The repair of complicated retinal detachments (RDs) entails substantial mechanical stresses on the globe due to ocular rotation for exposure, elevated intraocular pressure with infusion fluids and tamponades, and scleral alterations with buckling. We successfully repaired a total RD with grade C proliferative vitreoretinopathy in an eye with extreme scleral attenuation by strengthening the sclera prior to vitrectomy without the use of scleral buckling.
A 60-year-old man with a phthisical left eye due to an unrepaired RD after cataract surgery 10 years earlier was referred with a total RD in his right eye. Three years prior to being referred to us, the patient had undergone uneventful extracapsular cataract surgery with posterior chamber intraocular lens implantion in the right eye. Nine months later, a rhegmatogenous RD was successfully repaired using an encircling silicone sponge exoplant with visual recovery to 20/70. Six months prior to examination, a Staphylococcus epidermidis buckle infection necessitated removal of the exoplant, with redetachment 6 days later. Despite successful treatment with systemic antibiotics and steroids, severe temporal scleral thinning developed (Figure 1). There were no signs of external inflammation or active scleritis, and there was no clinical or laboratory evidence of collagen vascular disease. On examination, visual acuity was hand motions and results of funduscopic examination revealed marked vitreous debris and a total RD with grade C proliferative vitreoretinopathy.
Severe superotemporal scleral thinning present 1 month after removal of an infected scleral buckle.
At surgery, placement of the eyelid speculum alone provoked ectasia of the temporal sclera with impending rupture. An 18 × 10-mm full-thickness donor scleral patch graft was placed over the thinned area and sutured to healthy sclera along its edges (Figure 2). Immediately, a 3-port pars plana vitrectomy was performed. Following vitreous removal, extensive preretinal and subretinal fibrous proliferation surrounding an inferotemporal peripheral retinal break was identified. The retina was reattached by membrane peeling, relaxing retinotomy for 3 clock hours, and perfluorocarbon liquid (Perfluoron, Infinitech, Chesterfield, Mo). Endolaser retinopexy was performed, the perfluorocarbon liquid exchanged for air, and the air exchanged for 16% perfluoropropane gas. It was not possible to completely cover the scleral graft by mobilizing conjunctiva; 1 week later, a free conjunctival autograft from the contralateral eye was placed over the exposed sclera.
Left, Intraoperative exposure of a large region of drastically attenuated sclera prior to patching. Right, An 18 × 10-mm donor scleral graft being sized to cover the area of missing eye wall.
At the last examination, 6 weeks after vitrectomy, the visual acuity was 20/500. While necrosis of the conjunctival autograft had necessitated its excision 2 weeks earlier, vascularization of the healthy-appearing scleral patch was evident (Figure 3). The retina was completely reattached and there were no signs of recurrent proliferative vitreoretinopathy. At no time during the postoperative period was control of intraocular pressure a problem.
Left, Well-positioned scleral patch graft, 6 weeks after vitrectomy. The conjunctival autograft had necrosed and been removed by this time. Right, Early vascularization of the scleral patch has begun.
Donor sclera is commonly used to cover ectatic areas of sclera in patients with inflammatory diseases, wrap orbital implants, cover glaucoma seton hardware, support extremely thin eye walls prior to scleral buckling,1 and cover exoplants that have become exposed.2,3 Although the conjunctival autograft became necrotic despite aggressive management with 1% topical progesterone drops, the scleral graft appears to be surviving and the importance of conjunctival covering remains unclear.4
Intraoperative trauma and postoperative activity posed a serious risk of globe rupture in this one-eyed patient with a defect of almost one third of the eye wall. Reinforcement by placement of a scleral patch permitted successful repair of a complex RD using vitrectomy techniques that did not cause scleral buckling.
Reprints: Donald J. D'Amico, MD, Retina Service, Massachusetts Eye & Ear Infirmary, 243 Charles St, Boston, MA 02114-3096.
Theodossiadis PG, D'Amico DJ, Weissgold DJ. Repair of a Complex Retinal Detachment With Proliferative Vitreoretinopathy in an Eye With Extreme Scleral Thinning. Arch Ophthalmol. 1998;116(6):812-814. doi: