Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Indirect Intraoperative Visualization of the Posterior Sclera

John Chopin Hwang, MD, MBA; Anne Sarah Steiner, MD

Abstract

Adequate exposure of the sclera during posterior ruptured globe repair remains challenging because the globe traction required for direct visualization of the posterior laceration may result in expulsion of intraocular contents through the scleral wound. The authors describe a new technique for indirect visualization of the posterior sclera that allows for meticulous exploration and repair of posterior globe lacerations, while minimizing the need for globe traction and risk of intraocular content loss.

Abstract

Adequate exposure of the sclera during posterior ruptured globe repair remains challenging because the globe traction required for direct visualization of the posterior laceration may result in expulsion of intraocular contents through the scleral wound. The authors describe a new technique for indirect visualization of the posterior sclera that allows for meticulous exploration and repair of posterior globe lacerations, while minimizing the need for globe traction and risk of intraocular content loss.

Indirect Intraoperative Visualization of the Posterior Sclera

From the University of Edward S. Harkness Eye Institute, Trauma Service, Columbia University Medical Center, New York, New York.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to John C. Hwang, Edward S. Harkness Eye Institute, Columbia University Medical Center, 635 West 165th Street, Box 100, New York, NY 10032.

Posted Online: March 22, 2010

Introduction

Visualization of the posterior sclera is critical for numerous ocular surgeries including posterior ruptured globe repair, scleral buckle placement, and plaque radiotherapy implantation. Direct visualization of the posterior sclera is typically achieved by globe rotation, which may provide only limited exposure due to counter-traction by the extraocular muscles and optic nerve. The induced globe traction required for direct visualization may also increase the risk of intraocular content loss through the scleral wound during posterior ruptured globe repair, when adequate scleral exposure and exploration is essential. We describe an intraoperative technique used to improve visualization of the posterior sclera without induction of globe traction.

Report

A 16-year-old woman sustained a globe laceration to her right eye during an altercation involving a razor blade. Visual acuity was limited to hand motion in the right eye at the time of presentation. A large scleral laceration was noted at 5-o’clock position approximately 4 mm inferior to the limbus and extended superotemporally without a clear termination point. The patient was transported to the operating room for emergent repair. A 360° peritomy was conducted and the inferior and lateral recti muscles were disinserted. The scleral laceration continued superotemporally through the insertion of the lateral rectus muscle and then extended posteriorly. The visible portion of the laceration was closed with 10-0 nylon sutures. Gentle traction was used to rotate the globe in an attempt to visualize the posterior extent of laceration. However, this technique was limited by traction-induced herniation of intraocular contents through the scleral wound. A circular mirror was placed tangential to the posterior globe, allowing indirect visualization of the posterior scleral wound without globe traction. The mirror was advanced posteriorly along the globe and eventually revealed the posterior endpoint of the laceration. Using indirect visualization, the posterior laceration was closed using 10-0 nylon sutures without induction traction or expulsion of intraocular contents through the wound (Fig. 1).

Intraoperative Photograph. Indirect Visualization of the Posterior Scleral Laceration Is Demonstrated Using a Circular Mirror Placed Tangential to the Globe. Indirect Visualization Was Used During Exploration of the Posterior Ruptured Globe and Placement of Sutures for Closure. Direct Visualization Using Globe Rotation and Traction Was Initially Attempted but Was Limited by Herniation of Intraocular Contents Through the Scleral Wound.

Figure 1. Intraoperative Photograph. Indirect Visualization of the Posterior Scleral Laceration Is Demonstrated Using a Circular Mirror Placed Tangential to the Globe. Indirect Visualization Was Used During Exploration of the Posterior Ruptured Globe and Placement of Sutures for Closure. Direct Visualization Using Globe Rotation and Traction Was Initially Attempted but Was Limited by Herniation of Intraocular Contents Through the Scleral Wound.

Discussion

The exploration and closure of posterior ruptured globes is typically achieved by direct visualization of the posterior sclera, which requires torsion and traction of the globe for adequate surgical exposure. The utility of direct visualization may be limited by intraocular content loss through the scleral wound, particularly in cases where the laceration extends far posteriorly and a significant degree of globe traction is required for direct visualization. This case report introduces indirect visualization of the posterior sclera during ruptured globe repair, which allowed for meticulous exploration of the posterior sclera without inducing globe traction or subsequent loss of intraocular contents through the scleral wound. In addition, indirect visualization was used during the closure of the posterior laceration to minimize globe traction.

Limited surgical visualization of the posterior sclera can pose difficult management issues in patients with posterior segment pathology. Ophthalmologists may only partially close a posterior ruptured globe due to inadequate visualization of the posterior extent of the scleral wound. Visualization and placement of sutures can be particularly difficult during posterior ruptured globe repair1 because the traction required for posterior scleral exposure may result in intraocular expulsion through the wound. Similarly, vitreoretinal surgeons may pursue pars plana vitrectomy instead of scleral buckling in patients with a posterior retina break,2 due to the challenge of accessing the posterior sclera and placing a posterior segmental buckle. Indirect visualization may be helpful in such cases.

In summary, indirect visualization during ruptured globe repair may improve surgical exposure of the posterior sclera while minimizing the need for globe traction and subsequent loss of intraocular contents through the scleral wound.

References

  1. Bloom JN, Duffy MT, Davis JB, McNally-Heintzelman KM. A light-activated surgical adhesive technique for sutureless ophthalmic surgery. Arch Ophthalmol. 2003;121(11):1591–1595. doi:10.1001/archopht.121.11.1591 [CrossRef]
  2. Schwartz SG, Flynn HW. Primary retinal detachment: scleral buckle or pars plana vitrectomy?Curr Opin Ophthalmol. 2006;17(3): 245–250. doi:10.1097/01.icu.0000193097.28798.fc [CrossRef]
Authors

From the University of Edward S. Harkness Eye Institute, Trauma Service, Columbia University Medical Center, New York, New York.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to John C. Hwang, Edward S. Harkness Eye Institute, Columbia University Medical Center, 635 West 165th Street, Box 100, New York, NY 10032.

10.3928/15428877-20100210-83

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