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OPHTHALMOLOGY PRACTICE
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Year : 2001 | Volume : 49 | Issue : 3 | Page : 199-202
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Previous Article Finding the retinal break in rhegmatogenous retinal detachment
Table of Contents
Saxena Sandeep, Lincoff Harvey
Department of Ophthalmology, New York Presbyterian Hospital-Cornell
University Medical Center, New York, U.S.A,
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Correspondence Address:
PUBMED
Lincoff Harvey
Search Pubmed New York Presbyterian Hospital, 525 East 68[th] Street, Suite F-832, New
for York 10021, USA

- Saxena S
- Lincoff H Abstract

[PDF Not The development of subretinal fluid is governed by a limited number of

available] * anatomical factors and gravity. As a result, rhegmatogenous retinal
Citation Manager detachments form in a predictable manner around the retinal break of
their origin. The shape of the detachments points to the position of the
Access Statistics break. The purpose of this review is to describe the characterstic
Reader contours of subretinal fluid in rhegmatogenous retinal detachments,
Comments and to highlight some rules and methodology which can help in the
Email Alert * detection of the retinal break in phakic, psuedophakic and recurrent
retinal detachments.
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Keywords: Retinal break, rhegmatogenous retinal detachment, subretinal
fluid.

Abstract
How to cite this article:
Finding the brea... Saxena S, Lincoff H. Finding the retinal break in rhegmatogenous retinal
Finding the brea... detachment. Indian J Ophthalmol 2001;49:199-202
Finding the brea...
 References How to cite this URL:
Article Figures Saxena S, Lincoff H. Finding the retinal break in rhegmatogenous retinal
detachment. Indian J Ophthalmol [serial online] 2001 [cited 2006 Sep
29];49:199-202. Available from: http://www.ijo.in/article.asp?issn=0301-
Article Access 4738;year=2001;volume=49;issue=3;spage=199;epage=202;aulast=Saxena
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Printed 43 The success of retinal surgery for rhegmatogenous retinal detachment
depends on findings the retinal break. A precise drawing of the fundus and
Emailed 7
the position of the break will guide the surgeon at the time of surgery.
Comments [Add] Attempts should be made to search for additional breaks that might be
present in addition to the primary break. There is one break in about 50% of
detachments but 2 breaks in 30% and 3 or more breaks in 20% of the
cases.[1]

The characteristics of rhegmatogenous detachments are: (1) they have

convex surface and borders: (2) they develop dependent shapes in relation
to the position of the most superior retinal break; (3) they extend from ora
towards optic disc; and (4) they are progressive. Nonrhegmatogenous retinal
detachments tend to be confined and do not extend from ora to optic disc.
Exudative detachments are dependent and symmetrical around 6 o'clock. If
Click on image for
the patient is examined lying flat, the fluid spreads posteriorly and if the
details.
patient is turned onto one or another side, the fluid runs up symmetrically on
either side.

The position of the retinal break can be deducted from the shape of the
detachment because subretinal fluid forms in a predictable manner from the
break of origin. The growth and eventual shape of retinal detachment is
governed by the position of the retinal break, the effect of gravity on
subretinal fluid in relation to the erect posture and the anatomical limits
such as the disc, the ora serrata and any chorioretinal adhesions that might
be present. The most superior break in a detachment with multiple breaks is
designated the primary break because it would produce the same contour if
it were a single break.

[TAG:2]Finding the break in retinal detachment[2][/TAG:2]

(A) Superior temporal and nasal detachment

The detachment that arises from a superior break first forms around the
break, then extends to the ora and then towards the optic disc. The
detachment may initially be restricted to one quadrant. Once a bullous
detachment has begun to form, the effects of gravity and ocular motion
cause a dependent progression. The detachment descends as a front that
revolves around the inferior pole of the disc and rises on the opposite side.
Fluid may rise as high on the opposite side of the disc as the level of the
primary retinal break, but never as high as the fluid level on the primary
side. The primary break will be found within 1½ clock hours, of the highest
border of the detachment, in 98% cases (Figure).
(B) Detachments that cross the 12 o'clock radian and total detachment

Detachments that cross the 12 o'clock radian originate from breaks at or

near 12 o'clock. These detachments can become total. The more posterior
the break, the more it can deviate from 12 o'clock position and still cause a
detachment that will cross the vertical radian. In 93% of cases, the hole of
origin lies with great frequency within a triangle whose apex is at 12 o'clock
position at ora and whose sides intersect the equator one hour to at either
side of 12 o'clock (Figure).

Attempts to reattach to total retinal detachment by repairing a break in an

inferior quadrant, which must be a secondary break, are doomed to failure
barring the presence of unusual traction. When studying a total detachment,
it is important to look for a wedge of attached retina near 12 o'clock. The
presence of a wedge of attached retina converts the problem of searching for
the break in three clock hours (1½ clock hours to either side of 12 o'clock)
of suspect retina in a total retinal detachment to one of searching 1½ clock
hours in a superolateral or nasal detachment.

(C) Inferior detachment

The subretinal fluid that arises from breaks below the level of the optic disc
develops first around the break and then descends to the ora serrata. It
advances across the eye and towards the disc, rising higher on that side of
the disc where the break lies. Thus, the higher side points to the position of
the retinal break. The break need only be 1 or 2 mm from the 6 o'clock
position for it to cause a difference in fluid levels. When the levels are
equal, the hole is at the 6 o'clock radian. Detachments that arise from
inferior breaks progress slowly and may be recognized late. The higher side
of the detachment predicts the side of the break in 95% cases (Figure).

Occasionally, what appears to be an inferior detachment, equal in height on

both sides of the disc, arises from a superior break which connects with the
detachment by a shallow peripheral sinus. A history of rapid development
and the absence of pigment demarcation lines suggests the presence of a
superior break. When an inferior detachment is bullous, the primary break is
above the horizontal radian. Inferior detachments that emanate from the
inferior holes are relatively shallow.

All retinal breaks need to be closed at surgery. To avoid the pitfall of

repairing a secondary break and omitting the treatment of the primary one, it
is important to organize the examination. First, draw the limits of the
detachment, then search the appropriate area for the primary break. Second,
search for additional breaks. In more than 50% cases these will be in the
same latitude as the primary break and close to it. Goldmann 3-mirror
contact lens can be used to detect tiny breaks in phakic and aphakic retinal
detachments. Slitlamp biomicroscope beam with maximum illumination is
used. On rare occasions when no break can be found, or when the breaks
that are found do not fit the criteria for the primary break, it is advisable to
explore the appropriate area at the operating table with cryopexy to elicit the
break.

Prospective segmental buckling can be used to localize the breaks. Carrying

out this procedure implies that only the extent of the area of probability
should be buckled, since the primary break is localized there 95% of the
time. For a superior temporal or nasal detachment, buckle the upper 1½
clock hours. With superior detachment that crosses the 12 o'clock radian,
buckle 1½ hours on either side of 12 o'clock, i.e., buckle 3 clock hours.
With an inferior detachment, buckle up to 3 clock hours beneath the higher
border of the detachment to 6 o'clock. If the retina reattaches the next day
then the break was buckled. Interrupted laser must be applied over the entire
length of the prospective segmental buckle. This is not to secure the
tamponaded breaks but any undetected breaks on it. If the retinal fails to
reattach after prospective segmental buckling the area buckled probably
does not contain the break or all of the breaks. The retina should be again
examined using the biomicroscope and the various contact lenses.

The advancing meniscus of an expanding gas bubble or the receding

meniscus of an intraocular gas bubble, being absorbed, can be used to find
the level of retinal break in cases in which the break is not identified by
usual examined techniques.[3] When an advancing meniscus of an
expanding bubble is used, small amount of perfluorocarbon gas is injected,
into the vitreous cavity, without drainage of subretinal fluid. As the gas
bubble expands it reattaches the retina from above downward. When the
bubble covers the retinal break, it tamponades it and the remaining fluid
below absorbs within hours. The level of the meniscus when the retina
becomes reattached marks the level of the retinal break. When a receding
meniscus is used, the bubble closes the break and maintains reattachments.
The level of the meniscus when the redetachment first occurs indicates the
level of the break.

[TAG:2]Finding the break in the pseudophakic eye with retinal

detachment[4][/TAG:2]

Retinal breaks in pseudophakic eyes are almost invariably anterior to the

equator. The wide field indirect contact lens (Volk Equator Plus scanning
fundus lens, Mentor, Ohio, USA) with some tilting, provides a clear image
for biomicroscopy anterior to the equator. The indirect optics provides an
image around moderate lens opacities and through thin capsular opacities,
similar to the view obtained with the indirect ophthalmoscope. Through a 6-
mm pupil, it is possible to bring the anterior retina and frequently the ora
serrata into view in pseudophakic eyes. Their value for examining the retina
anterior to the equator in the pseudophakic eye has so for been
underappreciated.

With the wide-field indirect contact lens, a short slitlamp beam with
maximum illumination, lined up at zero angle with the oculars, is used. To
extend the view the patient is asked to look one-half inch towards the area to
be studied. The axis of the lens is tilted towards this area, which is
depressed through the eyelids with the round end of a curved stick
depressor. When an area of suspicion is obstructed by a dense posterior
capsular opacification, it can be notched with the YAG laser. The opening
need not be wide if the radian of the cut is oriented towards the area to be
studied.

In the pseudophakic eye, the wide-field indirect contact lens can produce an
image anterior to the equator for the slitlamp almost to the extent as can be
obtained by viewing with an indirect ophthalmoscope. The keys to bringing
the anterior retina into view are rotating the eye, tilting the axis of the lens a
few degrees towards the area to be examined and applying scleral
depression.

The wide field indirect contact lens augments the retinal examination for the
psuedophakic eye by detecting small breaks that can be overlooked with
indirect ophthalmoscopy. The indirect contact lens has an advantage over
the Goldmann lens because it eliminates the blur of marginal astigmatism
induced by the intraocular lens and because the indirect image suffers less
interference from lenticular and capsular opacities. The image through the
indirect contact lens is inverted, as it is with the indirect ophthalmoscope,
and can be transferred directly to an inverted retinal chart.

[TAG:2]Finding the break in the eye with redetachment[5][/TAG:2]

Three patterns of detachment can emerge after a failed buckle surgery in

eyes that undergo surgery without drainage:

1. (1) When the superior border of a temporal or nasal detachment falls

below the buckle and the surface of the residual detachment is
convex to the ora and persists, it implies the presence of another
break below the new superior border.

2. (2) When the pattern of the detachment (lateral, superior, or inferior)

converts to another pattern, it indicates the presence of an undetected
break consistent with the new pattern.

3. (3) When the borders of the detachment remain unchanged after

buckling surgery and the buckle appears to be in a good position, the
most probable cause is an undetected break above the buckle.

At least 88% of rhegmatogenous retinal detachments are relatively

uncomplicated when they first present, and will respond to one or more
segmental buckle augmented occasionally by an encircling band, with or
without drainage of fluid.[6] Failure in the drained eye is manifested by
partial or complete redetachment and in the undrained eye by incomplete or
no attachment. The pattern of the detached retina will remain the same upon
mobilization after either procedure,

A minimum of extraocular surgery for a rhegmatogenous retinal detachment

can yield attachment only if it is preceded by a maximum search for the
retinal breaks.

References

1. Kreissig I. A Practical Guide to Minimal Surgery for Retinal

Detachment. Vol. I. Stuttgart: Thieme;2000. p 25.
2. Lincoff H, Gieser R. Finding the hole. Arch Ophthalmol 1971;85:565-
69. [PUBMED] [FULLTEXT]
3. Lincoff H, Kreissig I, Coleman DJ, Chang S. Use of an intraocular gas
tamponade to find retinal breaks. Am J Ophthalmol 1983;96:510-16.
[PUBMED] [FULLTEXT]
4. Lincoff H, Kriessig I. Finding the.retinal hole in the pseudophakic eye
with detachment. Am J Ophthalmol 1993;117:442-46.
5. Lincoff H. Kreissig I. Extraocular repeat surgery of retinal detachment.
A minimal approach. Ophthalmology 1996;103:1586-92.
6. Kreissig I, Rose D, Jost B. Minimized surgery for retinal detachments
with segmental buckling and non drainage. An 11-year follow up.
Retina 1992;12:224-31. [PUBMED] [FULLTEXT]

Figures

[Figure - 1]

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