Retina Today - Posterior Scleral Buckle for Posterior Perforating Eye Injuries (October 2011)

摘要

Ocular trauma is a leading cause of monocular blindness worldwide, with estimates of 500,000 blinding ocular injuries occurring annually.1 Posterior penetrating injuries beyond the rectus muscle insertion planes are a known risk factor for poor visual prognosis.2 A recent metaanalysis of published reports revealed a final visual acuity of worse than 5/200 in 44% of cases.3 A common cause for severe vision loss is thought to arise from proliferative retinopathy. Studies of the efficacy of prophylactic encircling scleral buckles have revealed lower rates of retinal detachments with use of these devices.4-6 To the best of our knowledge, however, there have been no human studies assessing the efficacy of very posterior radial scleral buckling procedures. In this article, we present three cases of a large radial sponge extending posteriorly to support the rupture site and exit wounds for prophylaxis of retinal detachment. CASE STUDY 1 A 17-year-old man presented to Wilford Hall Medical Center, San Antonio, TX, having sustained a shotgun blast to the face. Two pellets were found perforating the globe near the optic nerve. There was a 6-mm radial scleral rupture beginning posterior to the medial rectus insertion and a shotgun pellet embedded in the scleral wall. A second pellet perforated the posterior eye wall just superonasal to the optic nerve and came to rest at the left orbital apex just lateral to the optic nerve. Vision was light perception with projection. Primary management consisted of closure with removal of the shotgun pellet that was lodged within the scleral wall (Figure 1). This was followed 2 weeks later by secondary retinal repair. A Type 506 radial sponge was placed from the ora serrata to the optic nerve and secured with posterior mattress sutures to support the entrance and exit wound sites. Orbital fat also provided buckle height posteriorly. A pars plana vitrectomy (PPV) with lensectomy was performed to repair the retinal detachment. The exit wound and rupture sites were heavily cauterized, and a limited retinectomy was performed with silicone oil injection. Postoperatively, the patient developed severe superior and medial fibrosis surrounding the wound sites without retinal detachment due to the high posterior buckle. A large pucker developed temporally with macular traction. The patient underwent a final surgery to remove the radial element and repair the macular pucker. The silicone oil was removed, and an IOL was placed in the sulcus. Final visual acuity 12 months after the initial injury was 20/30 (Figure 2). CASE REPORT 2 A 28-year-old man presented to Wilford Hall Medical Center after having sustained an open globe injury from a beer bottle fight. He was found to have a scleral laceration 13 mm posterior to the temporal limbus, extending approximately 20 mm posterior, just under the lateral rectus. The patient was able to count fingers at 3 feet. Management consisted of primary closure followed by secondary repair 5 days later. A Type 506 radial sponge spanning the extent of the 20-mm laceration posteriorly was placed, followed by a PPV. Extensive endolaser was applied around the rupture sites and 360?° in the far periphery with 14% C3F8. Figure 3 shows the reattached retina at 6 months after sponge placement, PPV, and endolaser. At 12 months after the initial injury, the patienta??s retina has remained attached with a visual acuity of 20/20-2. CASE REPORT 3 A 20-year-old man presented to Wilford Hall Medical Center after sustaining an open globe injury due to a gunshot wound. Vision was light perception without projection, and a 2+ relative afferent pupillary defect was present. An anterior 5-mm laceration was identified with dense hyphema and vitreous hemorrhage. The posterior extent of the wound could not be identified on initial examination. Management consisted of primary closure followed by secondary retin