A O S 2000 354 Simultaneous, bilateral rhegmatogenous retinal detachment Jørgen Krohn and Johan H. Seland Department of Ophthalmology, University of Bergen, Bergen, Norway ABSTRACT. Purpose: To examine the incidence, the preoperative findings and the surgical outcome of patients presenting with simultaneous, bilateral retinal detachment. Methods: A retrospective analysis of the medical records of patients undergoing surgery for rhegmatogenous retinal detachment between 1990 and 1998. Results: During this period a total of 827 operations for rhegmatogenous retinal detachment were done in 791 consecutive patients. Eighteen patients (2.3%) had simultaneous, bilateral retinal detachment, giving an annual incidence of 0.35 patients per 100 000 population. They all presented with unilateral symptoms. Compared with the group of unilateral or consecutive, bilateral retinal detach- ments, patients suffering from simultaneous, bilateral retinal detachments were significantly younger, with a mean age of 40.3 years. Thirteen patients had multiple, round retinal holes associated with lattice degeneration. Sixteen pa- tients were myopic, ranging from ª3 to ª9.25 diopters. The retina was reat- tached in 35 (97%) of the 36 eyes operated on during the study period. Conclusion: Simultaneous, bilateral retinal detachment is usually found in rela- tively young, myopic patients with round, atrophic retinal holes, presenting with unilateral visual symptoms. Key words: retinal detachment – bilateral – simultaneous – retinal break – myopia – lattice de- generation – incidence – age – symptoms – surgery. Acta Ophthalmol. Scand. 2000; 78: 354–358 Copyright c Acta Ophthalmol Scand 1999. ISSN 1395-3907 A severe eye disease threatening both eyes is the most challenging situ- ation in ophthalmological practice. This is especially so in the case of vitreoretinal disorders, where bilateral morbidity is the rule rather than a rare exception. In the course of time retinal degenerations or detachment in one eye often necessitate prophylactic or curative treatment of the fellow eye. There are several reports in the literature concerning the frequency of bi- lateral involvement. Lattice degeneration is present in about 6% of the population and is bilateral in approximately 50% of the affected patients (Glasgow et al. 1993). Among patients with unilateral retinal detachment retinal degenerative changes were found in 63–90% and reti- nal breaks in about 20% of the unde- tached fellow eyes (Merin et al. 1971; Ci- urlo et al. 1980). According to previous studies, retinal detachment has a strong bilateral tendency, varying from 10 to 20% depending on the criteria of se- lecting the patients and the length of fol- low-up (Schepens & Marden 1961; De- laney & Oates 1978; Folk & Burton 1982; Laatikainen & Harju 1985). In aphakic detachment series, the risk of bilaterality has been reported to be higher (Benson et al. 1975; Folk & Burton 1983; Laati- kainen & Harju 1985). The interval between the detachment in the first and second eye usually covers a period of several years (Delaney & Oat- es 1978). Patients may, however, also present with simultaneous retinal detach- ment in both eyes at the initial examina- tion. To bring further knowledge on the clinical course of simultaneous, bilateral retinal detachment, an eight-year review was undertaken among all patients sur- gically treated for retinal detachment at our department. Material and Methods Study group The relevant data of patients treated for retinal detachment at the Department of Ophthalmology, Haukeland University Hospital, Bergen, between January 1990 and the end of 1998 were collected from a computerised database. The referral area for the hospital comprised the coun- ties of Sogn & Fjordane, Hordaland and the northern part of Rogaland (1998 total populationΩ637813). All patients undergoing primary operations for rheg- matogenous retinal detachment (RD) were included in the study. Thus, the study group included all retinal detach- ments except exudative detachments and tractional detachments without second- ary retinal breaks. A repeated operation for RD on the same eye more than one year after the first operation was desig- nated as a new case of RD and the surgery was classified as a primary oper- ation. If, on a later occasion, the patient’s fellow eye was treated for RD, this was also classified as a new case, primarily operated on for RD. The age was re- corded at the time of the first detachment in patients undergoing more than one op- eration. RD was defined as two or more disc diameters of subretinal fluid sur- rounding the margin of a retinal break. Round holes without opercula were con- sidered to be atrophic retinal breaks. Pa- tients with RD in both eyes, observed by indirect ophthalmoscopy at the initial ex- 16000420, 2000, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0420.2000.078003354.x by Readcube (Labtiva Inc.), Wiley Online Library on [06/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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Simultaneous, bilateral rhegmatogenous retinal detachmentDepartment of Ophthalmology, University of Bergen, Bergen, Norway
ABSTRACT. Purpose: To examine the incidence, the preoperative findings and the surgical outcome of patients presenting with simultaneous, bilateral retinal detachment. Methods: A retrospective analysis of the medical records of patients undergoing surgery for rhegmatogenous retinal detachment between 1990 and 1998. Results: During this period a total of 827 operations for rhegmatogenous retinal detachment were done in 791 consecutive patients. Eighteen patients (2.3%) had simultaneous, bilateral retinal detachment, giving an annual incidence of 0.35 patients per 100 000 population. They all presented with unilateral symptoms. Compared with the group of unilateral or consecutive, bilateral retinal detach- ments, patients suffering from simultaneous, bilateral retinal detachments were significantly younger, with a mean age of 40.3 years. Thirteen patients had multiple, round retinal holes associated with lattice degeneration. Sixteen pa- tients were myopic, ranging from ª3 to ª9.25 diopters. The retina was reat- tached in 35 (97%) of the 36 eyes operated on during the study period. Conclusion: Simultaneous, bilateral retinal detachment is usually found in rela- tively young, myopic patients with round, atrophic retinal holes, presenting with unilateral visual symptoms.
Key words: retinal detachment – bilateral – simultaneous – retinal break – myopia – lattice de- generation – incidence – age – symptoms – surgery.
Acta Ophthalmol. Scand. 2000; 78: 354–358 Copyright c Acta Ophthalmol Scand 1999. ISSN 1395-3907
Asevere eye disease threatening both eyes is the most challenging situ-
ation in ophthalmological practice. This is especially so in the case of vitreoretinal disorders, where bilateral morbidity is the rule rather than a rare exception. In the course of time retinal degenerations or detachment in one eye often necessitate prophylactic or curative treatment of the fellow eye. There are several reports in the literature concerning the frequency of bi- lateral involvement. Lattice degeneration is present in about 6% of the population and is bilateral in approximately 50% of the affected patients (Glasgow et al. 1993). Among patients with unilateral retinal detachment retinal degenerative changes were found in 63–90% and reti- nal breaks in about 20% of the unde-
tached fellow eyes (Merin et al. 1971; Ci- urlo et al. 1980). According to previous studies, retinal detachment has a strong bilateral tendency, varying from 10 to 20% depending on the criteria of se- lecting the patients and the length of fol- low-up (Schepens & Marden 1961; De- laney & Oates 1978; Folk & Burton 1982; Laatikainen & Harju 1985). In aphakic detachment series, the risk of bilaterality has been reported to be higher (Benson et al. 1975; Folk & Burton 1983; Laati- kainen & Harju 1985).
The interval between the detachment in the first and second eye usually covers a period of several years (Delaney & Oat- es 1978). Patients may, however, also present with simultaneous retinal detach- ment in both eyes at the initial examina-
tion. To bring further knowledge on the clinical course of simultaneous, bilateral retinal detachment, an eight-year review was undertaken among all patients sur- gically treated for retinal detachment at our department.
Material and Methods Study group The relevant data of patients treated for retinal detachment at the Department of Ophthalmology, Haukeland University Hospital, Bergen, between January 1990 and the end of 1998 were collected from a computerised database. The referral area for the hospital comprised the coun- ties of Sogn & Fjordane, Hordaland and the northern part of Rogaland (1998 total population637813). All patients undergoing primary operations for rheg- matogenous retinal detachment (RD) were included in the study. Thus, the study group included all retinal detach- ments except exudative detachments and tractional detachments without second- ary retinal breaks. A repeated operation for RD on the same eye more than one year after the first operation was desig- nated as a new case of RD and the surgery was classified as a primary oper- ation. If, on a later occasion, the patient’s fellow eye was treated for RD, this was also classified as a new case, primarily operated on for RD. The age was re- corded at the time of the first detachment in patients undergoing more than one op- eration. RD was defined as two or more disc diameters of subretinal fluid sur- rounding the margin of a retinal break. Round holes without opercula were con- sidered to be atrophic retinal breaks. Pa- tients with RD in both eyes, observed by indirect ophthalmoscopy at the initial ex-
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amination, were grouped as having simul- taneous, bilateral, rhegmatogenous reti- nal detachment (SRD).
Pre- and postoperative variables The total group of RD patients, includ- ing both the unilateral and consecutive, bilateral cases, were compared with the SRD patients regarding the incidence rates and the age and sex distribution.
All patients in the SRD group had their hospital records analysed for the following data: history of previous eye disease and eye surgery, preoperative re- fraction (spherical equivalent), presence of predisposing peripheral retinal de- generations and duration of symptoms. The hospital records and retinal drawings were analysed for the extent and location of detachment and the type and location of retinal breaks. In addition, the pre- and postoperative visual acuity, the surgi- cal technique used, the interval between surgery of the first and second eye and the final condition of the retina were re- corded.
Statistical methods The data were analysed by the Student’s t test and the c2-test with Yates correc- tion. For all tests p-values less than 0.05 were considered statistically significant.
Results Epidemiology Incidence During the eight-year period 827 primary operations for new cases of RD were per- formed on 791 different patients. Inci- dence rates, adjusted to the age and gen- der distribution of the population in our referral area were calculated. The overall annual incidence rate of all RD cases was 16.2 per 100 000 population.
In 18 patients (2.3%) SRD was ob- served at the initial examination. The overall annual incidence rate of SRD was 0.35 patients per 100 000 population. The age- and sex-specific annual incidences of RD and SRD are presented in Table 1.
Age and sex In the total group of 791 patients oper- ated on for RD, 432 (55%) were men and 359 (45%) were women. The mean age at the time of surgery was 58.4 years (range 6–95 years).
Among the 773 patients with unilateral or consecutive, bilateral RD, there were 421 (54.5%) men and 352 (45.5%)
women. The mean age at the time of surgery was 58.8 years (range 6–95 years), and it was significantly higher in women than in men (p∞0.002). The correspond- ing numbers in the SRD group were 11 (61%) men and 7 (39%) women. The mean age at the time of surgery was 40.3 years (range 7–76 years), with no signifi- cant difference between men and women. The differences in age and sex distri- bution between the two groups are pre- sented in Table 2.
The patients with SRD were signifi- cantly younger than those with unilateral or consecutive, bilateral RD (p∞0.002). The predominance of men in the SRD group was not significantly different compared to the patients with unilateral or consecutive, bilateral RD. The age and sex distribution in the SRD group are il- lustrated in Fig. 1.
Table 1. Age- and sex-specific annual incidences (cases per 100 000 population) of rhegmatogenous retinal detachment (RD) and simultaneous, bilateral rhegmatogenous retinal detachment (SRD).
RD SRD
Age (years) Male Female Male Female
0–19 1.9 1.6 0.1 0.1 20–39 9.9 4.4 0.6 0.3 40–59 24.6 16.5 0.5 0.5 60–79 52.8 47.5 0.6 0.2 ±80 35.6 28.1 0 0
Table 2. Mean age in years of patients with rhegmatogenous retinal detachment. The numbers in parentheses represent the total number of patients in each group.
Male Female Total
Unilateral or consecutive, bilateral retinal detachment 56.0 (421) 62.1 (352) 58.8 (773) Simultaneous, bilateral retinal detachment 40.5 (11) 40.0 (7) 40.3 (18)
Fig. 1. Age and sex distribution in 18 patients with simultaneous, bilateral retinal detachment.
Characteristics of the SRD patients Previous eye disease The youngest patient in the SRD group (male, age 7) had Pierre Robin syndrome, a rare anomaly occasionally associated with high myopia and RD (Cosman & Keyser 1974). One patient (male, age 76) had primary open-angle glaucoma, oper- ated with trabeculectomies 4 and 10 years prior to the SRD. He also underwent an uncomplicated extracapsular cataract ex- traction in the left eye two years earlier and in the right eye two months before the diagnosis of SRD was made. One pa- tient (age 32) was in her 28th week of an otherwise uncomplicated pregnancy when the SRD occurred. Another patient (female, age 51) had undergone a strabis- mus operation when she was 16 years old. The remaining 14 patients had no other known eye disease and no history of ocu-
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356
lar or orbital trauma. Two patients re- ported familial occurrences of nontrau- matic retinal detachments.
Refraction One patient (male, age 65) was em- metropic. The male patient (age 76) with posterior chamber IOLs was hyperme- tropic π1 diopters (D) prior to the catar- act extractions. Sixteen patients (89%) were myopic, with a spherical equivalent ranging from ª3 to ª9.25 D. High my- opia (ª5 D or more in both eyes) was found in 9 patients (50%).
Peripheral retinal degenerations Lattice degeneration of the retina was found in 14 patients (78%) with SRD. The lesions were bilateral and occurred in
Fig. 2. The columns represent the percentage of which each of the four quadrants was in- volved in the retinal detachment of 18 patients (36 eyes) with simultaneous, bilateral retinal detachment.
Fig. 3. The columns represent the total number of retinal breaks found in each of the four quadrants of 18 patients (36 eyes) with simul- taneous, bilateral retinal detachment.
Fig. 4. Scattergram comparing preoperative visual acuity (horizontal axis) and final postoperative visual acuity (vertical axis) of 18 patients (36 eyes) with simultaneous, bilateral retinal detachment. Each point represents one eye. (NLPno light perception, LPlight perception, CFcounting fingers).
all sectors, but were most prominent in the two upper quadrants. The male pa- tient (age 76) previously treated for glau- coma and cataract had a degenerative re- tinoschisis located in the inferior, tem- poral quadrant of his left eye.
Symptoms All patients with SRD had symptoms from only one eye. Thus, the bilateral condition was first recognised after rou- tine examination of the fellow eye. In all cases the presenting eye had the most ex- tensive retinal detachment. Usually, the patients experienced floaters or a periph- eral visual field defect, and patients with macular involvement reported an impair- ment of the central vision. Only two pa- tients had noticed light flashes as the ini- tial symptom. The duration of symp- toms, before the diagnosis of SRD was made, varied from 2 days to 9 months (mean 2 months). In 11 patients (61%) the right eye was the first to give symp- toms.
Retinal detachment The two temporal quadrants were more often detached than the nasal quadrants. The frequency of which each of the four quadrants was involved in the retinal de- tachment is illustrated in Fig. 2. In 7 eyes (19%) the detached area was less than one quadrant (∞90æ). Total detachment was
found in two eyes (5.5%). The macular area was detached in 11 eyes (30.5%).
Retinal breaks The number of retinal breaks in each eye varied from 1 to 10 (mean 4). Multiple breaks (two or more) were found in 26 eyes (72%). Retinal breaks could be ob- served in all quadrants, but were most commonly located in the upper, temporal quadrant. The total number of retinal breaks found in each of the four quad- rants is illustrated in Fig. 3. Fourteen pa- tients (78%) with SRD had round, atrophic retinal holes in both eyes. In 13 of these patients the holes were associated with lattice degeneration. Two patients (female, age 51 and male, age 21) had bi- lateral retinal dialysis located in the in- ferior, temporal retina. In two patients, one female (age 65) and one male (age 76, previously operated on for bilateral glaucoma and cataract), ‘‘horseshoe- shaped’’ retinal breaks (flap tears) were observed in both eyes.
Surgery All patients underwent surgery of the first eye within three days (mean 1.3 days) after the diagnosis of SRD was made. The time interval between surgery of the first and second eye varied from 4 days to 28 weeks (mean 4 weeks), depending on the severity of the condition and the pref-
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erences of the patients. In 10 patients (55.5%) the time lag from the first to the second operation was less than two weeks. The surgical techniques used in- cluded cryotherapy (all 36 eyes), seg- mental scleral buckling (8 eyes) and scleral buckling with an encircling band (27 eyes). In addition, intravitreal injec- tion of gas was done in 5 eyes, and in one eye pars plana vitrectomy and silicone oil tamponade were necessary.
Results of treatment After surgery of the SRD patients, the retina was reattached in 35 of the 36 eyes (97%). In 4 patients (6 eyes) re- peated surgery was necessary to achieve retinal reattachment. One patient (male, age 35) lost vision in his right eye (vis- ual acuity: light perception) due to pro- liferative vitreoretinopathy. After reoper- ation with vitrectomy and silicone oil tamponade, the retina was still partially detached and considered inoperable. He retained, however, a good visual func- tion (corrected visual acuity: 1.2) in his left eye. During a follow-up period varying from 4 months to 8 years (mean 18 months) no recurrences oc- curred in any of the 18 patients treated for SRD. A scattergram illustrating the preoperative and latest postoperative visual acuity of both eyes for all the pa- tients is presented in Fig. 4.
Discussion In the present study the overall annual incidence of RD was 16.2 cases per 100 000 population. In previous population studies the estimated annual incidence of RD has differed considerably. Laati- kainen et al. (1985) found that the an- nual incidence of RD was 6.9 per 100 000 population in Finland. In a Swed- ish detachment series covering the years 1971–81, the annual incidence was 10.6 cases per 100000 population (Tornquist et al. 1987). In a more recent study from Minnesota Rowe et al. (1999) re- ported the annual incidence of RD to be 17.9 cases per 100 000 population. These different incidence rates may be due to disparity in the methods of data collection, or they could reflect an ac- tual increase in the number of RD cases over the past years.
It is unusual, however, for RD to affect both eyes simultaneously. In our study we found that 2.3% of all patients with RD
also had a detached retina in the fellow eye, resulting in an annual incidence of SRD of 0.35 patients per 100000 popula- tion. In a retrospective analysis of 931 pa- tients with primary RD, Bodanowitz et al. (1995) found 11 patients (1.2%) with SRD. In other studies the frequency of SRD has been calculated on the basis of all bilateral RD cases. Hartwig & Hart- wig (1981) observed simultaneous de- tachments in 6%, Folk & Burton (1983) in 30% and Laatikainen & Harju (1985) in 18% of the bilaterally affected individ- uals.
In the present study we found a slight predominance of men in the SRD group, and the patients were significantly younger than those with unilateral or consecutive, bilateral RD. We also found that the majority of the SRD patients were myopic with lattice degeneration and round, atrophic retinal holes in both eyes. These results are in accordance with the study of Bodanowitz et al. (1995) where most of the SRD patients were young men with multiple, round retinal holes and a high frequency of myopia. In a study of bilateral detachment, including both simultaneous and consecutive cases, Delaney & Oates (1978) found a pre- dominance of myopic men with multiple retinal breaks. The topographical distri- bution of the retinal breaks and detach- ments found in our study is compatible with previous reports. In both unilateral and bilateral detachment series atrophic, round holes are most common in the su- perior and inferior temporal quadrants (Hartwig & Hartwig 1981; Laatikainen & Tolppanen 1985).
It is noteworthy that all our SRD pa- tients reported symptoms from only one eye. One explanation could be that most of the patients had multiple, round reti- nal holes, due to a gradual thinning of the retina. Such retinal atrophy is rarely associated with vitreous traction, and the detachment progresses more slowly and with less warning symptoms compared to eyes with suddenly occurring retinal tears leading to photopsia or vitreous haemor- rhage (Davis 1974). In addition, symp- toms from one eye may also be ignored by some patients due to more severe symptoms from the eye with the most ex- tensive retinal detachment.
Although our material is limited, the surgical results and visual function of the SRD patients presented in this study do not seem to differ much from that to be expected after treatment of unilateral cases. Other authors have re-
ported less successful surgery, with po- orer visual outcome and more recur- rences, in bilaterally affected patients compared to patients with unilateral RD (Delaney & Oates 1978; Tornquist et al. 1987). This has been explained by a more severe retinal disease in patients with bilateral detachment (Delaney & Oates 1978). SRD patients appear to be a subgroup of patients with bilateral RD and may reflect an even more se- vere retinal weakness, as both eyes usually are affected earlier in life com- pared to patients with consecutive de- tachments. Young patients with myopia and multiple, round retinal holes seem to be particularly predisposed to SRD. These patients often present with uni- lateral symptoms, which stresses the im- portance of a careful clinical examina- tion of the fellow eye in all cases of RD.
References Benson WE, Grand MG & Okun E (1975):
Aphakic retinal detachment. Arch Ophthal- mol 93: 245–249.
Bodanowitz S, Hesse L & Kroll P (1995): Gle- ichzeitige bilaterale rhegmatogene Netzhaut- ablosung. Klin Monatsbl Augenheilkd 206: 148–151.
Ciurlo G, Zingirian M & Rossi P (1980): The fellow eye in retinal detachment. Graefeøs Arch Clin Exp Ophthalmol 214: 83–87.
Cosman B & Keyser JJ (1974): Eye abnormali- ties and skeletal deformities in the Pierre Robin syndrome: A balanced evaluation. Cleft Palate J 11: 404–411.
Davis MD (1974): Natural history of retinal breaks without detachment. Arch Ophthal- mol 92: 183–194.
Delaney WV & Oates RP (1978): Retinal de- tachment in the second eye. Arch Ophthal- mol 96: 629–634.
Folk JC & Burton TC (1982): Bilateral phakic retinal detachment. Ophthalmology 89: 815– 820.
Folk JC & Burton TC (1983): Bilateral aphakic retinal detachment. Retina 3: 1–6.
Glasgow BJ, Foos RY, Yoshizumi MO & Straatsma BR (1993): Degenerative diseases of the peripheral retina. In: Duane’s Clinical Ophthalmolgy 3, 26: 20–22. Lippincott, Philadelphia.
Hartwig H & Hartwig M (1981): Frequenz und Prognose der Netzhautablosung des 2. Aug- es. Folia ophthalmol 6: 5–10.
Laatikainen…
ABSTRACT. Purpose: To examine the incidence, the preoperative findings and the surgical outcome of patients presenting with simultaneous, bilateral retinal detachment. Methods: A retrospective analysis of the medical records of patients undergoing surgery for rhegmatogenous retinal detachment between 1990 and 1998. Results: During this period a total of 827 operations for rhegmatogenous retinal detachment were done in 791 consecutive patients. Eighteen patients (2.3%) had simultaneous, bilateral retinal detachment, giving an annual incidence of 0.35 patients per 100 000 population. They all presented with unilateral symptoms. Compared with the group of unilateral or consecutive, bilateral retinal detach- ments, patients suffering from simultaneous, bilateral retinal detachments were significantly younger, with a mean age of 40.3 years. Thirteen patients had multiple, round retinal holes associated with lattice degeneration. Sixteen pa- tients were myopic, ranging from ª3 to ª9.25 diopters. The retina was reat- tached in 35 (97%) of the 36 eyes operated on during the study period. Conclusion: Simultaneous, bilateral retinal detachment is usually found in rela- tively young, myopic patients with round, atrophic retinal holes, presenting with unilateral visual symptoms.
Key words: retinal detachment – bilateral – simultaneous – retinal break – myopia – lattice de- generation – incidence – age – symptoms – surgery.
Acta Ophthalmol. Scand. 2000; 78: 354–358 Copyright c Acta Ophthalmol Scand 1999. ISSN 1395-3907
Asevere eye disease threatening both eyes is the most challenging situ-
ation in ophthalmological practice. This is especially so in the case of vitreoretinal disorders, where bilateral morbidity is the rule rather than a rare exception. In the course of time retinal degenerations or detachment in one eye often necessitate prophylactic or curative treatment of the fellow eye. There are several reports in the literature concerning the frequency of bi- lateral involvement. Lattice degeneration is present in about 6% of the population and is bilateral in approximately 50% of the affected patients (Glasgow et al. 1993). Among patients with unilateral retinal detachment retinal degenerative changes were found in 63–90% and reti- nal breaks in about 20% of the unde-
tached fellow eyes (Merin et al. 1971; Ci- urlo et al. 1980). According to previous studies, retinal detachment has a strong bilateral tendency, varying from 10 to 20% depending on the criteria of se- lecting the patients and the length of fol- low-up (Schepens & Marden 1961; De- laney & Oates 1978; Folk & Burton 1982; Laatikainen & Harju 1985). In aphakic detachment series, the risk of bilaterality has been reported to be higher (Benson et al. 1975; Folk & Burton 1983; Laati- kainen & Harju 1985).
The interval between the detachment in the first and second eye usually covers a period of several years (Delaney & Oat- es 1978). Patients may, however, also present with simultaneous retinal detach- ment in both eyes at the initial examina-
tion. To bring further knowledge on the clinical course of simultaneous, bilateral retinal detachment, an eight-year review was undertaken among all patients sur- gically treated for retinal detachment at our department.
Material and Methods Study group The relevant data of patients treated for retinal detachment at the Department of Ophthalmology, Haukeland University Hospital, Bergen, between January 1990 and the end of 1998 were collected from a computerised database. The referral area for the hospital comprised the coun- ties of Sogn & Fjordane, Hordaland and the northern part of Rogaland (1998 total population637813). All patients undergoing primary operations for rheg- matogenous retinal detachment (RD) were included in the study. Thus, the study group included all retinal detach- ments except exudative detachments and tractional detachments without second- ary retinal breaks. A repeated operation for RD on the same eye more than one year after the first operation was desig- nated as a new case of RD and the surgery was classified as a primary oper- ation. If, on a later occasion, the patient’s fellow eye was treated for RD, this was also classified as a new case, primarily operated on for RD. The age was re- corded at the time of the first detachment in patients undergoing more than one op- eration. RD was defined as two or more disc diameters of subretinal fluid sur- rounding the margin of a retinal break. Round holes without opercula were con- sidered to be atrophic retinal breaks. Pa- tients with RD in both eyes, observed by indirect ophthalmoscopy at the initial ex-
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amination, were grouped as having simul- taneous, bilateral, rhegmatogenous reti- nal detachment (SRD).
Pre- and postoperative variables The total group of RD patients, includ- ing both the unilateral and consecutive, bilateral cases, were compared with the SRD patients regarding the incidence rates and the age and sex distribution.
All patients in the SRD group had their hospital records analysed for the following data: history of previous eye disease and eye surgery, preoperative re- fraction (spherical equivalent), presence of predisposing peripheral retinal de- generations and duration of symptoms. The hospital records and retinal drawings were analysed for the extent and location of detachment and the type and location of retinal breaks. In addition, the pre- and postoperative visual acuity, the surgi- cal technique used, the interval between surgery of the first and second eye and the final condition of the retina were re- corded.
Statistical methods The data were analysed by the Student’s t test and the c2-test with Yates correc- tion. For all tests p-values less than 0.05 were considered statistically significant.
Results Epidemiology Incidence During the eight-year period 827 primary operations for new cases of RD were per- formed on 791 different patients. Inci- dence rates, adjusted to the age and gen- der distribution of the population in our referral area were calculated. The overall annual incidence rate of all RD cases was 16.2 per 100 000 population.
In 18 patients (2.3%) SRD was ob- served at the initial examination. The overall annual incidence rate of SRD was 0.35 patients per 100 000 population. The age- and sex-specific annual incidences of RD and SRD are presented in Table 1.
Age and sex In the total group of 791 patients oper- ated on for RD, 432 (55%) were men and 359 (45%) were women. The mean age at the time of surgery was 58.4 years (range 6–95 years).
Among the 773 patients with unilateral or consecutive, bilateral RD, there were 421 (54.5%) men and 352 (45.5%)
women. The mean age at the time of surgery was 58.8 years (range 6–95 years), and it was significantly higher in women than in men (p∞0.002). The correspond- ing numbers in the SRD group were 11 (61%) men and 7 (39%) women. The mean age at the time of surgery was 40.3 years (range 7–76 years), with no signifi- cant difference between men and women. The differences in age and sex distri- bution between the two groups are pre- sented in Table 2.
The patients with SRD were signifi- cantly younger than those with unilateral or consecutive, bilateral RD (p∞0.002). The predominance of men in the SRD group was not significantly different compared to the patients with unilateral or consecutive, bilateral RD. The age and sex distribution in the SRD group are il- lustrated in Fig. 1.
Table 1. Age- and sex-specific annual incidences (cases per 100 000 population) of rhegmatogenous retinal detachment (RD) and simultaneous, bilateral rhegmatogenous retinal detachment (SRD).
RD SRD
Age (years) Male Female Male Female
0–19 1.9 1.6 0.1 0.1 20–39 9.9 4.4 0.6 0.3 40–59 24.6 16.5 0.5 0.5 60–79 52.8 47.5 0.6 0.2 ±80 35.6 28.1 0 0
Table 2. Mean age in years of patients with rhegmatogenous retinal detachment. The numbers in parentheses represent the total number of patients in each group.
Male Female Total
Unilateral or consecutive, bilateral retinal detachment 56.0 (421) 62.1 (352) 58.8 (773) Simultaneous, bilateral retinal detachment 40.5 (11) 40.0 (7) 40.3 (18)
Fig. 1. Age and sex distribution in 18 patients with simultaneous, bilateral retinal detachment.
Characteristics of the SRD patients Previous eye disease The youngest patient in the SRD group (male, age 7) had Pierre Robin syndrome, a rare anomaly occasionally associated with high myopia and RD (Cosman & Keyser 1974). One patient (male, age 76) had primary open-angle glaucoma, oper- ated with trabeculectomies 4 and 10 years prior to the SRD. He also underwent an uncomplicated extracapsular cataract ex- traction in the left eye two years earlier and in the right eye two months before the diagnosis of SRD was made. One pa- tient (age 32) was in her 28th week of an otherwise uncomplicated pregnancy when the SRD occurred. Another patient (female, age 51) had undergone a strabis- mus operation when she was 16 years old. The remaining 14 patients had no other known eye disease and no history of ocu-
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lar or orbital trauma. Two patients re- ported familial occurrences of nontrau- matic retinal detachments.
Refraction One patient (male, age 65) was em- metropic. The male patient (age 76) with posterior chamber IOLs was hyperme- tropic π1 diopters (D) prior to the catar- act extractions. Sixteen patients (89%) were myopic, with a spherical equivalent ranging from ª3 to ª9.25 D. High my- opia (ª5 D or more in both eyes) was found in 9 patients (50%).
Peripheral retinal degenerations Lattice degeneration of the retina was found in 14 patients (78%) with SRD. The lesions were bilateral and occurred in
Fig. 2. The columns represent the percentage of which each of the four quadrants was in- volved in the retinal detachment of 18 patients (36 eyes) with simultaneous, bilateral retinal detachment.
Fig. 3. The columns represent the total number of retinal breaks found in each of the four quadrants of 18 patients (36 eyes) with simul- taneous, bilateral retinal detachment.
Fig. 4. Scattergram comparing preoperative visual acuity (horizontal axis) and final postoperative visual acuity (vertical axis) of 18 patients (36 eyes) with simultaneous, bilateral retinal detachment. Each point represents one eye. (NLPno light perception, LPlight perception, CFcounting fingers).
all sectors, but were most prominent in the two upper quadrants. The male pa- tient (age 76) previously treated for glau- coma and cataract had a degenerative re- tinoschisis located in the inferior, tem- poral quadrant of his left eye.
Symptoms All patients with SRD had symptoms from only one eye. Thus, the bilateral condition was first recognised after rou- tine examination of the fellow eye. In all cases the presenting eye had the most ex- tensive retinal detachment. Usually, the patients experienced floaters or a periph- eral visual field defect, and patients with macular involvement reported an impair- ment of the central vision. Only two pa- tients had noticed light flashes as the ini- tial symptom. The duration of symp- toms, before the diagnosis of SRD was made, varied from 2 days to 9 months (mean 2 months). In 11 patients (61%) the right eye was the first to give symp- toms.
Retinal detachment The two temporal quadrants were more often detached than the nasal quadrants. The frequency of which each of the four quadrants was involved in the retinal de- tachment is illustrated in Fig. 2. In 7 eyes (19%) the detached area was less than one quadrant (∞90æ). Total detachment was
found in two eyes (5.5%). The macular area was detached in 11 eyes (30.5%).
Retinal breaks The number of retinal breaks in each eye varied from 1 to 10 (mean 4). Multiple breaks (two or more) were found in 26 eyes (72%). Retinal breaks could be ob- served in all quadrants, but were most commonly located in the upper, temporal quadrant. The total number of retinal breaks found in each of the four quad- rants is illustrated in Fig. 3. Fourteen pa- tients (78%) with SRD had round, atrophic retinal holes in both eyes. In 13 of these patients the holes were associated with lattice degeneration. Two patients (female, age 51 and male, age 21) had bi- lateral retinal dialysis located in the in- ferior, temporal retina. In two patients, one female (age 65) and one male (age 76, previously operated on for bilateral glaucoma and cataract), ‘‘horseshoe- shaped’’ retinal breaks (flap tears) were observed in both eyes.
Surgery All patients underwent surgery of the first eye within three days (mean 1.3 days) after the diagnosis of SRD was made. The time interval between surgery of the first and second eye varied from 4 days to 28 weeks (mean 4 weeks), depending on the severity of the condition and the pref-
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erences of the patients. In 10 patients (55.5%) the time lag from the first to the second operation was less than two weeks. The surgical techniques used in- cluded cryotherapy (all 36 eyes), seg- mental scleral buckling (8 eyes) and scleral buckling with an encircling band (27 eyes). In addition, intravitreal injec- tion of gas was done in 5 eyes, and in one eye pars plana vitrectomy and silicone oil tamponade were necessary.
Results of treatment After surgery of the SRD patients, the retina was reattached in 35 of the 36 eyes (97%). In 4 patients (6 eyes) re- peated surgery was necessary to achieve retinal reattachment. One patient (male, age 35) lost vision in his right eye (vis- ual acuity: light perception) due to pro- liferative vitreoretinopathy. After reoper- ation with vitrectomy and silicone oil tamponade, the retina was still partially detached and considered inoperable. He retained, however, a good visual func- tion (corrected visual acuity: 1.2) in his left eye. During a follow-up period varying from 4 months to 8 years (mean 18 months) no recurrences oc- curred in any of the 18 patients treated for SRD. A scattergram illustrating the preoperative and latest postoperative visual acuity of both eyes for all the pa- tients is presented in Fig. 4.
Discussion In the present study the overall annual incidence of RD was 16.2 cases per 100 000 population. In previous population studies the estimated annual incidence of RD has differed considerably. Laati- kainen et al. (1985) found that the an- nual incidence of RD was 6.9 per 100 000 population in Finland. In a Swed- ish detachment series covering the years 1971–81, the annual incidence was 10.6 cases per 100000 population (Tornquist et al. 1987). In a more recent study from Minnesota Rowe et al. (1999) re- ported the annual incidence of RD to be 17.9 cases per 100 000 population. These different incidence rates may be due to disparity in the methods of data collection, or they could reflect an ac- tual increase in the number of RD cases over the past years.
It is unusual, however, for RD to affect both eyes simultaneously. In our study we found that 2.3% of all patients with RD
also had a detached retina in the fellow eye, resulting in an annual incidence of SRD of 0.35 patients per 100000 popula- tion. In a retrospective analysis of 931 pa- tients with primary RD, Bodanowitz et al. (1995) found 11 patients (1.2%) with SRD. In other studies the frequency of SRD has been calculated on the basis of all bilateral RD cases. Hartwig & Hart- wig (1981) observed simultaneous de- tachments in 6%, Folk & Burton (1983) in 30% and Laatikainen & Harju (1985) in 18% of the bilaterally affected individ- uals.
In the present study we found a slight predominance of men in the SRD group, and the patients were significantly younger than those with unilateral or consecutive, bilateral RD. We also found that the majority of the SRD patients were myopic with lattice degeneration and round, atrophic retinal holes in both eyes. These results are in accordance with the study of Bodanowitz et al. (1995) where most of the SRD patients were young men with multiple, round retinal holes and a high frequency of myopia. In a study of bilateral detachment, including both simultaneous and consecutive cases, Delaney & Oates (1978) found a pre- dominance of myopic men with multiple retinal breaks. The topographical distri- bution of the retinal breaks and detach- ments found in our study is compatible with previous reports. In both unilateral and bilateral detachment series atrophic, round holes are most common in the su- perior and inferior temporal quadrants (Hartwig & Hartwig 1981; Laatikainen & Tolppanen 1985).
It is noteworthy that all our SRD pa- tients reported symptoms from only one eye. One explanation could be that most of the patients had multiple, round reti- nal holes, due to a gradual thinning of the retina. Such retinal atrophy is rarely associated with vitreous traction, and the detachment progresses more slowly and with less warning symptoms compared to eyes with suddenly occurring retinal tears leading to photopsia or vitreous haemor- rhage (Davis 1974). In addition, symp- toms from one eye may also be ignored by some patients due to more severe symptoms from the eye with the most ex- tensive retinal detachment.
Although our material is limited, the surgical results and visual function of the SRD patients presented in this study do not seem to differ much from that to be expected after treatment of unilateral cases. Other authors have re-
ported less successful surgery, with po- orer visual outcome and more recur- rences, in bilaterally affected patients compared to patients with unilateral RD (Delaney & Oates 1978; Tornquist et al. 1987). This has been explained by a more severe retinal disease in patients with bilateral detachment (Delaney & Oates 1978). SRD patients appear to be a subgroup of patients with bilateral RD and may reflect an even more se- vere retinal weakness, as both eyes usually are affected earlier in life com- pared to patients with consecutive de- tachments. Young patients with myopia and multiple, round retinal holes seem to be particularly predisposed to SRD. These patients often present with uni- lateral symptoms, which stresses the im- portance of a careful clinical examina- tion of the fellow eye in all cases of RD.
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