The "string Syndrome" Seen as a Complication of Arruga's Cerclage Suture.

OF the techniques used in the surgery of retinal detachment to appose choroid and retina, Arruga's equatorial cerclage suture (see Arruga, 1958a, b, 1961, 1962), which is a modification of a technique used by Schepens, Okamura, and Brockhurst (1957, 1958), is probably one of the simplest yet most rewarding. The equatorial cerclage suture seals the intra-retinal space at the equator, at first mechanically and subsequently by a sterile choroiditis, allowing the retina of the posterior part of the globe within the suture to remain flat. Anterior to this apposition of choroid and retina there may remain subretinal fluid, tears, and other pathology, but theoretically, as long as the seal is complete, the retina of the posterior pole will remain flat. The technique has been used with increasing frequency as a primary procedure in the Ophthalmic Department of the Royal Victoria Infirmary, Newcastle upon Tyne. Its useful application is enhanced by the ability to combine it with other techniques. Our experience has inevitably included failures, some of which show several characteristic features which, for the lack of a suitable collective term, we call the "string syndrome". The fundus appearance of a cerclage suture is shown in Fig. 1 (opposite). Of the 36 cases treated with a cerclage suture, four have exhibited the "string syndrome" post-operatively. The constancy of the clinical signs associated with what appears to be inevitable amaurosis would appear to warrant its consideration and discussion in some detail. The signs of this syndrome are oedema of the lids, true proptosis of the globe, chemosis of the conjunctiva, uveitis, and ocular hypotension. The onset of these signs is variable, having been seen between the 4th and 19th post-operative day. The conjunctival chemosis is gross and in one case the conjunctiva prolapsed through the palpebral aperture and had ultimately to be excised (Fig. 2). Arruga described, among the complications of his cerclage suture the occurrence of a rather marked conjunctival reaction. We have also experienced this, but the nature of this reaction and the appearance of the conjunctiva is unmistakably different from the type of conjunctival reaction seen in the string syndrome. The former is a much milder form of reaction (Fig. 3) and invariably resolves quite quickly. The most striking difference between the two reactions is the colour of the conjunctiva. In the case which resolves quickly it has a rosy hue, although it may be quite chemotic, in the serious string type it has more the colour of a ripe tomato. In the string syndrome, while the cornea remains clear, the anterior chamber is very deep, the iris being fixed and assuming a distinct green colour (Fig. 4).