JOURNAL BRITISH MEDICAL LONDON SATURDAY SEPTEMBER 9 1944 RETINAL DETACHMENT: A SERIES OF 78 CASES IN THE MIDDLE EAST FORCE BY H. B. STALLARD, M.B.E., M.D., F.R.C.S. Major, R.A.M.C.(T.A.); Assistant Eye Surgeon, St. Bartholomew's Hospital In the war of 1914-18 the treatment of retinal detachment one, two, and very rarely more punctures were made in the was a failure, and indeed this was so up till 1929, when sclera with the diathermy needle carrying a current of 40 mA Jules Gonin (Switzerland) described to the International Con- for 1 second (see Fig. 1). The interretinal fluid was sucked gress of Ophthalmology in Amsterdam his successes obtained into a glass tube and rubber suction bulb applied to the sclera surgically by sealing a retinal tear or tears and evacuating 'the over the diathermy penetration. The patients were soldiers in interretinal fluid by means of puncture with a galvano-cautery. good health between the ages of 20 and 47, the majority being Before this discovery very few cases of retinal detachment in the third decade of life. This survey differs from a survey underwent improvement and spontaneous recovery; such were of retinal detachment in civil practice in two respects: (1) the quite exceptional. incidence of myopia in retinal detachment would be appreciably Gonin's principles still hold good to-day, but the operative higher than 3 in 78 cases; and (2) in civil practice injuries technique has changed. Accurate location of the retinal tear peculiar to war are of course not present. In the last the or tears in relation to the outside of the sclera is essential. prognosis is adversely affected by the severity of the intraocular The edges of the retinal tear and the choroid overlying this damage caused by blast and the ravages of high-velocity metallic site are rendered adhesive by electro-coagulation. This is missiles with ragged edges and rough surfaces. effected through diathermy, applied either to the surface of I have classifld the 78 cases as follows: the sclera at the site of the tear or by a diathermy needle (1) Cystic degeneration .. .. .. .. 13 penetrating the sclera and choroid to reach the retina but not (2) Choroido-retinal degeneration .. .. 21 The interretinal fluid beneath the detachment (3) Myopia' .. .. .. .. .. .. .. 3 entering it. is (4) Trauma (civil) .. .. .. .. .. 23 drained thoroughly either by penetrating diathermy needle (5) Trauma (military) .. .. .. .. .. 18 punctures and suction or by trephining the sclera and puncturing Of these, 11- were officers-one a nursing officer (Q.A.I.M.N.S.). the choroid, and secure choroido-retinal adhesions completely The remainder were other ranks, and included: Royal Navy, 2 cases; surrounding the tear are encouraged by placing the patient's Royal Air Force, 2 cases; Royal Canadian Air Force, 1 case; and head so that the retinal tear and the drainage puncture lie in the Merchant Navy, 1 case. The following table shows the age the most dependent position obtainable. The effects of gravity incidence in decades in these five groups. of the vitreous assist this. TABLE I.-Age Incidence Age Choroido- Cystic retinal Myopia Trauma, Trrauma, (Years) Degeneration Degeneration Civil Military -1- - 20-30 9 16 18 15 31-40 4 3 2 5 3 41-47 2, The nationalities were: British, 60; Canadian, 2; New Zealand, 1; South African, 3; Indian, 3; Greek, 4; Polish, 2; Czech, 1I German, 1; Italian, 1. 1. Cystic Degeneration (13 Cases) The date of origin of the detachment was unknown in 11 cases. In these the condition was discovered in the course of routine examination. In two cases a sudden spread of the detachment from the limits of the cystic area caused separation of the macula so that the soldier noticed the visual defect. One sought advice one week after this event and the other four months later. The position of the cystic area was peripheral in all cases. In 10 it was in the lower temporal quadrant, and in two of these it had spread to strip off the macula; in 2 cases the upper and lower FIG. 1 temporal quadrants were affected at the periphery, and in 1 case the lower temporal and lower nasal quadrants were involved. In 9 The following statistics concern 78 officers and men of the cases there was a well-defined arc of pigmentary disturbance in Middle East Force suffering from retinal detachment and the choroid and retina at the posterior periphery of the cyst up admitted to a military hospital in Egypt for investigation and to the ora serrata, where these changes ceased. In 3 others this was treatment of this disorder from 1941 to 1943. Seventy-six were faint. The ophthalmoscopic appearance suggested a line of adhesion operated on; for one case surgical treatment was not between the retina and choroid, which was more marked in some advised, cases than in others. In one case these changes were present in only and another made a spontaneous recovery. part of the arc at the posterior periphery of the cyst. The operation performed in these cases was a combination In one case of haemangiogliomatosis retinae a retinal cyst was of surface diathermy (90 to 100 mA for 8 seconds) placed at the periphery of the lower temporal quadrant, remote from the around the-edges of a tear or tears and penetrating diathermy; neoplasm, which was behind the equator along the course of the 4366 330 SEPT. 1944 RETINAL DETACHMENT BRITISH 9, MEDICAL JOURNAL upper temporal vessels. There were no apparent degenerative and eye in 1 case and 2.25 mm. Hg higher in another. In the remainder pigmentary changes in the retina and choroid at the edge of the the intraocular pressure was equal in both eyes. In all cases the cyst. retina was replaced and the visual field restored. A retinal tear or tears were found in 12 cases; in the remaining Visual Result and Refraction.-In 18 cases in this group the one, which was associated with haemangiogliomatosis retinae, there macula was detached. Two of these recovered 6/12, two 6/18, one was no tear. The retinal tears were at the ora serrata in 9 cases, in 6/24, and the remainder 6/36 to 6/60. The 6/60 was obtained five of which a single tear was present; in 2 there were two tears, in eccentrically by a few. Two patients had visual acuity of 6/5 and there were two tears at the ora serrata and two posterior to-this, one 6/6. In 4 cases astigmatism of 1.25 D-two myopic and two in another case four at the ora serrata and three posterior to this. hypermetropic-was present after operation. In one case the tear was a single round hole about 1.5 mm. behind the ora serrata. In two instances no clearly defined hole was 3. Myopia (3 Cases) evident; in one of these there were two thin areas of atrophic The degree of myopia was 8 D in one case, 5.5 D with 2.5 D retina and in another four such areas, two of which were minute. astigmatism in another, and 3.75 D in the third. The duration of These were all placed about 1.5 to 2 mm. behind the ora serrata. the detachment wa§ two to three weeks in all cases. The area of The right eye was affected in 9 and the left in 4 cases. The detachmtient was in the upper temporal quadrant in I case, the upper intraocular pressure was 1 to 2 mm. Hg below normal in 3 cases, temporal and upper nasal quadrants in case, and the upper and in I it was 2 mm. Hg above lower nasal quadrants in the that in the other (normal) eye, other. and in the. remainder it was Retinial Tears.-In one case equal in both eyes. One month LEGENDS FFOa)R FIGURES there were seven tears between it was 6 mm. after operation Hg, the equator and the ora serrata often less, and it gradually re- FIG. I.-Retinal detachmernt operation. Exposure of the in the upper temporal quadrant. turned to normal in 3 to 6 sclera at the site of a retinal tear in the upper temporal months after operation. quadrant of the left eye. The flap of conjunctiva and Two of these were crescent- flehcted by two sutures. Two shaped and larger than the case capsule is held ref which were One operation in each Tenon's sh the tendon of the adjacent others, ragged and traction sutures pass throug The line of successfully replaced the retina, has been to the irregular. tears in tear, and restored the recti muscles. Surface diath rmy applied sealed the heirmy is made at the this case was continuous with field. There were no sclera and penetrating diatl being visual borut the equatori a zone of choroido-retinal de- failures. This type of case is posterior edge of the tear at generation about 2 mm. wide in particularly favourable for sur- FIG. 2.-Drawing of left fuin4dus of Dvr. H. E. Intraocular the lower temporal quadrant. gical treatment. The danger of contracting scar tissue on nassal side from 6.30 to 10 o'clock. In another case there was a a sudden spread of the detach- In the 3 o'clock meridian ttheere is a dense fibrous band single arrowhead-shaped split at ment justifies an operation in which runs posteriorly behinid the equator. The retina is the ora serrata in the upper which the chances of success are, detached above and below thilis band.