Closure of scleral perforations after trauma is frequently achieved by external suturing. Enlarged perforations towards the equator may require temporary removal of the external ocular muscle to visualise and fix the scleral wound.1Nakashizuka et al. attached ‘ab interno' a dislocated intraocular lens by introducing a 10–0 polypropylen loop, held by an intraocular forceps, into the vitreous cavity through a sclerotomy.2 Here, we describe the ‘ab interno' intravitreal suturing of a large traumatic posterior scleral perforation at the posterior pole.
A 34‐year‐old patient presented with a paracentral corneal perforation, collapse of the anterior chamber and severe vitreous haemorrhage OD. The patient's visual acuity was light perception. The patient was treated in a two‐step fashion according to Kuhn et al.3 A primary corneal wound closure and placement of a mild scleral buckle was immediately performed, with the application of topical and systemic corticosteroids. The following day, a computed tomography scan was ordered, which showed a 25‐mm‐length splinter at the posterior pole (fig 11).). On day four, we performed a comprehensive reconstruction under general anaesthesia, including a lensectomy and removal of the vitreous haemorrhage by complete three‐port vitrectomy. When the pars plana vitrectomy removed the crystalline lens and vitreous haemorrhage, a large metal foreign body, sticking in the posterior bulbus with a consecutive incarceration of the adjacent retina, became evident. After the splinter was removed from the sclera, a hypotonic globe with a Y‐shaped scleral rupture at the posterior pole remained. The size of the wound, 3 mm by 4 mm superotemporal to the optic nerve at the posterior pole, prevented suturing from outside or sufficient silicone oil endotamponade.
To avoid an enucleation of the globe, the scleral perforation had to be closed so that 5000 cst silicone oil would remain in the vitreous cavity. We decided to close the large scleral perforation from inside. After lowering the infusion pressure, incarcerated choroidal and retinal tissue was removed from the laceration site with the vitrectomy. A light pipe was introduced via a fourth sclerotomy and fixed with tape,4 thus freeing the surgeon's second hand for bimanual intraocular vitreo‐retinal manoeuvres. A 10/0 nylon suture with an attached needle was introduced with an intraocular forceps via a sclerotomy into the vitreous cavity. A second intraocular forceps was used to hold scleral tissue, while the needle was passed through the rigid sclera from inside. The knots sealed the scleral wound and a waterproof closure was achieved, completing the vitrectomy. The posterior hyaloid was now engaged at the optic disc and progressively removed up to the vitreous base.
Remaining retina reattached after drainage of the subretinal liquid, endotamponate with silicone oil and endolaser at the edges of the retinectomy. The vitreous cutter evacuated subretinal haemorrhages as well as all incarcerated tissues and debris in a ring of 2 mm around the exit wound. This prophylactic 360‐degree “chorioretinectomy”, combined with three rows of deep endolaser retinopexy around the exit, may reduce the incidence of proliferative vitreoretinopathy significantly.3
Three months after the initial surgery, the cornea section showed an unremarkable peripheral scar (fig 22),), the retina remained attached and the intraocular pressure (IOP) was 14 mmHg, so that silicone oil was removed (fig 33).). Visual acuity was limited to hand movements due to a large retinal defect at the posterior pole; however, the patient appreciated the regained peripheral visual field for orientation during 15 months' follow‐up.