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Late traumatic wound dehiscence after phacoemulsification1
Late traumatic wound dehiscence after phacoemulsification Panos Routsis, MD, Bernard Garston, FRCOphth ABSTRACT Scars from scleral tunnel or clear corneal incisions for phacoemulsification should theoretically be stronger than the larger incisions of planned extracapsular cataract extraction. They should also be more resistant to blunt trauma. We present a case of scleral tunnel wound dehiscence and expulsion of a posterior chamber silicone intraocular lens after blunt trauma. J Cataract Refract Surg 2000; 26:1092–1093 © 2000 ASCRS and ESCRS
R
eports have described serious damage from trauma to eyes that have had extracapsular cataract extraction (ECCE).1,2 Because of their small size, one would assume that scars from scleral tunnel and clear corneal incisions would be more resistant to blunt trauma.
Case Report A 92-year-old white woman was brought to the Eye Casualty Clinic. Earlier that day, she had fallen from her bed and hit the right side of her face on the corner. Immediately, vision in the right eye became blurred. The eye was slightly painful. Three and a half years previously at another center, the patient had 3.5 mm scleral tunnel phacoemulsification with implantation of a Staar plate-haptic silicone intraocular lens (IOL). The scleral tunnel was not sutured. Eighteen months later, the eye had an uneventful neodymium:YAG laser capsulotomy. After that, the left eye had uneventful phacoemulsification with IOL implantation. The patient had bilateral age-related macular degeneration. Two years before the reported injury, best spectaclecorrected visual acuity (BSCVA) was 20/50 in the right eye.
Accepted for publication October 13, 1999. From The Royal Oldham Hospital, Oldham, England. Neither author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Mr. Bernard Garston, FRCOphth, Department of Ophthalmology, The Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, England. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
The patient has atrial fibrillation. In the past, she has had recurrent falls. When the patient was examined at the Eye Casualty Clinic some hours after she had fallen, visual acuity in the right eye was counting fingers. In the left eye, BSCVA was 20/60. An examination revealed a large periorbital hematoma on the right side. The upper part of the conjunctiva was edematous with blackish discoloration. The cornea was clear. There was a total hyphema. Intraocular pressure was 0 mm Hg. The patient was admitted to hospital for exploratory surgery in the right eye using general anesthesia. When the superior conjunctiva was reflected, the platehaptic silicone IOL was found beneath it (Figure 1). It had extruded through the site of the scleral tunnel wound, which had opened and extended. Brown tissue surrounded the wound. The tissue was excised and sent for biopsy. The IOL was removed and the hyphema aspirated. An anterior vitrectomy was performed. The scleral incision was closed with 3 10-0 nylon sutures. A subconjunctival injection of gentamicin was administered. Postoperatively, the right eye was treated with ciprofloxacin and gentamicin drops. The patient was treated with oral ciprofloxacin 750 mg twice daily. On the first postoperative day, the right eye was comfortable. Intraocular pressure was 4 mm Hg. There was almost a complete absence of iris, and a vitreous hemorrhage was present. The hemorrhage slowly resolved. Histopathology showed the brown tissue was choroid and subchoroidal connective tissue. No retinal tissue was identified. An ultrasound B-scan of the right eye showed echogenic material in the vitreous suggestive of hemorrhage. There was no evidence of retinal detachment. 0886-3350/00/$–see front matter PII S0886-3350(00)00419-8
CASE REPORTS: ROUTSIS
Figure 1. (Routsis) The plate-haptic silicone IOL could be seen beneath the superior conjunctiva after it was reflected.
Two weeks after the injury, the vitreous hemorrhage was present only below. Intraocular pressure was 10 mm Hg. Although the eye settled from the effects of the injury (Figure 2), best corrected visual acuity never improved beyond counting fingers because of the macular condition.
Discussion There are many reports in the literature of eyes that have had ECCE with IOL implantation that have sustained serious injury after a blow of considerable force.3 Such injuries can occur days after surgery or many years later. Invariably, the scar from the cataract incision opens.4,5 Usually, the intraocular contents, including
the IOL, extrude. There is considerable iris damage and intraocular hemorrhage. Even after surgical repair, visual acuity is extremely poor. Because scleral tunnel and clear corneal incisions are much smaller than those used in ECCE, one might assume that the resultant scars would be more resistant to blunt trauma. If the blow is of sufficient force, however, even scars from small incisions may not be strong enough to withstand dehiscence. Rapid extrusion of the silicone IOL contributes to damage caused by the trauma. This is because it causes disruption and extrusion of the intraocular structures as well as hemorrhage inside the globe. In our patient 31⁄2 years after scleral tunnel phacoemulsification, the eye was still susceptible to injury. The original wound opened, and the IOL was expelled from the posterior chamber. There was almost total aniridia, vitreous prolapse, and vitreous hemorrhage. Until the conjunctiva was reflected, it was not obvious what had happened. The only option was to remove the silicone IOL and extruded material and suture the lips of the scleral incision. A recent case study6 reports that the scar from a clear corneal incision can rupture after relatively minor trauma. Given the great number of eyes that have had phacoemulsification with IOL insertion, the incidence of patients who have fallen and ruptured their globes must be extremely small.
References
Figure 2. (Routsis) Although the eye was quiet at final follow-up, visual acuity never improved beyond counting fingers.
1. Johns KJ, Sheils P, Parrish CM, et al. Traumatic wound dehiscence in pseudophakia. Am J Ophthalmol 1989; 108:535–539 2. Lambrou FH, Kozarsky A. Wound dehiscence following cataract surgery. Ophthalmic Surg 1987; 18:738 –740 3. Kas MA, Lahav M, Albert DM. Traumatic rupture of healed cataract wounds. Am J Ophthalmol 1976; 81:722– 724 4. Bolling JP, Magargal LE, Shakin E, et al. Trauma to eyes containing posterior chamber lenses. Trans Penn Acad Ophthalmol Otolaryngol 1986; 38:307–310 5. Assia EI, Blotnick CA, Powers TP, et al. Clinicopathologic study of ocular trauma in eyes with intraocular lenses. Am J Ophthalmol 1994; 117:30 –36 6. Hurvitz LM. Late clear corneal wound failure after trivial trauma. J Cataract Refract Surg 1999; 25:283–284
J CATARACT REFRACT SURG—VOL 26, JULY 2000
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R
eports have described serious damage from trauma to eyes that have had extracapsular cataract extraction (ECCE).1,2 Because of their small size, one would assume that scars from scleral tunnel and clear corneal incisions would be more resistant to blunt trauma.
Case Report A 92-year-old white woman was brought to the Eye Casualty Clinic. Earlier that day, she had fallen from her bed and hit the right side of her face on the corner. Immediately, vision in the right eye became blurred. The eye was slightly painful. Three and a half years previously at another center, the patient had 3.5 mm scleral tunnel phacoemulsification with implantation of a Staar plate-haptic silicone intraocular lens (IOL). The scleral tunnel was not sutured. Eighteen months later, the eye had an uneventful neodymium:YAG laser capsulotomy. After that, the left eye had uneventful phacoemulsification with IOL implantation. The patient had bilateral age-related macular degeneration. Two years before the reported injury, best spectaclecorrected visual acuity (BSCVA) was 20/50 in the right eye.
Accepted for publication October 13, 1999. From The Royal Oldham Hospital, Oldham, England. Neither author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Mr. Bernard Garston, FRCOphth, Department of Ophthalmology, The Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, England. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
The patient has atrial fibrillation. In the past, she has had recurrent falls. When the patient was examined at the Eye Casualty Clinic some hours after she had fallen, visual acuity in the right eye was counting fingers. In the left eye, BSCVA was 20/60. An examination revealed a large periorbital hematoma on the right side. The upper part of the conjunctiva was edematous with blackish discoloration. The cornea was clear. There was a total hyphema. Intraocular pressure was 0 mm Hg. The patient was admitted to hospital for exploratory surgery in the right eye using general anesthesia. When the superior conjunctiva was reflected, the platehaptic silicone IOL was found beneath it (Figure 1). It had extruded through the site of the scleral tunnel wound, which had opened and extended. Brown tissue surrounded the wound. The tissue was excised and sent for biopsy. The IOL was removed and the hyphema aspirated. An anterior vitrectomy was performed. The scleral incision was closed with 3 10-0 nylon sutures. A subconjunctival injection of gentamicin was administered. Postoperatively, the right eye was treated with ciprofloxacin and gentamicin drops. The patient was treated with oral ciprofloxacin 750 mg twice daily. On the first postoperative day, the right eye was comfortable. Intraocular pressure was 4 mm Hg. There was almost a complete absence of iris, and a vitreous hemorrhage was present. The hemorrhage slowly resolved. Histopathology showed the brown tissue was choroid and subchoroidal connective tissue. No retinal tissue was identified. An ultrasound B-scan of the right eye showed echogenic material in the vitreous suggestive of hemorrhage. There was no evidence of retinal detachment. 0886-3350/00/$–see front matter PII S0886-3350(00)00419-8
CASE REPORTS: ROUTSIS
Figure 1. (Routsis) The plate-haptic silicone IOL could be seen beneath the superior conjunctiva after it was reflected.
Two weeks after the injury, the vitreous hemorrhage was present only below. Intraocular pressure was 10 mm Hg. Although the eye settled from the effects of the injury (Figure 2), best corrected visual acuity never improved beyond counting fingers because of the macular condition.
Discussion There are many reports in the literature of eyes that have had ECCE with IOL implantation that have sustained serious injury after a blow of considerable force.3 Such injuries can occur days after surgery or many years later. Invariably, the scar from the cataract incision opens.4,5 Usually, the intraocular contents, including
the IOL, extrude. There is considerable iris damage and intraocular hemorrhage. Even after surgical repair, visual acuity is extremely poor. Because scleral tunnel and clear corneal incisions are much smaller than those used in ECCE, one might assume that the resultant scars would be more resistant to blunt trauma. If the blow is of sufficient force, however, even scars from small incisions may not be strong enough to withstand dehiscence. Rapid extrusion of the silicone IOL contributes to damage caused by the trauma. This is because it causes disruption and extrusion of the intraocular structures as well as hemorrhage inside the globe. In our patient 31⁄2 years after scleral tunnel phacoemulsification, the eye was still susceptible to injury. The original wound opened, and the IOL was expelled from the posterior chamber. There was almost total aniridia, vitreous prolapse, and vitreous hemorrhage. Until the conjunctiva was reflected, it was not obvious what had happened. The only option was to remove the silicone IOL and extruded material and suture the lips of the scleral incision. A recent case study6 reports that the scar from a clear corneal incision can rupture after relatively minor trauma. Given the great number of eyes that have had phacoemulsification with IOL insertion, the incidence of patients who have fallen and ruptured their globes must be extremely small.
References
Figure 2. (Routsis) Although the eye was quiet at final follow-up, visual acuity never improved beyond counting fingers.
1. Johns KJ, Sheils P, Parrish CM, et al. Traumatic wound dehiscence in pseudophakia. Am J Ophthalmol 1989; 108:535–539 2. Lambrou FH, Kozarsky A. Wound dehiscence following cataract surgery. Ophthalmic Surg 1987; 18:738 –740 3. Kas MA, Lahav M, Albert DM. Traumatic rupture of healed cataract wounds. Am J Ophthalmol 1976; 81:722– 724 4. Bolling JP, Magargal LE, Shakin E, et al. Trauma to eyes containing posterior chamber lenses. Trans Penn Acad Ophthalmol Otolaryngol 1986; 38:307–310 5. Assia EI, Blotnick CA, Powers TP, et al. Clinicopathologic study of ocular trauma in eyes with intraocular lenses. Am J Ophthalmol 1994; 117:30 –36 6. Hurvitz LM. Late clear corneal wound failure after trivial trauma. J Cataract Refract Surg 1999; 25:283–284
J CATARACT REFRACT SURG—VOL 26, JULY 2000
1093