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Br J Ophthalmol. 2007; 91(12): 1721–1722.
PMCID: PMC2095494

‘Ab interno' intravitreal suturing of a large traumatic scleral perforation at the posterior pole

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.

figure bj112201.f1
Figure 1 Orbital computed tomography scan after the primary corneal wound closure and placing an encircling buckle: A splinter of 25 mm length is seen at the posterior pole sticking through the sclera. The location of the cerclage is seen ...

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 mm Hg, 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.

figure bj112201.f2
Figure 2 3 months after the initial trauma: The cornea presents a crescent‐shaped wound in the infero‐temporal quadrant.
figure bj112201.f3
Figure 3 Postoperative finding 6 months after the initial trauma and following silicone oil removal. The globe had a normal shape, normal intraocular pressure and an attached peripheral retina.

Comment

Eyes with double perforation are encountered through injuries. Individuals frequently become blind due to retinal detachment, hypotony, endophthalmitis or phtisis. The surgical goal is to maintain limited function and integrity of the globe. Although ocular hypotony secondary to scleral rupture of a choroidal coloboma is treatable by scleral silicone buckling,5 we sutured the sclera ‘ab interno'.

It is known that the primary wound closure should be performed as early as possible. However, in complex ocular trauma, we prefer a staged approach with an immediate wound closure and a delayed comprehensive globe reconstruction. A delay may diminish the threat of intraoperative haemorrhage and increase the chance of a spontaneous posterior vitreous detachment (Relja Zivojnovic, personal communication).

‘Ab interno' suturing is feasible for achieving a waterproof closure of large scleral perforation at the posterior pole, leaving an eye with good cosmetic appearance, normal IOP and maintained peripheral visual function.

Acknowledgements

This case was presented in parts at the annual Vitreous Society Meeting in New York, NY, USA, and achieved the First prize of the Video award 2004. This video may be seen at the BJO online video collection at http://bjo.bmj.com/supplemental.

The supplemental video is available at http://bjo.bmj.com/supplemental

Supplementary Material

[web only media]

Footnotes

This work has been supported by the Fehr Foundation, Marburg, Germany.

Competing interests: None declared

The supplemental video is available at http://bjo.bmj.com/supplemental

References

1. Carpineto P, Ciancaglini M, Scaramucci S. et al Management of scleral rupture during retinal detachment surgery: a case report. Eur J Ophthalmol 2002. 12553–555.555 [PubMed]
2. Nakashizuka H, Shimada H, Iwasaki Y. et al Pars plana suture fixation for intraocular lenses dislocated into the vitreous cavity using a closed‐eye cow‐hitch technique. J Cataract Refract Surg 2004. 30302–306.306 [PubMed]
3. Kuhn F, Mester V, Morris R. A proactive treatment approach for eyes with perforating injuries. Klin Monatsbl Augenheilkd 2004. 221622–628.628 [PubMed]
4. Schmidt J C, Rodrigues E B, Meyer C H. A simple technique to fixate the bullet pipe and perform bimanual vitreous surgery. Ind J Ophthalmol 2004. 52337–338.338
5. Viola F, Morescalchi F, Gandolfo E. et al Ocular hypotony secondary to spontaneously ruptured sclera in choroidal coloboma. Arch Ophthalmol 2004. 1221549–1551.1551 [PubMed]

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