Case Report Managing a case of buckle intrusion with recurrent vitreous haemorrhage: a case report Sharan Shetty1 and Muna Bhende2

1Fellow, Introduction preferred in view of high chance of intraoperative Sri Bhagwan Mahavir Scleral buckling (SB) with silicone implants is an globe rupture. However, patient did not undergo Vitreoretinal Services, effective method to reattach the retina. Silicone the surgery and reported back to us after 3 Sankara Nethralaya, Chennai, India implants used for SB in retinal detachment months. Anterior migration of the scleral buckle surgery have been associated with various compli- was noted this visit. Patient was taken up for cations which include buckle infection, granuloma scleral buckle removal along with trimming the 2Senior Consultant & Deputy formation, extrusion of the implant through the encirclage over the segmental buckle element. Director, conjunctiva, double vision and restriction of An external approach was planned for buckle Sri Bhagwan Mahavir ocular motility. Intrusion of the implant through removal. A standby scleral graft was made Vitreoretinal Services, the sclera may develop due to progressive scleral available to patch any visible scleral defect. The Sankara Nethralaya, 1 Chennai, India thinning. conjunctiva and the tenons were dissected of Intrusion is defined as erosion, followed by the scleral buckle in the supero-temporal quad- protrusion of the scleral implant into the vitreous rant. The two anchor sutures were cut and Correspondence: cavity. The intruding material may either be the removed. The buckle element was cut at the Muna Bhende, material implanted on the sclera or the sutures. centre and gentle expressed out. The encirclage Deputy Director and Senior Intrusion of the buckle through the sclera into the over the buckle was trimmed and edges were Consultant, fi Sri Bhagwan Mahavir subretinal space is particularly dif cult to manage repositioned into the sub-tenons space. The Vitreoretinal Services, and can result in severe vision loss, recurrent tenons and the conjunctiva were sutured in Sankara Nethralaya, retinal detachment and subretinal or vitreous layers (Figure 3). Chennai, India. hemorrhage.2 We report a case of a patient suffer- Postoperatively, the retina remained attached Email: [email protected] ing from recurrent vitreous haemorrhages follow- with a BCVA of 20/30. Two months later, patient ing scleral buckle intrusion 14 years after surgery, had maintained a vision of 20/30 with reduction managed by buckle removal without removing the in the buckle indent with no further episodes of encirclage band. vitreous haemorrhage with persisting NVE at the area of buckle intrusion (Figure 4). Case report A 31-year-old male presented to us with history Discussion of recurrent floaters in the left eye since 3 SB with exogenous material is an effective months. He had undergone SB 14 years back for method to reattach the retina. Retrospective series rhegmatogenous retinal detachment following a have reported complications of SB, most com- blunt trauma. Patient had good vision following monly extrusion and infection, in 1.3–24.4% of the surgery and was on regular follow-up. He eyes. Intrusion and erosion are rarely reported developed recurrent retinal detachment for which complications of SB, noted to occur in approxi- he underwent pars plana vitrectomy, 3 months mately 4 of 4400 cases.3 It has been associated ago. On examination, his best-corrected visual with myopia because of the related scleral thin- acuity (BCVA) was 20/40 with intraocular pres- ning and altered scleral strength.4 SB erosion and sure of 30 mmHg. Slit-lamp examination was intrusion may cause visual symptoms and result within normal limits. Fundus examination in retinal detachment, vitreous haemorrhage and revealed an attached retina with high buckle endophthalmitis. An intruding or eroding SB may indentation and buckle intrusion in the inferior be left untouched unless there is any complica- half (Figure 1) along with neovascularization and tions, or is a significant danger to the integrity of haemorrhage over the area of intrusion the ocular structures.5 (Figure 2). Patient was started on topical 0.5% The decision to remove an SB can be puzzling, timolol maleate twice a day. On follow-up visit as each case is unique. SB removal can be consid- after a month, he gave a history of one more ered necessary if signs and symptoms are progres- episode of vitreous haemorrhage. On examin- sive or additional complications occur (e.g., ation, subconjunctival haemorrhage was noted endophthalmitis and scleral necrosis). If signs and over the superior bulbar conjunctiva with anter- symptoms are chronic and stable (e.g., extrusion), ior migration of the buckle element. Patient was SB removal is elective. The most dreaded conse- put on a full course of oral antibiotic along with quence of SB removal is recurrent detachment.6 topical antibiotics and was advised removal of The cause of retinal detachment after buckle the segmental buckle. General anaesthesia was removal can be proliferative vitreoretinopathy or a

Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | 37 Case Report

Figure 1: Fundus photo montage of the left eye showing attached retina with buckle intrusion in the infero-nasal quadrant.

new retinal break.7 Patients with areas of traction SB removal is performed in the operating room or high-risk lesions should have laser prophylaxis with topical, local or general anaesthesia. A local before SB removal. anaesthetic injection should be performed with

Figure 2: Neovascularization and haemorrhage over the area of buckle intrusion.

38 Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | Case Report

Figure 3: (A) Intraoperative photo showing buckle element in situ with the encirclage band cut over it. (B) The buckle element is cut at the centre. (C) The buckle element is expressed out. (D) The encirclage band is trimmed and repositioned in the sub-tenons space.

Figure 4: Postoperative fundus photo showing reduction in buckle indent height with resolution of haemorrhage.

Sci J Med & Vis Res Foun July 2017 | volume XXXV | number 2 | 39 caution as many eyes are myopic with a distorted Removed SB and sutures should be sent for micro- globe after buckle surgery. General anaesthesia biological examination. should be opted for in cases where scleral necrosis, In this case, a conservative approach of erosion and intrusion are suspected as chances of removal of the just the buckle element without globe perforation are high. removal of the encirclage was followed as there Often the SB can be removed with opening one was anterior migration of the scleral buckle quadrant of conjunctiva or using a pre-existing element along with the intrusion of the encirclage exposure site. Information of which elements were in the opposite quadrant. used and where their ends lie is vital, as dissecting without a clear plan is difficult. When this infor- mation is unavailable, SB details can sometimes References be gathered by examining the conjunctiva and 1. Kokame GT, Germar GG. Successful management of intruded hydrogel buckle with buckle removal, scleral patch graft, and looking at the buckle indentation on fundus vitrectomy. Retina 2003;23(4):536–8. examination. The route of removal of buckle 2. Shami MJ, Abdul-Rahim AS. Intrusion of a scleral buckle: a late element depends on the degree of intrusion. For complication of retinal reattachment surgery. Retina 2001;21 example, if the segment is intravitreal then it can (2):195–7. be removed via the pars plana. 3. Deutsch J, Aggarwal RK, Eagling EM. Removal of scleral explant Depending on the indication, SB-related com- elements: a 10-year retrospective study. Eye 1992;6(6):570–3. plications can be managed by 1) cutting the 4. Nguyen QD, Lashkari K, Hirose T, et al. Erosion and intrusion of silicone rubber scleral buckle: presentation and management. encircling band, 2) removing the exposed segmen- Retina 2001;21(3):214–20. tal buckle element with the other elements left in 5. Kitagaki T, Morishita S, Kohmoto R, et al. A case of intraocular place and 3) most often, all elements removed erosion and intrusion by an arruga suture. Case Rep Ophthalmol. along with sutures.8 Sutures can be removed or 2016;7(1):174–8. left in place, depending on if they are causing pro- 6. Deokule S, Reginald A, Callear A. Scleral explant removal: the – blems and their accessibility. Irrigation with anti- last decade. Eye 2003;17(6):697 700. 7. Goezinne F, La Heij EC, Berendschot TT, et al. Incidence of biotics should be considered after the procedure, redetachment 6 months after scleral buckling surgery. particularly with an infected SB. If scleral necrosis Actaophthalmologica 2010;88(2):199–206. or erosion and intrusion are suspected, patch 8. Tsui I. Scleral buckle removal: indications and outcomes. Survey materials and sutures should be kept available. Ophthalmol. 2012;57(3):253–63.

How to cite this article Shetty S. and Bhende M. Managing a case of buckle intrusion with recurrent vitreous haemorrhage: a case report, Sci J Med & Vis Res Foun 2017;XXXV:37–40.

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