The scleral buckle was cut adjacent to the existing conjunctival opening, held by the Watzke sleeve that was in the superonasal quadrant, and removed, limiting exposure of the scleral buckle tunnel to any potential pathogenic microorganisms. Careful and meticulous dissection of the conjunctiva and Tenon’s capsule adjacent to the extruded scleral buckle was performed. The patient was taken to the OR for scleral buckle removal, scleral patch graft, and amniotic membrane graft to close the large conjunctival defect (Video). The patient was asked to discontinue the prednisolone acetate and ketorolac drops. The patient was started on ofloxacin drops four times per day in the right eye and given doses of intravenous vancomycin and moxifloxacin in the emergency department. Swabs were also sent for varicella zoster and herpes simplex virus detection via polymerase chain reaction. The buckle and conjunctival defect were cultured for fungal, bacterial, and mycobacterial infections. The CT scan revealed the implanted scleral buckle with a somewhat diagonal orientation in the axial plane, but no evidence of associated pre- or post-septal cellulitis. The anterior segment examination was notable for an area of focal superonasal injection surrounding a full-thickness conjunctival defect with an extruded scleral buckle and an underlying area of significant scleral thinning (Figure 1).įigure 2. Extraocular motility was globally diminished in the right eye. There were no afferent pupillary defects and IOPs were within normal limits. On examination in the emergency department, his VA was 20/40 OD and 20/20 OS. Postoperatively, he was treated with 1% prednisolone acetate one drop four times per day and 0.5% ketorolac one drop twice per day in the right eye. He underwent multiple scleral buckle revisions, most recently in October 2021. He returned to his surgeon and was told that his scleral buckle was exposed. He was seen by his original surgeon who trimmed an “exposed suture,” following which his symptoms worsened. In July of 2021, he developed recurrent episodes of pain and discharge in his right eye. He experienced a redetachment in late 2015 that required repeat surgery with a scleral buckle, PPV, and gas tamponade. He underwent uncomplicated cataract surgery and IOL placement in the capsular bag in 2015, after which he developed an RD in his right eye that was repaired with PPV and gas tamponade. He had no past medical history, but his ocular history was robust. ![]() THE CASEĪ 73-year-old man presented to the emergency department 1 month after a scleral buckle revision with complaints of sudden worsening of ocular pain that woke him up in the middle of the night. Here, we present a case of an extruded silicone scleral buckle with associated scleral thinning and a large conjunctival defect and the surgical steps we took to treat the patient. 10 Larger defects are difficult to close because of the location typically near the conjunctival fornix, loss of tissue integrity due to necrosis, and limited mobility of the surrounding conjunctival tissue due to scarring and adhesions.Īdjunct techniques such as the use of dehydrated amniotic membrane graft secured with fibrin sealant have been shown to successfully repair large conjunctival defects secondary to an extruded buckle. Similarly, primary closure of a small defect may be attempted but is typically futile with frequent recurrence. 9 Observation of the exposed elements coupled with topical antibiotic drops has generally been found inadequate. 2-9 Despite few implants being removed for suspected clinical infection (8.2%), a majority of the extruded and subsequently removed buckles have been shown to be colonized with bacteria. 1 One of the most frequent indications for silicone scleral buckle removal is extrusion through the conjunctiva with rates of extrusion and infection ranging from 0.5% to 5.6%. ![]() Scleral buckling remains a popular technique to repair retinal detachments (RDs), either as primary treatment or as an adjunct to pars plana vitrectomy (PPV).
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