Tissue Adhesive in the Management of Leaking Pars Plana Sclerotomy Causing Hypotony and Choroidal Detachment

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.

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 360^o choroidal detachment more prominent in the superotemporal quadrant with overlying photocoagulation scars (Figure 1, 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 Hg.

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).