|Year : 2021 | Volume
| Issue : 3 | Page : 571-573
Scleral rupture during micro-incision vitrectomy surgery for primary rhegmatogenous retinal detachment - A case report
Rohini Grover1, Abhishek Varshney1, Supreet Juneja2
1 Department of Vitreoretina, C L Gupta Eye Institute, Moradabad, Uttar Pradesh, India
2 Department of Vitreoretina, Sunetra Eye Care Centre, Ghaziabad, Uttar Pradesh, India
|Date of Submission||02-Sep-2020|
|Date of Acceptance||08-Feb-2021|
|Date of Web Publication||02-Jul-2021|
Dr. Rohini Grover
Department of Vitreoretina, C L Gupta Eye Institute, Ram Ganga Vihar, Phase 2 (Ext) Moradabad - 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Scleral rupture during 23-gauge pars plana vitrectomy (PPV) for primary rhegmatogenous retinal detachment, without known predisposing factors, is a rare but catastrophic complication. Scleral rupture in our patient developed in superotemporal quadrant corresponding to the area of chorioretinal atrophy in retina. Prompt suturing of scleral rupture, usage of perfluoro-N-octane (PFO) as short-term endo-tamponade, and removal of epiretinal membrane (ERM) under silicone oil (SO) were the major contributing factors leading to successful outcome. High index of suspicion should be kept for any chorioretinal atrophic patches and sclera corresponding to these areas should be carefully examined for any pathosis.
Keywords: Pars plana vitrectomy, rhegmatogenous retinal detachment, scleral rupture
|How to cite this article:|
Grover R, Varshney A, Juneja S. Scleral rupture during micro-incision vitrectomy surgery for primary rhegmatogenous retinal detachment - A case report. Indian J Ophthalmol Case Rep 2021;1:571-3
|How to cite this URL:|
Grover R, Varshney A, Juneja S. Scleral rupture during micro-incision vitrectomy surgery for primary rhegmatogenous retinal detachment - A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:571-3. Available from: https://www.ijoreports.in/text.asp?2021/1/3/571/320007
Scleral rupture is a rare but serious complication during pars plana vitrectomy (PPV). The predisposing factors are reoperation after a failed scleral buckling (SB) procedure, preexisting scleral disease, and pathological myopia. In this case report, we describe the management and the favorable outcome in a patient who developed scleral rupture during PPV for rhegmatogenous retinal detachment (RRD) with no identifiable predisposing factors.
| Case Report|| |
A 56-year-old woman presented with diminution of vision for four days in her right eye. She had no history of ocular trauma or high myopia. Her best-corrected visual acuity (BCVA) in right and left eye was 20/50 and 20/20, respectively, with intraocular pressure (IOP; by applanation tonometry) of 12 mm Hg in both eyes. She was pseudophakic with right eye having subtotal bullous RRD-macula-off with horseshoe tear (HST) at 11 o'clock. Left eye examination was normal.
A complete 23G PPV and vitreous base dissection was performed with scleral indentation. An area of chorioretinal atrophy (CRA) from 9 to 12 o'clock was noticed [Figure 1]a. With PFO (Auro-octane) retina was flattened and endolaser done. A PFO-air exchange was performed. While injecting 1000 centistoke (cSt) SO (Aurosil) using viscous fluid injection setting (80 mmHg) in air filled eye (IOP 25 mm Hg), sudden hypotony with serous choroidal detachment, vitreous hemorrhage, subretinal hemorrhage, and giant retinal tear (GRT) in superotemporal quadrant was noted. Subconjunctival SO bubbles were noticed at superotemporal port site [Figure 1]b. Conjunctival peritomy and exploration showed scleral rupture of 4 mm circumferentially, at the equator in superotemporal quadrant [Figure 1]c, and its repair was done with 7-0 vicryl (Ethicon). Residual SO was aspirated from vitreous cavity. PFO was reinjected to reattach the retina, to prevent the downward spread of subretinal hemorrhage [Figure 2]a and [Figure 2]b and left as endo-tamponade. Conjunctiva and all ports were closed with 7-0 vicryl.
Ten days later, PFO-air exchange, endolaser was done and 1000 cSt SO was injected. Two weeks later, BCVA was 20/60, IOP 14 mm hg with attached retina. A month after second surgery, she complained about distortion of vision and BCVA dropped to 20/100. Fundus examination and optical coherence tomography (OCT) [Figure 3]a and [Figure 3]b showed a thick ERM over macula with edema. ERM peeling was performed under SO. SO removal was advised at the end of three months (March 2020) but due to corona pandemic the patient refused. At six months, her BCVA is 20/40, retina attached with SO in situ and OCT showing no ERM [Figure 4]a ,[Figure 4]b, [Figure 4]c.
|Figure 1: (a) Intraoperative photograph: Right eye fundus with horseshoe tear (red arrow in the centre of photo) corresponding to 11 o ‘clock equator position of fundus with chorioretinal atrophy (blue arrow) in a RRD and triamcinolone acetonide stained vitreous (yellow arrow) during 23G vitrectomy, (b) Intraoperative photograph: Migration of SO into the subconjunctival space (yellow arrows) was noted at superotemporal quadrant adjacent to sclerotomy site, (c) Intraoperative photograph: scleral defect of 4 mm (blue arrow) detected during surgery|
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|Figure 2: (a) Intra-operative fundus picture of right eye showing GRT and bare choroid (white arrows) along with of SR in the same quadrant, (b) PFO (Yellow arrow) reinjection to reattach retina and curtail the macular spread of subretinal hemorrhage (Blue arrow) and bare choroid (area outside dotted line)|
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|Figure 3: (a) Colored fundus photo of right eye after six weeks of vitrectomy showing thick ERM with SO in situ,(b) OCT raster lines showing thick ERM (red arrows) and macular edema (blue arrows)|
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|Figure 4: (a) Colored fundus photo of right eye after two weeks of ERM removal under SO, (b) OCT raster lines showing blunted foveal contour with resolving macular edema nasal side, (c) Color fundus photo showing the healed area corresponding to GRT and scleral rupture|
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| Discussion|| |
Scleral rupture is rare but catastrophic complication of PPV for RRD surgery. Previous SB, scleral pathosis, cryotherapy or any ocular surgery associated with scleral inflammation and weakening of the sclera are the risk factors. Our patient was a moderate myope, had no history of scleral pathology or trauma. No scleral pathosis could be noted in view of no discoloration and having not done peritomy. She had retinal tear at 11'O clock with an area of CRA and subsequently developed scleral rupture in the same quadrant. Our findings correlate with a study by S. Stenkula et al. in which primary scleral atrophy was associated with retinal detachment with none of their patient's scleral pathosis was diagnosed before surgery. We hereby postulate that intraoperative indentation on areas of CRA corresponding with undiagnosed primary scleral atrophy too could have led to weakening of the ocular layers and finally scleral rupture at the time of SO injection.
The immediate management at the time of scleral rupture is aimed at limiting the loss of intraocular contents and restoration of IOP. When hypotony and subconjunctival SO bubbles were noticed, wound was explored and scleral rupture was sutured. In a series by H. Tabandeh et al., scleral rupture was managed with sutures, cadaveric donor scleral patch graft or scleral explant. Remaining SO was extruded from vitreous cavity and PFO reinjected for reattaching the GRT and limiting macular spread of subretinal hemorrhage. At this stage patient developed respiratory distress and the anesthetist advised against the further continuation of surgery, hence PFO was left as a short-term endo-tamponade in the vitreous cavity. PFOs are safe and useful as an intraoperative adjunct in complicated RRD, GRT as it lowers pooling of RPE cells, chemo attractants, and serum components over inferior retina. PFO used as short-term endo tamponade leads to chorioretinal adhesion without side effects.
Our patient developed thick ERM after six weeks of primary surgery accompanied by diminution and distortion of vision. The ERM developing in eyes after SO tamponade for RRD are bilayered membranes, difficult to remove. It was managed judiciously by peeling it under SO without removing it as we intended to keep SO for at least three months. The advantages of this approach as advocated by Steve Charles are reduced damage to the tissues, better assessment of traction relief and decreased operating time.
Only 30% patients show visual improvement after scleral rupture intraoperatively in RRD cases. Our case was unique as we got scleral rupture in PPV without any prior identifiable predisposing factors, used PFO as the short-term endo-tamponade, removed ERM under SO and achieved a good anatomical and functional outcome, with SO in situ. Area of CRA with tear in the same quadrant should heighten our senses to the rare possibility of scleral rupture and subsequent sequelae. And lastly, always start the SO injection at low pressures or keep the side port open while injecting.
| Conclusion|| |
Heightened anticipation of possibility of scleral rupture in eyes with CRA and tear in the same quadrant along with prompt redressal aimed at preventing the loss of intraocular contents and maintaining the IOP is the key to successful management of scleral rupture.
Authors would like to thank Mr. Lokesh Chauhan, for his technical support.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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