerlinse

In a series of 6000 cases of pseudophakia following extracapsular cataract extraction and implantation of Simcoe-type posterior chamber lenses, observed for a minimum of 20 months, the incidence of retinal detachment was 21 cases (0.33%). Significant risk factors include male sex (18/21, 82%), high myopia (axial length, over 25 mm in men), intraoperative rupture and late discussion of the posterior capsule. The frequency of retinal detachment following intracapsular cataract extraction without lens implantation was four times greater than that after extracapsular cataract extraction with implantation of a posterior chamber lens. After intracapsular cataract extraction and implantation of an iris-fixation lens it was eight times greater. Horseshoe tears, most of which were located in the peripheral superior quadrants, were seen in 14 eyes (76%). In three eyes no holes were detected. Reattachment was less successful in eyes with posterior chamber implants than in phakic eyes with retinal detachments.

Analysis of prophylactic laser coagulation of retinal defects and degenerations performed in patients of the Free University of Amsterdam during the period from 1982 to July 1986.

In order to evaluate the prophylactic effect on retinal detachment a retrospective analysis was made of the prophylactic laser coagulations for retinal defects and degenerations performed on patients of the Free University of Amsterdam during the period from 1982 to July 1986. The main conclusion is that in a total of 273 treated eyes only two developed a spontaneous retinal detachment after coagulation. This is an incidence of 0.7%, which compares favourably with untreated groups. The treatment criteria were: 1. symptomatic defects; 2. defects and degenerations in fellow eyes; 3. asymptotic defects in aphakia, myopia greater than 5 D, single eyes and a positive family history. The most frequent complication was vitreous haemorrhage due to rupture of a patent vessel bridging the detached lip of a horseshoe tear, but vision was restored to normal in all but one case after the haemorrhage cleared.

Clinical factors predisposing to massive proliferative vitreoretinopathy in rhegmatogenous retinal detachment.

A series of 354 consecutive rhegmatogenous retinal detachments, operated on by means of microsurgery, is evaluated to determine the clinical factors that may predispose to the development of postoperative massive proliferative vitreoretinopathy (MPVR). Three statistically significant parameters in the development of postoperative MPVR are demonstrated: failure of previous surgery, preoperative fixed retinal folds, and horseshoe retinal tear(s) exposing a total surface of 3 disc diameters or more of pigment epithelium. For further study, it is suggested that in retinal detachments with such horseshoe tears, early destruction of the exposed pigment epithelium by argon laser photocoagulation may be a valuable means of decreasing the incidence of MPVR after retinal detachment repair.

Prevention, in the contralateral eye, of a giant tear ablation

In this paper the authors report on 11 patients with giant tear detachment, whose fellow eyes were prophylactically treated with cryopexy or laser coagulation. The patients were followed up for between 4 and 12 years. The prophylactic lesions were located radially or circumferentially (circumscribed or extending through 180 degrees). In 4 out of 11 patients new tears developed during the follow-up period. The tears occurred between 1 month and 7 1/2 years after prophylactic treatment. In one of these cases a giant tear (90 degrees) developed in spite of prophylaxis: this was a case in which the coagulations extended circumferentially for 180 degrees; the new tear originated posteriorly to the scars. In contrast to this only multiple small horseshoe tears were observed in the other 3 patients: in these cases the prophylactic lesions were arranged radially or were circumferential and circumscribed. Some of these horseshoe tears were still attached and were treated with cryopexy or laser coagulation; others were already detached, reattachment was achieved by cryopexy and radial buckling of the tears.