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Authors:
Dr. Ayman Sami Madanat, FRCS, FRCOphth, DO.
Head of Ophthalmology Dept.
P. O. Box: 8141. Amman 11121, Jordan
Tel:
077767494
Fax: NA
E- Mail: drayman2@hotmail.com
Dr. Thabit Ali Abdullah Mustafa, FRCS
(Glasg), JOphth
OPHTHALMOLOGY DEPT., KING HUSSEIN MEDICAL CENTER, ROYAL
MEDICAL SERVICES, AMMAN, JORDAN.
Tel: 077 417917
Fax: NA
Correspondence:
DR. Thabit Ali Abdallah Mustafa, FRCS (Glasg).
P.O.Box: (2740). Irbid 21110, Jordan._
Tel: 077 417 917.
E-Mail: thabitodat@hotmail.com
ABSTRACT
Purpose: To determine the aetiologies,
clinical features, surgical and visual outcome of retinal
detachments in 30 paediatric patients that were treated
at our tertiary referral hospital.
Method: A retrospective analysis
of 30 paediatric patients' charts (33 eyes) younger
than 16 years of age who underwent surgical repair for
retinal detachment consecutively between May 1998 and
April 2004 at King Hussein medical hospital, was conducted.
The following items were recorded: Age, sex, date of
admission, family history of retinal detachment, history
of trauma, diagnosis, pre-operative assessment of visual
acuity, anterior segment, motility, and posterior segment,
systemic associations and aetiology. The type of surgery
was recorded. Follow up periods extended from A few
months to 6.5 years with a mean of 1.95 years.
Results: Twenty-four (80%) of patients
were males and 6 (20%) were females. The ages ranged
from 5 months to 16 years with a mean age of 9.43 years.
The right eye was involved in 18 (54.54%) cases, the
left in 9 (27.3%) and both eyes in 3 (9.1%) cases. The
commonest cause was trauma 45.5% followed by myopia
15.2%. Bilateral cases were seen in 3 patients. One
had myopia (more than - 4 diopters) and 2 had Down syndrome.
The most
frequent procedures were pars-plana vitrectomy (PPV),
intra-ocular gas (SF6), external band with or without
internal drainage, and cryotherapy or laser. The visual
acuity improvement was documented in 8 (24.2%) cases,
while in 6 (18.2%) cases it was the same, and in 5 (15.2%)
cases it was worse or the eye was enucleated. Anatomical
retinal reattachment was achieved in 25 (75.75%) cases.
Conclusion: In this series, paediatric
retinal detachment was mainly due to trauma and was
more frequent in males. Most of the cases were treated
by pars-plana vitrectomy (PPV) and the final visual
acuity was relatively poor which rprovides a real clinical
challenge to retinal surgeons, who requires good outcomes
and proper preparation. Prophylactic treatment of the
fellow
eye should be undertaken without delay in patients with
a history of non-traumatic RD.
Key words: Paediatric retinal detachment,
pars-plana vitrectomy, intra-ocular gas.
INTRODUCTION
The paediatric patient presents many challenges
to the vitreoretinal surgeon that require special consideration.
Due to the difficulty of examining the signs as well
as recognising the symptoms of retinal detachment in
children, and because of the variety of the underlying
diseases and rarity of patients (1&2), the timing
of retinal detachment repair is often unavoidably delayed
despite appropriate referral. As the paediatric patients
are unable to verbalise their visual complaints most
of the time, they are often referred for one of the
following reasons: No red reflex, suspected retinal
detachment, unexplained strabismus, leukocoria, history
of trauma, a change in visual function, or unexplained
irritability.
Rhegmatogenous retinal detachment is infrequent
in the paediatric age group with an incidence of 1.7-
5.9% of all retinal detachments (2- 4), while traumatic
retinal detachment is 2.5- 2.9 per 100,000 between the
ages of 10 and 19 years (5&6), and 0.6 per 100,000
less than one year and 9 years (5).
We retrospectively reviewed the medical
charts of paediatric patients younger than 18 years
old who had undergone surgical treatment for retinal
detachment at King Hussein medical centre.
MATERIALS & METHODS
A retrospective analysis of 30 paediatric
patients' charts (33 eyes) younger than 16 years of
age who underwent surgical repair for retinal detachment
consecutively between May 1998 and April 2004 at King
Hussein medical centre, was conducted. The following
items were recorded: Age, sex, date of admission, family
history of retinal detachment, history of trauma, diagnosis,
pre-operative assessment of visual acuity, anterior
segment, motility, and posterior segment, systemic associations
and aetiology. We also recorded type of surgery, intra-ocular
gas, intra-ocular silicone oil, intra-ocular heavy liquids,
explants, drainage, complications including intra-operative
and post-operative, results, and follow up periods.
Follow up periods extended from a few months to 6.5
years with a mean of 1.95 years.
RESULTS
A total of 33 eyes in 30 paediatric patients
with retinal detachments were reviewed over 6.5 years.
Twenty- four (80%) patients were males
and 6 (20%) were females. The ages ranged from 5 months
to 16 years with a mean age of 9.43 years. The right
eye was involved in 18 (54.54%) cases, the left in 9
(27.3%) and both eyes in 3 (9.1%) cases. The aetiology
of retinal detachments was as follows: Trauma was the
commonest cause (45.5%) followed by myopia (15.2%).
Perforating trauma was encountered in 9 cases (60% of
trauma) and blunt trauma in 6 cases (40% of trauma).
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The majority of those patients were males
(93.3% of trauma). Bilateral cases were seen in 3 patients
one had myopia (more than - 4 diopters) and 2 with Down
syndrome. Toxocara, Coat's disease, Retinopathy of prematurity,
Persistent hyperplastic primary vitreous and Eals disease
constituted 15% of all the cases.
The presenting clinical features were
as follows: The majority of cases (46.7%) were referred
as traumatic retinal detachment from primary or secondary
care centers, visual loss 23.3%, leukocoria 10%, post-
operative 10%, squint ± nystagmus 6.6 % and buphtha-lmos
3.3 %.
Table- 1 summarises
the surgical procedures that were performed for the
patients. The most frequent procedures were pars-plana
vitrectomy (PPV), intra-ocular gas (SF6), external band
with or without internal drainage, and cryotherapy or
laser. Systemic associations with the retinal detachment
are shown in Table- 2.
The majority of cases (70%) were not associated
with any systemic anomalies.
Figure -1 compares the
pre- and post- operative best corrected visual acuity.
The visual acuity improvement was documented in 8 (24.2%)
cases, while in 6 (18.2%) cases it was the same, and
in 5 (15.2%) cases it was worse or the eye was enucleated.
In 14 (42.4%) cases it was not documented
in the files because of the difficulty in testing visual
acuity, either because of young age or mental retardation.
Figure- 3 shows the final anatomical
results where anatomical retinal reattachment was achieved
in 25 (75.75%) cases.
DISCUSSION
According to different reports (4, 7,
8), the incidence of paediatric retinal detachment is
quiet low. This may be due to difficulties in diagnosing
such conditions, which usually require examination under
general anaesthesia, and because of the variety of the
underlying causes. The most common cause of paediatric
retinal detachment in our study, was trauma, which accounts
for 45.5%, and is consistent with the previous reports
(3-4, 6-9). Males (93.3%) were affected more than females,
comparable to previous studies (8, 9) and this may be
due to engagement of boys in vision- threatening games.
Myopia with refractive error more than - 4 diopters,
was the second most common cause (15.2%) of paediatric
retinal detachment and the clinical diagnosis of those
patients was not recorded in the medical files. Rhegmatogenous
retinal detachments in children are often found accompanying
other vitreoretinal pathology or trauma and has been
reported in cases of Marfan's syndrome, Stickler's syndrome,
cataract extraction, and
trauma (10- 12).
Retinal detachment is also a well-known
complication of congenital cataract extraction. However,
the interval between surgery and the development of
retinal detachment is much longer in children (20 to
30 years) than in adults (50 percent occur within the
first year after surgery) (13- 17). Retinal detachment
after congenital cataract extraction was encountered
in 15.2% and all of them were diagnosed as Down syndrome.
The incidence of retinal detachment following surgery
for congenital cataract is not well established.
One review in the literature reported
incidences ranging from 2 to 8 percent and another reported
incidences of 5 to 25 percent (18-19). Three patients
(9.1%) had bilateral retinal detachment after cataract
extraction, so it is important to remember that when
dealing with retinal detachments following congenital
cataract extraction, 70 percent of these patients will
experience detachment in the fellow eye, and therefore
they require careful follow-up (16). Less frequent causes
were Toxocara, Coat's disease, retinopathy of prematurity
(ROP), persistent hyperplastic primary vitreous (PHPV)
and Eals' disease.
Most of the cases with retinal detachment
had a history of old or recent trauma (46.7%), Sarrazin
et al (9) found that more than half of cases with traumatic
retinal detachment presented late, probably because
of its late development. The late development of traumatic
retinal detachment in children may be because of the
tight adherence between the vitreous gel and the retina
and the absence of vitreous liquefaction and posterior
vitreous detachment (PVD) (9).
Pars-plana vitrectomy (PPV), intra-ocular
gas (SF6), external band with or without internal drainage,
and cryotherapy or laser was performed in about one
third of patients and this was because most cases were
due to penetrating eye injuries, while external band
with or without external drainage was done in 18.2%
of cases, as this procedure is preferred for paediatric
rhegmatogenous retinal detachment because the areas
of PVD are usually localised in those patients, making
vitrectomy more difficult (8).
Silicone oil was used in 18.2% of cases
and this is of advantage as the child is able to move
around freely; however all of the complications of silicone
oil must also be taken in consideration, such as cataract,
glaucoma, corneal decompensation, and reoperation for
removal (20).
Children's level of physical activity
and inability to position postoperatively make the consideration
of a long-acting tamponade very appealing. This may
free the child and caretaker from a rigorous positioning
regimen. Although 70% of cases had no systemic associations
with the retinal detachment, Down syndrome, brain damage,
prematurity and epilepsy were
encountered in few patients.
While the visual acuity was not documented
in most of the cases 42.4% either because of young age
or mental retardation, about one quarter of them had
a documented improvement of their vision, making the
surgical treatment a justified option.
Overall, anatomical retinal reattachment
was achieved in 75.75% cases in spite of lesser percentage
of achieved visual improvement (24.2%). This disparity
was due to other negative factors encountered in most
of the cases like amblyopic squint due to late presentation,
macular scar due to trauma, macular hole, postoperative
complications like cataract or prolix-ferative vitreous-retinopathy,
or PHPV, so early diagnosis and treatment are of paramount
importance before the development of any of the above
mentioned complications, which presents a real challenge
to the retinal surgeon.
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