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Case Reports and Small Case Series
June 2000

Clear Corneal Cataract Wound Dehiscence During Pneumatic Retinopexy

Arch Ophthalmol. 2000;118(6):847-848. doi:

Pneumatic retinopexy is generally accepted as a safe and effective treatment for certain types of retinal detachment. This procedure recently has been demonstrated to produce equivalent final visual outcomes and reattachment rates compared with scleral buckling for primary rhegmatogenous retinal detachment.1 The growing popularity of this technique was verified in a recent survey of members of the Retina and Vitreous Societies that revealed that pneumatic retinopexy is the treatment of choice for "uncomplicated" retinal detachments.2 Factors influencing the selection of this modality by vitreoretinal specialists included number of years since completion of clinical training and complexity of the detachment.2

Complications of pneumatic retinopexy have been well described and involve the anterior and posterior segments.3,4 These include: cataract, choroidal detachment, delayed resorption or shifting of subretinal fluid, endophthalmitis, pars plana/subconjunctival/subretinal gas, malignant glaucoma, peripheral subretinal hemorrhage, vitreous hemorrhage, iris incarceration, macular hole/pucker, neck pain, subretinal/vitreous pigment, proliferative vitreoretinopathy, refractive changes, untreated retinal breaks, uveitis, vitreous incarceration/loss, and central retinal artery occlusion.3,4

Self-sealing, clear corneal incisions for cataract extraction have become increasingly popular recently owing to the combined advantages of phacoemulsification, foldable intraocular lenses, and topical anesthesia.5 Wound strength was one of the early criticisms of this technique, although studies suggest that the integrity of small incision, clear corneal incisions is comparable with traditional limbal or scleral based incisions.5 Typically, self-sealing clear corneal incisions are reinforced via stromal hydration at the end of the procedure, and sutures can be used to enhance wound integrity.

The 2 cases in which clear corneal incisions from recent cataract surgery dehisced during pneumatic retinopexy. To our knowledge, this potentially dangerous complication of pneumatic retinopexy has not been reported previously. However, it may become increasingly common given the growing popularity of clear corneal cataract extraction and the increased risk of retinal detachment imparted by intraocular surgery and pseudophakia.

Report of Cases
Case 1

A 49-year-old white man underwent clear cornea cataract extraction and posterior chamber intraocular lens implantation in the left eye on June 11, 1999. The procedure was complicated by a small tear in the posterior lens capsule at the 4-o'clock position, which did not require anterior vitrectomy. The corneal wound was closed with a single 10-0 polyglactin (Vicryl) suture, and the wound was watertight at the conclusion of the operation. The postoperative course was uneventful until June 23, 1999, when the patient was diagnosed with a single retinal break at the 12:30-o'clock position and a macula-on, rhegmatogenous retinal detachment in the left eye superotemporally. Intraocular pressure (IOP) was noted to be 15 mm Hg. Topical and subconjunctival anesthesia were administered, and cryopexy was applied to the breaks. The 10-0 polyglactin suture placed at the conclusion of the cataract extraction was absent from the clear corneal wound. Pneumatic retinopexy then was performed using 0.5 cc of 100% sulfahexafluoride injected through the pars plana. During the gas injection, the clear corneal wound deshisced with iris prolapse. A paracentesis then was performed to allow further decompression of the eye. Viscoelastic was used to re-form the anterior chamber, and prolapsed iris was reposited via the wound. Subsequently, the clear corneal wound was found to be sealed without sutures, and the postoperative IOP was 15 mm Hg. The retina reattached completely following the procedure, and the gas was resorbed by 3 weeks postoperatively. However, 1 month postoperatively a new inferotemporal retinal tear and detachment developed in the left eye that were treated successfully on July 27, 1999, via cryopexy and scleral buckling.

Case 2

An 81-year-old white man underwent clear corneal cataract extraction in the left eye on July 31, 1998, complicated by posterior dislocation of the lens nucleus. An intraocular lens was inserted, and the clear corneal wound was closed without sutures. On postoperative day 1, increased intraocular inflammation and an IOP of 45 mm Hg prompted pars plana vitrectomy and lensectomy. Intraoperatively, a small retinal tear was noted inferonasally, and cryopexy was applied. No sutures were placed to secure the clear corneal wound as part of the secondary vitreoretinal procedure. On postoperative day 1 of the vitreoretinal procedure, examination revealed an essentially normal posterior segment in the left eye. On August 19,1998, follow-up examination revealed a small, rhegmatogenous retinal detachment superonasally in the left eye arising from a retinal break at a previous sclerotomy site. Cryopexy was applied to the breaks, and pneumatic retinopexy was attempted using 0.3 cc of 100% sulfahexafluoride. During the gas injection, the clear corneal wound dehisced, and aqueous fluid was ejected forcibly enough to impact the surgeon's face at a distance of approximately 2 ft (60.9 cm). No prolapse of ocular structures occurred, and the dehisced wound was allowed to self-seal without sutures. The postoperative IOP was 16 mm Hg. On September 4, 1998, the persistent retinal detachment was reattached successfully via pars plana vitrectomy, cryopexy, scleral buckling, fluid gas exchange, and endolaser treatment.

Comment

We reported 2 cases of a previously unreported complication of pneumatic retinopexy causing dehiscence of clear corneal incisions from recent cataract extractions. Despite the potential seriousness of this complication, these cases resolved without incident. Among the previously described complications of pneumatic retinopexy, central retinal artery occlusion also results from high IOPs created during this procedure.4 As suggested by Abe et al,4 such complications could be minimized via routine IOP monitoring and paracentesis during pneumatic retinopexy.

Both cases demonstrated wound dehiscence less than 3 weeks after cataract surgery. More cases of this complication will be required before a reliable estimate can be made of the length of time sufficient for such wounds to become fully stable for pneumatic retinopexy. Given the increasing popularity of clear corneal cataract extraction and the elevated risk of retinal detachment imparted by cataract extraction and intraocular lens implantation, this complication may be observed with greater frequency in the future. To reduce the potential for clear corneal wound dehiscence during pneumatic retinopexy, paracentesis may be performed prior to gas injection to minimize a rapid increase in IOP. Alternatively, smaller volumes of injected gas may be used for pneumatic retinopexy performed in the setting of recent clear corneal cataract extraction.

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Article Information

Corresponding author: Dante J. Pieramici, MD, Maumenee 215, Wilmer Ophthalmological Institute, The Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287-9277 (e-mail: dpieramici@jhmi.edu.).

References
1.
Han  DPMohsin  NCGuse  CEHartz  ATarkanian  CS Comparison of pneumatic retinopexy and scleral buckling in the management of primary rhegmatogenous retinal detachment. Am J Ophthalmol. 1999;126658- 668Article
2.
Benson  WEChan  PSharma  SSnyder  WBBloome  MABirch  DG Current popularity of pneumatic retinopexy. Retina. 1999;19238- 241
3.
Hilton  GFTornambe  PEThe Retinal Detachment Study Group, Pneumatic retinopexy: an analysis of intraoperative and postoperative complications. Retina. 1991;11285- 294Article
4.
Abe  TNakajima  ANakamura  HIshikawa  MSakuragi  S Intraocular pressure during pneumatic retinopexy. Ophthalmic Surg Lasers. 1998;29391- 396
5.
Fine  IHed Clear Corneal Lens Surgery.  Thorofare, NJ SLACK Inc1999;
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