Long-term retinal changes after strabismus surgery, suspected signs of past scleral perforations

Purpose: Scleral perforation during strabismus surgery is considered a rare complication that usually results in no significant consequences. The true rate of such occurrences is difficult to evaluate due to the young age of most patients and the occult nature of most events. This study aimed to evaluate long?term retinal changes under the suture areas in patients post?strabismus surgery as presumed signs indicating past undiscovered scleral perforations. Methods: The study population consisted of patients with a follow?up of at least 10 years post?strabismus surgery at the [redacted for review] Eye Institute and with no known retinal conditions as well as with wide fundus visibility. We performed slit?lamp retinal periphery examinations in search of retinal scars or changes at the suture sites. Results: Seventy?one eyes from 43 patients were examined. The mean age (±standard deviation [SD]) at the time of examination was 27 years (±14), and the mean number of strabismus surgeries per patient was 1.8. Three of the examined eyes showed retinal changes at the suture sites, yielding an overall incidence rate of suspected perforation/penetration of 4.2% per eye and 3.6% per strabismus surgery. These three patients were all asymptomatic. Conclusion: Scleral perforations during strabismus surgeries could remain unnoticed since a comprehensive exam of the retinal periphery is challenging in young children, especially during the postoperative period. While retinal changes caused by inadvertent scleral perforations appear to have no clinical sequelae in a time frame of 10 years, such changes should be noted for future fundoscopic examinations

Scleral Perforation During Inferior Rectus Muscle Recession in Congenital Fibrosis of the Extraocular Muscles

PURPOSE: We report a case of a scleral perforation during inferior rectus recession in congenital fibrosis of extraocular muscles and the management of this perforation with a scleral patch graft. CASE SUMMARY: A 20-month-old female with bilateral ptosis, absence of elevation and a chin-up position was diagnosed with congenital fibrosis of extraocular muscles. Because severe esotropia in the downward gaze was observed, we first performed esotropia surgery. After 1 year, she underwent a bilateral ptosis correction. We decided to perform bilateral inferior rectus recession due to an abnormal head posture and the absence of elevation. Because the inferior rectus muscles were extremely tight and adhered to the sclera, hooking and isolating these muscles during surgery was difficult. After muscle suture placement, a portion of the sclera that contacted the left inferior rectus was chipped off as this muscle was disinserted with blunt Westcott scissors. A scleral perforation was observed, thus, we placed a scleral patch graft using the donor sclera and finished the bilateral inferior rectus recession. No abnormal findings for the vitreous or retina were detected. At 8 months after surgery, the patient exhibited exotropia of 12 prism diopters in her primary gaze. Her abnormal head posture nearly disappeared. CONCLUSIONS: Careful isolation and disinsertion of the muscle from the globe is necessary in the treatment of patients who are expected to exhibit severe adhesions between the muscle and sclera, such as patients with congenital fibrosis of extraocular muscles.

Use of Autologous Tenon's Capsule Graft for Repair of Traumatic Scleral Perforation

PURPOSE: To report the use of autologous Tenon's capsule graft for repair of scleral defects caused by traumatic scleral perforation. CASE SUMMARY: An 81-year-old man presented with loss of vision in his right eye after a perforating injury caused by a cow horn. Examination showed a laceration of the sclera at 12 o'clock approximately 5~6 mm in length, and a uveal tissue was prolapsed into the wound. The best corrected visual acuity was 0.1. Primary repair of the eye was insufficient because of tissue loss. The inferonasal Tenon's capsule graft was carefully dissected from the sclera and tailored to fit the defect. The graft was covered with a conjunctival flap. The scleral defect was successfully closed with the autologous Tenon's capsule graft. Three months after grafting, phacoemulsification with intraocular lens implantation was performed. CONCLUSIONS: Autologous Tenon's capsule graft is an effective measure to repair traumatic scleral defects and is useful when patch grafts are unexpectedly needed.

A Case of Klebsiella Endogenous Endophthalmitis Accompanied by Necrotizing Scleral Perforation

PURPOSE: We report a case of endogenous endophthalmitis caused by Klebsiella pneumoniae, accompanied by orbital cellulitis and necrotizing scleral perforation secondary to liver abscess. METHODS: A fifty three year old woman patient who had received treatment for uveitis in local ophthalmic clinic for five days was referred to this ophthalmologic department in consultation for uncontrolled ocular pain and eyelid swelling accompanied by proptosis. Ten days before admission, she had already received antibiotic medication at internal medicine clinic for abdominal pain and fever. Since her ocular pain along with exophthalmos and eyelid swelling got worse, she received a whole body examination including blood culture, urine test, chest and abdominal radiologic examination to find out infectious focus. In addition, ultrasonography, computed tomography and aqueous culture for ophthalmic examination were performed. Then she was treated with antibiotic medication via systemic and topical route. RESULTS: The Klebsiella pneumoniae was cultured from vitreous in endogenous endophthalmitis accompanied by orbital cellulitis and necrotizing scleral perforation. Although the inflammation was improved with antibiotic medication, she lost her vision. CONCLUSIONS: From the fact that scleral perforation can be complicated by endogenous bacterial endophthalmitis, it is strongly urged that systemic work up such as radiologic examination and blood test be carried out with caution to detect infectious diseases.

Experimental Scleral Perforation by Cultured Bacteria in the Needle Used during Strabismus Surgery

PURPOSE: In order to investigate endophthalmitis and these causative organisms after accidental scleral perforation during strabismus surgery, the used needles after strabismus surgery were cultured and then the cultured bacteria were introduced into rabbit vitreous after perforating the sclera. METHODS: We cultured the needles of sixty strabismus patients, and the identified bacteria were introduced into rabbit vitreous after perforation of the sclera, by dilution at different concentrations, using either sterile syringe or staining on the needles. RESULTS: Positive cultures were found in 10 patients. Of these 10, 7 were identified with Staphylococcus epidermidis and 3 with Staphylococcus aureus. After culturing these two strains and diluting them to different concentrations, they were injected into rabbit vitreous using sterile syringe. It was found that S. aureusat the concentration of 10(3)colonies/ml produced endophthalmitis while at 10(5)~10(7)colonies/ml endophthalmitis was found to be present in all eyes. Although S. epidermidis at concentrations between 10(3) and 10(7) colonies/ml also produced endophthalmitis, the degree of inflammation was weaker than that induced by S. aureus, and some rabbits did not even develop endophthalmitis. After S. aureus was diluted to different concentrations, stained on needles and perforated into rabbits vitreous, endophthalmitis developed at the concentration of 10(7)colonies/ml. CONCLUSION: The two strains isolated after strabismus surgery were the same as the normal bacterial flora found in the lid and conjunctiva. Three days after introduction of both strains, endophthalmitis developed at the relatively high concentration of colonies. In order to prevent endophthalmitis after scleral perforation, the surgeon should decrease the concentration of normal flora in the lid and conjunctiva before strabismus surgery.