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Spontaneous Peeling of Epiretinal Membrane Associated with Nd:YAG Laser Injury

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Spontaneous Peeling of Epiretinal Membrane Associated with Nd:YAG Laser Injury CASE REPORTS AND SMALL CASE SERIES An Ocular Endoscope Enables a Goniotomy Despite a Cloudy Cornea Infantile glaucoma is often initially treated with a surgical goniotomy or trabeculotomy. A goniotomy is not possible if the cornea is too cloudy, despite preoperative glaucoma medi- cations and removal of the corneal epithelium. Bimanual endoscopic goniotomy has been reported in 1 child, but this technique requires great dexterity to maintain the en- doscopic image on the needle tip.1 In the following case, we used a new technique, coaxial endoscopic go- A niotomy,2 that allowed a goni- otomy to be performed when the an- terior chamber angle could not be distinguished through the surgical gonioprism. Report of a Case. A 19-month-old girl was referred with a several- month history of film covering both eyes. The child was photophobic, tearing, and had bilateral buphthal- mos with extremely cloudy cor- neas. She was prescribed timolol ma- leate, latanoprost, and acetazolamide sodium syrup while undergoing treatment for otitis media. She had no other health problems. An ex- amination under anesthesia 9 days later revealed intraocular pressures B of 31 mm Hg OD and 33 mm Hg OS, corneal diameters of 14.5 mm OD Figure 1. Images are from surgical videotapes. A, Structures in the anterior chamber angle in the left eye and 15 mm OS, circumferential and were not clearly visualized through a surgical gonioprism. A Haab stria is also present (arrow). B, The anterior chamber angle that was treated by coaxial endoscopic goniotomy is viewed several weeks later horizontal Haab striae in both eyes, through a surgical gonioprism. The incised area is to the right of the arrow. a cup-disc ratio of 0.8 OU, axial eye lengths of 25.4 mm OD and 27.0 mm mother and approved by the insti- scopic image. The coaxial endo- OS, and attached retinas by B-scan tutional review board of Vanderbilt scopic goniotomy needle was then ultrasound. A high-iris insertion was University, Nashville, Tenn. A thin inserted through a paracentesis af- present in the right eye by gonios- blood lancet (Microlance; Becton- ter viscoelastic material was placed copy, but the view was too hazy in Dickinson Co, Rutherford, NJ) had into the anterior chamber; the needle the left eye (Figure 1A). been formed to wrap tightly around was directed to the anterior cham- The child underwent bilateral a 20-gauge ocular endoscope (En- ber angle (Figure 2). The image of goniotomies with the aid of a co- doptiks, Little Silver, NJ) and was the anterior chamber angle was axial ocular endoscope in the left eye. sterilized separately. The lancet was viewed on a videoscreen as the lan- Permission for this procedure had placed on the endoscope with the cet tip cut the high-iris insertion for been obtained from the child’s needle tip observable in the endo- 130° (Figure 3). The corneal inci- (REPRINTED) ARCH OPHTHALMOL / VOL 119, JAN 2001 WWW.ARCHOPHTHALMOL.COM 134 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 3. Sun W, Shen JH, Shetlar DJ, Joos KM. Endo- scopic goniotomy with the free electron laser in congenital glaucoma rabbits. J Glaucoma. 2000; 116:199-202. Tissue Adhesive in the Management of Leaking Pars Plana Sclerotomy Causing Hypotony and Choroidal Detachment Nonhealing or persistent wound leakage can be encountered in scle- rotomy sites after multiple pars plana vitrectomies. Therapeutic modali- ties such as patch graft have been re- ported to manage the persistent lim- bal wound leaks.1 Cyanoacrylate tissue adhesives have been success- Figure 2. The coaxial endoscopic goniotomy needle was inserted through a paracentesis and was fully used in the management of cor- directed to the anterior chamber angle. The endoscope tip (arrow) is present inside the lancet. neal perforation and leaking filter- ing bleb to circumvent the need for visualization of the anterior cham- surgical interventions such as thera- ber angle structures is required. peutic keratoplasty and conjuncti- Coaxial endoscopic goniotomy val flap.2,3 We describe herein the permits visualization, as previously technique and successful use of cya- demonstrated in cadaver eyes2 and noacrylate adhesives to manage post- in the successful treatment of rab- operative hypotony and associated bits with congenital glaucoma.3 choroidal detachment caused by The coaxial alignment requires leakage from sclerotomy after pars only 1 corneal incision and permits plana vitrectomy. the lancet tip to be continuously viewed on the videoscreen as it Report of a Case. A 51-year-old incises the angle structures. The white woman with a history of in- operating time is similar to that of sulin-dependent diabetes had un- Figure 3. The image of the anterior chamber a routine goniotomy. dergone 3 prior pars plana vitrecto- angle was viewed on a videoscreen as the lancet tip cut the high-iris insertion. The incised angle mies in the right eye between 1995 is observable on the left side of the image. Karen M. Joos, MD, PhD and 1998 for proliferative diabetic Jin H. Shen, PhD retinopathy and recurrent vitreous sion was closed, and a routine go- Nashville, Tenn hemorrhage. After the first 2 sur- niotomy was performed on the right geries, the visual acuity had re- eye. This project was supported by a grant turned to 20/20 for several months. At the child’s next examina- from Research to Prevent Blindness Six months after the third surgery, tion under anesthesia, her intra- Inc, New York, NY. the visual acuity OD had decreased ocular pressures were still uncon- The authors have no commer- to counting fingers owing to recur- trolled at 35 mm Hg OD and 34 cial, financial, or proprietary inter- rent vitreous hemorrhage and mm Hg OS with poor medication est in the product or company, nor do nuclear sclerotic cataract. In the left compliance, but her left cornea had they receive payment as consultants, eye she had had a persistent retinal substantially cleared so that regular reviewers, or evaluators. detachment after pars plana vitrec- bilateral goniotomies could be per- Reprints: Karen M. Joos, MD, tomy in 1999 for a combined trac- formed. Corneal diameters were PhD, Department of Ophthalmology tional and rhegmatogenous retinal 14.5 mm OD and 14.5 mm OS, and Visual Sciences, Vanderbilt Uni- detachment. She was then referred and axial eye lengths were 25.4 versity, 1215 21st Ave S, 8017 MCE, to us for further management. mm OD and 26.8 mm OS. The pre- Nashville, TN 37232-8808. (e-mail: On our initial examination, her viously treated angle in the left eye [email protected]). best-corrected visual acuity was hand was observed by gonioscopy (Fig- motion in the right eye and light per- 1. Medow NB, Sauer HL. Endoscopic goniotomy ure 1B). for congenital glaucoma. J Pediatr Ophthalmol ception in the left. Ophthalmic echog- Strabismus. 1997;34:258-259. raphy showed dense vitreous hem- Comment. A goniotomy is a rela- 2. Joos KM, Alward WLM, Folberg R. Experimen- orrhage without retinal detachment tal endoscopic goniotomy: a potential treat- tively simple procedure to treat ment for primary infantile glaucoma. Ophthal- in the right eye and a rigid funnel- congenital glaucoma. However, mology. 1993;100:1066-1070. shaped retinal detachment with dif- (REPRINTED) ARCH OPHTHALMOL / VOL 119, JAN 2001 WWW.ARCHOPHTHALMOL.COM 135 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 tiple intraocular surgeries, a deci- sion was made to seal the leaking scle- rotomy with cyanoacrylate tissue adhesives instead of further surgical intervention. For leaking scle- rotomy with a soft globe in this pa- tient, tissue adhesive was applied un- der a slitlamp biomicroscope using topical anesthesia and a lid specu- lum. After the loose suture was re- moved, the necrotic scleral and con- junctival tissues overlying the scleral perforation were debrided. Prior to gluing, a sterile plastic disk was cut to the size slightly larger than the scle- rotomy using a 3-mm skin biopsy punch (Acu-Punch; Acuderm, Ft Lauderdale, Fla). The plastic disk was then placed on a small amount of ophthalmic ointment, which was pre- Figure 1. Leakage from pars plana sclerotomy associated with choroidal detachment (inset). placed at the end of the wooden stick of a cotton-tipped applicator as pre- viously reported.3 A small meniscus (about 1 to 2 µL) of the tissue adhe- sive (Histoacryl; B. Braun, Melsun- gen AG, Germany) was placed on the Leaking Sclerotomy 3-mm plastic disk (Figure 2, inset). The leaking area was dried with a cel- lulose sponge. The glue on the disk was gently pressed against the scle- rotomy for 10 to 20 seconds with the end of the applicator (Figure 2). On observing the polymerization of tis- sue adhesive and adequate adher- ence of the disk over the scle- rotomy, the cotton-tipped applicator was removed. The preplaced oint- ment facilitated the separation of the disk from the end of the applicator Ointment Glue and prevented dislodging of the po- Disk lymerized glue on the disk. Because the adhesive plug had a rough edge Figure 2. Application of tissue adhesive on a plastic disk (inset) over the sclerotomy. around the disk and could be poten- tially irritating, a therapeutic con- fuse vitreous hemorrhage in the left. lamp examination showed loosen- tact lens was used to ensure the pa- Because of the guarded visual prog- ing of the 8-0 polyglactin 910 (Vic- tient’s comfort and to prevent nosis for the left eye, surgery was rec- ryl) suture at the superotemporal dislodgement of the glue by eyelid ommended for the right.
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