Customize your JAMA Network experience by selecting one or more topics from the list below.
Nonhealing or persistent wound leakage can be encountered in sclerotomy
sites after multiple pars plana vitrectomies. Therapeutic modalities such
as patch graft have been reported to manage the persistent limbal wound leaks.1 Cyanoacrylate tissue adhesives have been successfully used in the
management of corneal perforation and leaking filtering bleb to circumvent
the need for surgical interventions such as therapeutic keratoplasty and conjunctival
flap.2,3 We describe herein
the technique and successful use of cyanoacrylate adhesives to manage postoperative
hypotony and associated choroidal detachment caused by leakage from sclerotomy
after pars plana vitrectomy.
Report of a Case
A 51-year-old white woman with a history of insulin-dependent diabetes
had undergone 3 prior pars plana vitrectomies in the right eye between 1995
and 1998 for proliferative diabetic retinopathy and recurrent vitreous hemorrhage.
After the first 2 surgeries, the visual acuity had returned to 20/20 for several
months. Six months after the third surgery, the visual acuity OD had decreased
to counting fingers owing to recurrent vitreous hemorrhage and nuclear sclerotic
cataract. In the left eye she had had a persistent retinal detachment after
pars plana vitrectomy in 1999 for a combined tractional and rhegmatogenous
retinal detachment. She was then referred to us for further management.
On our initial examination, her best-corrected visual acuity was hand
motion in the right eye and light perception in the left. Ophthalmic echography
showed dense vitreous hemorrhage without retinal detachment in the right eye
and a rigid funnel-shaped retinal detachment with diffuse vitreous hemorrhage
in the left. Because of the guarded visual prognosis for the left eye, surgery
was recommended for the right. A pars plana vitrectomy, lensectomy, endolaser
panretinal photocoagulation, and implantation of a posterior chamber intraocular
lens were performed in the right eye. The visual acuity improved to 20/400
with a normal intraocular pressure on the first postoperative day. One week
later, she complained of aching with decreased vision in the right eye. The
visual acuity remained at 20/400 OD and light perception in the left eye.
However, the intraocular pressure was 4 mm Hg OD and 12 mm Hg OS. Slitlamp
examination showed loosening of the 8-0 polyglactin 910 (Vicryl) suture at
the superotemporal sclerotomy site in the right eye (Figure 1). An open sclerotomy with partially retracted conjunctiva
and very thin surrounding sclera was noted. Findings from the Seidel test
were positive. The anterior chamber remained formed with moderate Descemet
membrane folds and corneal edema. Fundus examination revealed a 360o choroidal detachment more prominent in the superotemporal quadrant
with overlying photocoagulation scars (Figure
Leakage from pars plana sclerotomy
associated with choroidal detachment (inset).
Because of the thin remaining sclera and medical history of multiple
intraocular surgeries, a decision was made to seal the leaking sclerotomy
with cyanoacrylate tissue adhesives instead of further surgical intervention.
For leaking sclerotomy with a soft globe in this patient, tissue adhesive
was applied under a slitlamp biomicroscope using topical anesthesia and a
lid speculum. After the loose suture was removed, the necrotic scleral and
conjunctival tissues overlying the scleral perforation were debrided. Prior
to gluing, a sterile plastic disk was cut to the size slightly larger than
the sclerotomy using a 3-mm skin biopsy punch (Acu-Punch; Acuderm, Ft Lauderdale,
Fla). The plastic disk was then placed on a small amount of ophthalmic ointment,
which was preplaced at the end of the wooden stick of a cotton-tipped applicator
as previously reported.3 A small meniscus (about 1 to 2 µL)
of the tissue adhesive (Histoacryl; B. Braun, Melsungen AG, Germany) was placed
on the 3-mm plastic disk (Figure 2,
inset). The leaking area was dried with a cellulose sponge. The glue on the
disk was gently pressed against the sclerotomy for 10 to 20 seconds with the
end of the applicator (Figure 2).
On observing the polymerization of tissue adhesive and adequate adherence
of the disk over the sclerotomy, the cotton-tipped applicator was removed.
The preplaced ointment facilitated the separation of the disk from the end
of the applicator and prevented dislodging of the polymerized glue on the
disk. Because the adhesive plug had a rough edge around the disk and could
be potentially irritating, a therapeutic contact lens was used to ensure the
patient's comfort and to prevent dislodgement of the glue by eyelid blinking
(Figure 3). Application of 0.3%
topical ofloxacin 4 times a day and 1% prednisolone acetate every 2 hours
were prescribed. On the following day, persistent hypotony with a slow leakage
was noted at the inferior edge of the glued disk. Another application of the
tissue adhesive on a disk to the inferior edge of the initial disk was performed.
On the fourth day, no leakage was detected and the intraocular pressure was
10 mm Hg. Minimal corneal edema with residual folds of Descemet membrane was
noted, but the choroidal detachment persisted. During the examination, the
2 glued disks dislodged and the tissue adhesive on a new disk was reapplied.
Five days after the last gluing, the third glued disk dislodged and the scleral
wound was healed without evident leakage (Figure 4). Complete resolution of corneal edema and choroidal detachment
(Figure 4, inset) was noted. The
visual acuity improved to 20/100 OD with an intraocular pressure of 20 mm
Application of tissue adhesive
on a plastic disk (inset) over the sclerotomy.
A therapeutic contact lens over
the glued-on disk to prevent mechanical irritation.
Healed sclerotomy with complete
resolution of corneal edema and resolution of choroidal detachment (inset).
This report demonstrates the successful management of a leaking pars
plana sclerotomy by cyanoacrylate tissue adhesive. This gluing method should
be considered as an effective alternative to resuturing or to applying a scleral
patch graft. The application of tissue adhesive is simple and can be readily
performed in the office. Tissue adhesive applied to the thinned sclera or
macerated sclerotomy may prevent further tissue degradation and facilitate
wound healing and vascularization. Sutureless pars plana sclerotomy is a recently
described vitrectomy technique using a localized scleral tunnel.4
The gluing method could also be used to reinforce these sutureless sclerotomies
if leakage occurs. As demonstrated in this case, the gluing technique can
be repeated in sclerotomies with persistent wound leakage.
The authors have no financial interests in the products or procedures
mentioned. Dr Huang is now with the University of Minnesota in Minneapolis.
Corresponding author: Andrew J. W. Huang, MD, MPH, Department of
Ophthalmology, University of Minnesota, University of Minnesota, 420 Delaware
St SE, MMC 493, Minneapolis, MN 55455 (e-mail: huang088@umnedu).
Wichiensin P, McDonough RL, Huang AJW, Flynn HW. Tissue Adhesive in the Management of Leaking Pars Plana Sclerotomy Causing Hypotony and Choroidal Detachment. Arch Ophthalmol. 2001;119(1):135–137. doi:
Artificial Intelligence Resource Center