Finding the Retinal Hole
Harvey Lincoff, MD, and Richard Gieser, MD, New York
A method of predicting the location of retinal
holes has been formulated. It is based on the fact
that the development of subretinal fluid, follow-
ing the occurrence of a retinal tear, is governed
by a limited number of anatomical factors and
gravity. As a result, detachments form in a pre-
dictable manner around the tear or hole of their
origin, and the shape of the detachment points to
the position of the retinal hole. One thousand
retinal detachments were analyzed, and they con-
firm this concept.
HE POSITION of the retinal break can
be deduced from the shape of the detach¬
ment because subretinal fluid forms in a
predictable manner from the hole of origin.
An awareness of this comes to most retinal
surgeons and becomes second nature. It is
the purpose of this paper to describe the
characteristic contours of subretinal fluid
and propose some rules which may be useful
in finding the retinal break.
Materials and Method
To test the reliability of this concept, the
case records of 1,000 consecutive patients
treated for retinal detachment at the New York
Hospital-Cornell Medical Center were exam¬
ined. The usual record contained two preopera¬
tive diagrams, one by the surgeon and another
by the retinal fellow. There was a surgical note
in which the localization of the hole or holes
on the sclera was noted in terms of the meridian
to a half clock hour and millimeters from the
ora serrata. In addition there were postopera¬
tive sketches available from the clinic and
office records.
Two hundred and sixteen patients had small
detachments confined to a quadrant or less.
Two hundred and seventy-nine had temporal
Submitted for publication July 29, 1970.
From the Department of Ophthalmology, the New
York Hospital-Cornell Medical Center, New York.
Reprint requests to 440 E 57th St, New York
10021 (Dr. Lincoff).
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or nasal detachments that extended into more
than one quadrant. Three hundred and forty
had superior detachments that entered both
superior quadrants. In 106 of these, the de¬
tachment was total. One hundred and fifty-three
patients had inferior detachments. Twelve pa¬
tients had central detachments relating to
macular or paramacular holes.
Principles of Fluid Production
The growth and eventual shape of a reti¬
nal detachment is governed by the position of
the retinal break, the effect of gravity on
subretinal fluid in relation to the erect pos¬
ture of man, and anatomical limits such as
the disc, the ora serrata, and any chorioret¬
inal adhesions that might be present. The
most superior hole in a detachment with
multiple holes is designated the primary
hole because it would produce the same
contour if it were alone. It is useful to
regard the disc as the anatomical center of
the eye and a vertical line rising from it as
the 12 o'clock meridian.
Superior Temporal and Nasal Detach¬
ments.—The detachment that arises from a
superior hole first forms around the hole,
extends to the ora, and then towards the
disc. Once a bullous detachment has begun
to form, the effects of gravity and ocular
motion cause a dependent progression. With
fluid extending from ora to disc, the detach¬
ment descends as a front, revolves around
the inferior pole of the disc, and rises on the
opposite side. Fluid rises on the primary
side but does not cross the midline above.
Fluid may rise as high on the opposite side
of the disc as the level of the primary retinal
hole, but never as high as the fluid level on
the primary side (Fig 1). Thus, it is impor¬
tant to be accurate about the limits of the
detachment because the primary hole will be
found close to the border of the higher side.
When the records of superior detachments
were examined, the primary hole was found
 Fig 1.—Detachment with
primary hole in superotempor-
al quadrant. Fluid has revolved
around disc and risen on nasal
side to level of hole.

Fig 2.—Distribution of ret¬

inal breaks in 279 supero-
temporal or nasal detachments.

Fig 3.—Inferior detachment

with primary hole at 6:30
o'clock. Higher side of detach¬
ment corresponds with side of
retinal hole.

Fig 5.—Inferior detachment

of 14 years' duration. Side of
highest border of detachment
still corresponds with side of
retinal break.

Fig 6.—Distribution of ret¬

inal breaks in 153 inferior de¬
tachments.

to lie within \x/2 clock hours of the highest
border 275 times (98%). Two hundred and
seventeen times it lay within one clock hour.
Only four holes exceeded these limits and
were distributed as illustrated in Fig 2.
Inferior Detachments.—The subretinal
fluid that arises from holes below the level
of the optic disc develops first around the
hole and then descends to the ora serrata.
Next, it advances across the eye and to¬
wards the disc, rising higher on the side of
the disc where the hole lies (Fig. 3). Thus,

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 Fig 7.—Inferior detachment
in which fluid rises higher on
side opposite hole because of
traction on retina. Note con¬
cave contour of detachment on
secondary side (right).

Fig 8.—Inferior detachment-

in which fluid was blocked by
chorioretinal adhesions on a
previous scierai buckle.

the higher side points to the position of the by old chorioretinal adhesions (Fig 8). The
retinal hole. The relationship of the fluid reason for the disparity in two cases was
levels to the position of an inferior hole is not apparent.
very sensitive. A hole need only be 1 or 2 Occasionally, what appears to be an infe¬
mm from the six o'clock meridian for it to rior detachment, equal in height on the two
cause a difference in fluid levels. When the sides of the disc, arises from a superior hole
levels are equal, the hole is at six o'clock which connects with the detachment by a
(Fig 4). shallow peripheral sinus (Fig 9, left). A his¬
Detachments that arise from inferior tory of rapid development and the absence
holes progress slowly and may be recognized of pigment demarcation lines suggest the
late. Regardless of the duration, the higher presence of a superior hole. The crucial
side will continue to predict the side of the factor in the differential diagnosis is the
hole. The detachment illustrated in Fig 5 amount of elevation of the retina. Inferior
has been observed for 14 years. It is note¬ detachments that emanate from inferior
worthy that it has not become total, a char¬ holes are relatively shallow. When an inferi¬
acteristic of detachments from inferior holes or detachment is bullous, the primary hole is
unless unusual traction is present. superior. The pathway to the hole can be
Of 153 detachments caused by inferior elicted by examining the sides of the detach¬
holes, the higher side coincided with the side ment in a dependent position. When the
of the hole 145 times or 95% (Fig 6). In head is turned to the side of the hole, addi¬
three of the eight instances in which it did tional fluid is forced to communicate with it
not coincide, there was a visible traction line revealing the superior pathway (Fig 9, cen¬
which carried the fluid up the secondary ter and right).
side (Fig 7). In three instances fluid was Detachments That Cross the 12 O'clock
blocked from rising on the side of the hole Meridian and Total Detachments.—Detach-

Fig 9.—Left, Inferior bullous detachment caused by a superior hole

which connects by a shallow peripheral sinus. Rotating head demonstrates
pathway to hole, (center) with hole above and (right) with hole dependent.

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 Fig 10.—Detachment cross¬
es vertical meridian above,
caused by a tear near 12
o'clock. Lower edge corres¬
ponds with side of hole.

Fig 11.—Distribution of-

retinal breaks in 340 detach¬
ments that crossed 12 o'clock
meridian.

Fig 12.—Almost total de¬

tachment. Superior wedge of
attached retina discloses true
character and points to pres¬
ence of primary hole in pe¬
riphery near highest border.

ments that cross the 12 o'clock meridian
originate from holes at or near 12 o'clock.
These detachments become total. When they
are observed in an intermediate stage, the
lower edge suggests that the hole is on that
side of the 12 o'clock meridian (Fig 10).
The more posterior the hole, the more it can
deviate from 12 o'clock and still cause a de¬
tachment that will cross the vertical meridian.
An analysis of the detachments that cross
the midline revealed that their hole of origin
lies with great frequency within a triangle

Fig 13.—Appropriate area to buckle when retinal o'clock meridian IV2 hours to either side of 12; right,
hole has not been found, left, for a superotemporal or for an inferior detachment three clock hours or less
nasal detachment IV2 clock hours from upper limit; from limit of higher side to six o'clock.
center, for a total detachment or one that crosses 12

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 whose apex is at 12 o'clock and whose sides
intersect the equator approximately one hour
to either side (Fig 11). Of 340 detachments
in this category, 315 times the hole was with¬
in iy2 clock hours of 12 o'clock. Two hun¬
dred and ninety-seven times it was within
one hour, and 280 times within one-half
hour. Only 25 times did it exceed these
limits, 15 times relating to holes distributed
as indicated in Fig 12, and ten times in the
presence of massive preretinal retraction.
Total detachments arise from holes at or
near 12 o'clock. Attempts to replace a total
detachment by repairing a hole in an inferi¬
or quadrant, which must be a secondary
hole, is doomed to failure barring the pres¬
ence of unusual traction. Of 120 total de¬
tachments in the series, 104 had a primary
hole within IV2 clock hours of 12 o'clock (87
were within a half hour). Only 16 had holes
elsewhere, and ten of these were in the
presence of massive preretinal retraction.
When studying a total detachment, it is
important to look for a wedge of attached
retina near 12 o'clock. It may be present
only in the periphery and thus overlooked
or mistaken for a valley between two bullae
(Fig 12). The presence of a wedge of at¬
tached retina converts the problem of
searching for a hole in three clock hours (IV2
clock hours to either side of 12 o'clock) of
suspect retina in a total detachment to
searching IV2 clock hours in a superolateral
detachment.
Comment
The solution to a retinal detachment is to
close the retinal hole. As important as the
surgery is the preoperative examination to
find the hole. The shape of the detachment
indicates the position of the primary hole.
To avoid the pitfall of repairing a secondary
hole and omitting treatment of the primary
one, it is useful to organize the examination
as follows. First, draw the limits of the
detachment, then search the appropriate
area for the primary hole. Second, search for
additional holes. More than half of the time
these will be in the same horizontal meridi¬
an as the primary hole and close to it.
On the rate occasion when no hole can be
found after diligent study, or when the holes
that are found do not fit the criteria for the
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primary hole, it is advisable to explore the
appropriate area at the operating table with
the cryosurgical probe in an effort to elicit
the hole. Freezing demonstrates a hole in
sharp relief. If still no hole can be found
and the posterior retina can be cleared, it is
conceivable to coagulate and buckle in the
presence of a superolateral detachment \x/2
clock hours of the periphery, descendent
from the upper limit (Fig 13, left). In a total
detachment or one that crosses the 12
o'clock meridian, IV2 clock hours on each
side of the 12 o'clock meridian may be
buckled (Fig 13, center). In an inferior de¬
tachment, three clock hours or less of the
periphery, from the upper limit of the
higher side to the six o'cock meridian, may
be buckled (Fig 13, right). These are low
morbidity procedures that may be per¬
formed with a reasonable expectation of suc¬
cess. They are suggested as an alternative to
the frequent practice of coagulating and
buckling the entire periphery of a detach¬
ment or to circlage, when no hole has been
found.
Retinal detachments form in a predictable
manner around the hole of origin. The
shape of the detachment indicates the posi¬
tion of the primary hole 96% of the time.
1. In superior nasal or temporal detach¬
ments, the hole lies within IV2 clock hours
of the highest border 98% of the time.
2. In total detachment or superior detach¬
ments that cross the midline, the primary
hole is at 12 o'clock or in a triangle, the
apex of which is at the ora serrata, and the
sides of which intersect the equator one hour
to either side of 12 o'clock. This occurs 93%
of the time.
3. In inferior detachments the higher side
indicates to which side of the disc an inferi¬
or hole lies 95% of the time.
4. When an inferior detachment is bul-
lous, the primary hole lies above the hori¬
zontal meridian.
This investigation was supported by Public Health
Service research grant NB-05547-06 from the Na¬
tional Institute of Neurological Diseases and Blind¬
ness.
Key Words.—Retinal hole; break; detach¬
ment; subretinal fluid; contour; preoperative
examination.