From the Department of Ophthalmology, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Hüseyin Gürsoy, MD, Eskisehir Osmangazi University Ophthalmology Department, Meselik Eskisehir, Turkey, 26480.
Although extraocular muscle surgery is generally safe and complications are rarely seen, many complications ranging from mild to severe have been reported, including scleral dellen.1–3 The aim of our article is to report a case of scleral dellen after the use of fibrin glue for conjunctival closure following strabismus surgery.
Significant irritation and foreign body sensation, uncommon suture reactions, abscesses, and granulomas can be seen after conjunctival closure with polyglactin 910 sutures in strabismus surgery.4,5 These disturbing complications can be avoided by the sutureless closure of conjunctiva with fibrin glue.6 In the future, conjunctival closure using fibrin glue may be an alternative to closure with suture materials in strabismus surgery.
A 37-year-old woman who was otherwise healthy and had no previous systemic disease history was referred with a right-sided exotropia. She had not previously received any ocular surgery. On ophthalmic examination, her visual acuity was 0.22 logarithm of the minimum angle of resolution (LogMAR) (with −7.00+3.00 @ 90) in the right eye and 0.22 LogMAR (with −6.00+4.00 @ 90) in the left eye. Slit-lamp biomicroscopic and fundus examinations were normal in both eyes. There was 40 prism diopters of right exotropia. Eye movements were free in every direction.
The patient underwent strabismus surgery under topical anesthesia. Initially, 8-mm lateral rectus recession on the left side through routine limbal approach was performed. Adjustable strabismus surgery through Swan incision was preferred on the right side. The Swan incision method, which has the advantage of direct access and good exposure of the muscle insertion, places the conjunctival incision behind the muscle incision parallel to the limbus.7 The conjunctiva was then dissected anteriorly and the Tenon capsule was opened just anterior to the muscle insertion. The main problems with the Swan incision are increased risk of muscle belly injury7 and its tendency to scar to the sclera insertion site if not closed well.8 On the right-side lateral rectus recession, a “bow-tie” adjustable suture technique was preferred. At the end of the operation the cover test was applied. Adjustment and permanent suturation was performed immediately in the operating room. The conjunctiva in the right eye was closed with fibrin glue (Tisseel; Baxter, Deerfield, IL) instead of sutures.
On the first postoperative day, no postoperative complication was observed. Ofloxacin and dexamethasone drops were prescribed every 6 hours daily.
The patient complained of redness, discomfort, burning, and pain in the right eye on the third postoperative day. On ophthalmologic examination, visual acuity was 0.22 LogMAR (with −7.00+3.00 @ 90) in the right eye. Slit-lamp biomicroscopic examination revealed an opening on the conjunctiva and scleral thinning just posterior to the stump of the right lateral rectus muscle (Fig. 1). The choroid reflex was seen on the area of scleral thinning. The fundus examination was normal.
Figure 1. Scleral Dellen on the Third Postoperative Day.
The conjunctiva was reopened and released and then was sutured with 7-0 Vicryl sutures (Ethicon, Somerville, NJ) under topical anesthesia. The patient was treated with high viscosity tear drops every 3 hours and she was observed in daily examinations. After 48 hours, the pain was completely relieved, the sclera and the conjunctiva recovered to normal appearance, and the choroid reflex was not taken. One week later, the conjunctiva was completely epithelialized (Fig. 2). The patient was orthophoric and not suffering from any complaints.
Figure 2. Two Weeks After Conjunctival Repair.
The most commonly recognized findings after strabismus surgery are foreign body sensation, conjunctival swelling, and irritation. The most commonly recognized complications are pseudoptosis, punctate keratopathy, conjunctival folds, and scars, but scleral dellen is an uncommon complication.5 The relatively common findings and complications related to conjunctival closure with sutures can be avoided by using fibrin glue instead of sutures.6
Fibrin glue is a biodegradable biological tissue adhesive and appears to promote angiogenesis (the formation of new blood vessels), local tissue growth, and repair without inducing inflammation and foreign body reactions.9 Fibrin glue reaches its maximum adhesive capacity within 2 hours after its application. The duration of fibrin glue on eyes in vivo is typically less than 2 weeks.10 In ophthalmology, fibrin glue has been successfully used for perforated and preperforated corneal ulcers, leaking filtration blebs, mucous membrane grafting of the fornix, and conjunctival closure following retinal detachment, glaucoma filtering, and strabismus surgeries.6 In a study conducted by Mohan et al. with 15 patients who underwent strabismus surgery, normal conjunctival healing occurred in all patients and none of the patients had irritation or foreign body sensation.6
Scleral dellen occurred on the thinner sclera posterior to the muscle stump on the third postoperative day following conjunctival closure with fibrin glue. Myopia could be a predisposing factor for our case. The mechanism in scleral dellen is local dehydration, such as that in corneal dellen during the postoperative period.1 Reasons for this include scleral exposure and irregular distribution of tears due to conjunctival folding.2 In our case, conjunctival contracture after rectus recession led to scleral exposure because of inadequate closure with fibrin glue. The blue color of the uvea can be seen over the thin sclera. Scleral dellen is more frequent following muscle surgery through limbal incision,2 but our approach was through the Swan incision.
Scleral dellen is a benign situation and no globe perforation secondary to scleral dellen has been reported in the literature.3 Although it is a benign complication, it is important to differentiate it from surgically induced necrotizing scleritis, which is mostly seen after cataract surgery but also reported after strabismus surgery. Pain and local inflammation accompanying scleral dellen, late postoperative occurrence, and association with systemic disease are distinguishing features of necrotizing scleritis. Immune suppressive treatments are used for alleviation of disease.11
Most authors have speculated that scleral dellen usually can be treated with rehydration of the ocular surface without any surgical interventions.2,5 In our case, there was a big gap between conjunctival edges so the conjunctiva was sutured in addition to intensive lubrication with artificial tears. This case may alert surgeons preferring fibrin glue for conjunctival closure to the possibility of scleral dellen occurrence.
- Sharma P, Ayra AV, Praskash P. Scleral dellen in strabismus surgery. Acta Ophthalmol. 1990;68:493–494. doi:10.1111/j.1755-3768.1990.tb01683.x [CrossRef]
- Perez I. The “scleral dellen,” a complication of adjustable strabismus surgery. J AAPOS. 2002;6:332–333. doi:10.1067/mpa.2002.125762 [CrossRef]
- Lee DH, Herion MA, Unwin DR, Cruz OA. Scleral dellen after bilateral adjustable suture medial rectus muscle resection. J AAPOS. 2003;7:221–222. doi:10.1016/S1091-8531(03)00004-1 [CrossRef]
- Von Noorden GK, Campos EC. Binocular Vision and Ocular Motility. St. Louis: Mosby; 2001:621.
- Scharwey K, Gräf M, Becker R, Kaufmann H. Healing process and complications after eye muscle surgery [article in German]. Ophthalmologe. 2000;97:22–26. doi:10.1007/s003470050005 [CrossRef]
- Mohan K, Malhi RK, Sharma A, Kumar S. Fibrin glue for conjunctival closure in strabismus surgery. J Pediatr Ophthalmol Strabismus. 2003;40:158–160.
- Swan KC, Talbot T. Recession under Tenon’s capsule. AMA Arch Ophthalmol. 1954;51:32–41.
- Wright KW. Color Atlas of Strabismus Surgery Strategies and Techniques. New York: Springer Science+Business Media; 2007:104.
- Radosevich M, Goubran HI, Burnouf T. Fibrin sealant: scientific rationale, production methods, properties, and current clinical use. Vox Sang. 1997;72:133–143. doi:10.1046/j.1423-0410.1997.7230133.x [CrossRef]
- Lagoutte FM, Gauthier L, Comte PR. A fibrin sealant for perforated and preperforated corneal ulcers. Br J Ophthalmol. 1989;73:757–761. doi:10.1136/bjo.73.9.757 [CrossRef]
- O’Donoghue E, Lightman S, Tuft S, Watson P. Surgically induced necrotising sclerokeratitis (SINS): precipitating factors and response to treatment. Br J Ophthalmol. 1992;76:17–21. doi:10.1136/bjo.76.1.17 [CrossRef]