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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 488-489

Management of inadvertent scleral penetration during retinal detachment surgery


Department of Vitreoretina and Ocular Oncology, Sankara Eye Hospital, Bangalore, Karnataka, India

Date of Submission13-May-2021
Date of Acceptance28-Sep-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Surendra Pal
Department of Vitreoretina and Ocular Oncology, Sankara Eye Hospital, Kundanahalli Gate, Varthur Road, Vaikuntam Layout, Bangalore, Karnataka - 560037
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1202_21

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  Abstract 


We report the management of a case of inadvertent full-thickness scleral penetration during rhegmatogenous retinal detachment (RRD) surgery in a 14-year-old high myope while making partial-thickness scleral tunnel for the passage of the 240 silicone band. Sudden and gross hypotony with subretinal hemorrhage were noted post-penetration. Hypotony was immediately addressed by suturing the penetration site with a 7-0 vicryl suture. Subretinal blood was removed by performing 360° relaxing retinotomy and retinectomy and the retina was attached. This case report highlights the possible reasons for the full-thickness scleral penetration and one of the various methods to handle the same.

Keywords: Retinal detachment surgery, scleral buckling complication, scleral penetration, sutureless scleral buckling


How to cite this article:
Ramanjulu R, Pal S, Shanmugam M, Mishra D. Management of inadvertent scleral penetration during retinal detachment surgery. Indian J Ophthalmol Case Rep 2022;2:488-9

How to cite this URL:
Ramanjulu R, Pal S, Shanmugam M, Mishra D. Management of inadvertent scleral penetration during retinal detachment surgery. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 24];2:488-9. Available from: https://www.ijoreports.in/text.asp?2022/2/2/488/342870



Inadvertent scleral penetration during the suturing of the scleral buckle (SB) is reported in about 5% of the cases.[1] This article addresses the various points in relation to such an inadvertent complication such as the risk factors, immediate management, and late complications.


  Case Report Top


A 14-year-old girl, a known case of Down's syndrome, presented with decreased vision in both eyes since childhood with a further drop in the left eye for the last 2 years. She underwent left eye cataract surgery 2 years ago but reported no improvement in vision. On examination, her best-corrected visual acuity was 6/36 in the right eye with a refractive correction of −20 D sphere and 1/60 in the left eye. The anterior segment was normal in the right eye and the left eye showed aphakia with posterior capsular opacification. On fundus examination, the right eye showed a normal optic disk and myopic tessellated background with areas of white without pressure in the periphery. The left eye showed total rhegmatogenous retinal detachment (RRD) with retinal dialysis in the inferonasal quadrant extending 1 clock hour with grade C2 proliferative vitreoretinopathy (PVR), causing retinal fold and dragging of the macula inferior to the disk up to the ora serrata. Vitreo-retinal surgery was planned, with combined encerclage, pars plana vitrectomy (PPV), endolaser, and silicone oil tamponade under general anesthesia.

After bridling all recti muscles, while making partial-thickness scleral tunnel in the inferonasal quadrant for the encerclage, an inadvertent full-thickness scleral entry occurred, which caused a sudden gush of uveal pigments and subretinal fluid. Tension on muscle sutures was released immediately. A scleral penetration of 3–4 mm in length, 10–12 mm posterior, and parallel to the limbus was noted [Figure 1]a. It was sutured using a 7-0 vicryl and watertight closure was achieved. Hypotony was corrected by injecting balanced salt solution through pars plana using a 30 G needle. Three standard 23 G pars plana ports were made and subretinal blood was noted at the macula as well as the periphery [Figure 1]b. Even after removing the PVR membranes, the retina did not settle because of the extensive subretinal blood clots. Perfluorocarbon liquid (PFCL) was injected over the posterior pole to stabilize the retina. A 360-degree relaxing retinotomy and retinectomy were done and the subretinal blood clots were removed using forceps and cutter aided with chandelier illumination [Figure 1]c. An inferior peripheral iridectomy was made. Air-PFCL exchange was done maintaining the retina in the attached state. A 360-degree internal retinopexy were done using an endolaser and 1,000 centistroke silicone oil was injected for internal tamponade. The silicone oil was retained for 3 months and the retina was noted to be flat [Figure 1]d captured using TOPCON TRC 50DX). She underwent silicone oil removal (SOR) at the end of 3 months.
Figure 1: Intraoperative photograph showing the site of scleral penetration (black arrow) (a), subretinal blood clot seen after a relaxing retinectomy was performed (b), clinical photograph 1 week post-operatively showing attached retina under silicone oil tamponade (c), and clinical photograph 3 months post-operatively showing attached retina under silicone oil tamponade (d)

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  Discussion Top


The sutureless Scleral buckle (SB) technique avoids common complications such as globe penetration by needle, buckle infection, and extrusion in which the suture usually acts as a nidus for infection.[2] This technique involves making partial-thickness scleral tunnel.

Our patient had high myopia and was a known case of Down's syndrome. Pathological myopia causes scleral thinning which has been reported to be a cause for scleral perforation during surgery.[3] Tabandeh et al.[3] reported re-surgery and pre-existing scleral pathology to be significant risk factors for scleral rupture. However, in their study, the ruptures majorly occurred due to raised intraocular pressure (IOP) during scleral depression or during scleral dissection for revision of scleral implant. Similarly, rupture has been reported due to raised IOP during silicone oil[4] and perfluorocarbonliquid[5] injections. On the other hand, hypotony is another predisposing factor for penetration.[6] However, in our case, it occurred inadvertently during the scleral tunnel preparation using a crescent blade.

The immediate management of this complication includes relieving all the traction on the globe with the restoration of globe integrity, and thereby, not only treating the hypotony but also preventing the extrusion of the intraocular contents. In our case, we immediately released traction on muscle sutures and sutured the scleral wound using a 7-0 vicryl. Various other techniques have been described for the closure, which include the use of scleral or dural patch grafts, silicone explants, and fibrin glue.[3]

The penetration caused by the crescent blade differs from the needle penetration in being of much larger size, and thereby, causing potentially more serious consequences. In our case, it led to the drainage of subretinal fluid and hypotony but as the retina was detached, there was no incarceration of the retina or the vitreous. However, extensive subretinal hemorrhage arising from the choroid prevented the retina from flattening. Hence, PFCL was injected over the posterior pole and a 360-degree retinotomy and retinectomy were made for better access to the clotted blood. The retina was completely attached to the table after complete removal of the subretinal blood, endolaser, and silicone oil tamponade.

Various other complications have been described after scleral rupture such as retinal incarceration, vitreous hemorrhage, suprachoroidal, and subretinal hemorrhage.[3] Suprachoroidal hemorrhage is a sight-threatening complication carrying a poor visual prognosis. Usually treated with external drainage after 1–2 weeks allowing time for hemolysis of the clot.[7]

Poor long-term outcomes have been described due to PVR and re-detachment of the retina.[3] In our case, the retina was fully attached at the end of 3 months and she underwent SOR.


  Conclusion Top


This case highlights the successful management of an extremely rare but serious intraoperative complication.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brown MP, Chignell AH. Accidental drainage of subretinal fluid. Br J Ophthalmol 1982;66:625-6.  Back to cited text no. 1
    
2.
Shanmugam PM, Singh TP, Ramanjulu R, Rodrigues G, Reddy S. Sutureless scleral buckle in the management of rhegmatogenous retinal detachment. Indian J Ophthalmol 2015;63:645-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Tabandeh H, Flaxel C, Sullivan PM, Leaver PK, Flynn HW Jr, Schiffman J. Scleral rupture during retinal detachment surgery: Risk factors, management options, and outcomes. Ophthalmology 2000;107:848-52.  Back to cited text no. 3
    
4.
Domínguez Yates AL, Rojas J, Saravia MJ. Scleral rupture during intraoperative silicone oil injection in pars plana vitrectomy. Am J Ophthalmol Case Rep 2019;15:100506.  Back to cited text no. 4
    
5.
Agarwal L, Agrawal N, Aditya K. Intra-operative scleral rupture during 23 gauge pars plana vitrectomy: A case report. J Med Case Rep 2021;15:16.  Back to cited text no. 5
    
6.
Kuchenbecker J, Schmitz K, Behrens-Baumann W. Inadvertent scleral perforation in eye muscle versus retinal detachment buckle surgery. Strabismus 2006;14:163-6.  Back to cited text no. 6
    
7.
Qureshi A, Jalil A, Sousa DC, Patton N, Dhawahir-Scala F, Charles SJ, et al. Outcomes of suprachoroidal haemorrhage drainage with and without vitrectomy: A 10-year study. Eye 2020;35:1879-85.  Back to cited text no. 7
    


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