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Video Report

Intrusion of an encircling band with recurrent retinal detachment: surgical approach

¹St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
²Moorfields Eye Hospital, City Road, London, EC1V 2PD, UK

Correspondence: Mr Edward Doyle
Eye Department, Correspondence: St Thomas' Hospital; Email: edrachie{at}btinternet.com

Date of acceptance: 4th April 2006

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Introduction

Erosion and intrusion of buckling elements from prior retinal detachment repair can cause a management dilemma. Progression of erosion can cause vitreous haemorrhage and retinal detachment and the options include observation, cutting encircling bands, removal of buckling materials and closure of scleral defects by sutures or scleral patch grafts.
We present the management of a case of intrusion of an encircling silicone band resulting in retinal detachment.

Case Report

An 88-year-old man presented with painless loss of left eye vision over the previous week. The right eye had seen poorly for some time as a result of glaucoma. He had undergone bilateral retinal detachment surgery and trabeculectomies more than 20 years previously and was bilaterally pseudophakic with posterior chamber intraocular lenses. The original retinal surgery had involved bilateral encirclement with silicone bands. A recurrence of left retinal detachment in 1999 was treated with a vitrectomy with laser and sulphur hexafluoride tamponade. At that time signs of early implant erosion were noted in the superior periphery.
On examination visual acuities were hand movements only on both sides with bilateral advanced glaucomatous cupping and an atrophic right macula. On the left there was a macula-off retinal detachment with proliferative vitreoretinopathy grade CP2 temporally (figure 1). The encircling band was intruding into the vitreous cavity superonasally and elsewhere was sitting superficially beneath the retinal pigment epithelium.

Figure 1

He underwent surgery (DAHL) under general anaesthesia involving removal of the intraocular lens implant (in anticipation of the possible use of oil), vitrectomy, retinectomy, laser and gas tamponade with 30% sulphur hexafluoride. The encircling buckle was not disturbed. The retina was still attached at the most recent visit 6 months after surgery (figure 2) and visual acuity was 6/60.

Figure 2

Discussion

Buckle erosion is the result of gradual thinning of the sclera underlying a scleral buckle, with fibrous overgrowth externally leading ultimately to buckle intrusion, where the buckle erodes through the retina to lie within the vitreous cavity. Subclinical erosion is common with 17% of silicone explants and 23% of silicone sponges having only a thin layer of fibrous tissue separating them from the choroid in post-mortem eyes.[1] As a result there can be a potential route for organisms to enter the eye.[2]
Clinically significant intrusion and erosion are rare and usually associated with multiple surgeries for retinal detachment,[3,4] excessive use of diathermy or cryotherapy,[4] glaucoma,[4] myopia,[4], Marfan's syndrome[5] and encircling buckles.[4,5] It was more common with now obsolete polyethylene tubing[3,6] and Arruga encircling sutures.[7,8]
Patients with intrusion can present with vitreous haemorrhage and retinal detachment.[4,9]
Surgical approaches to erosion include removal of the band and closure of the scleral defect with non-absorbable sutures[4,5] application of cyanoacrylate glue to the defect,[4] or a scleral patch graft.[4] Cutting the encircling band may prevent further erosion but can cause redetachment.[4]
In our case the retina developed a defect around the intruding encircling buckle, resulting in a retinal detachment. A vitrectomy was performed without disturbing the intruding band. 360° endolaser and 30% sulphur hexafluoride gas tamponade successfully reattached the retina, which remained attached until the most recent follow-up appointment at 6 months.

Conflict of Interest Statement

The authors have no commercial interests in any products mentioned in this article.

References

• Wilson DJ, Green WR. Histopathologic study of the effect of retinal detachment surgery on 49 eyes obtained post mortem. Am J Ophthalmol 1987;103:167-79.
• Hugkulstone CE, Rubasingham AS. Endophthalmitis after removal of an encircling band. Brit J Ophthalmol 1991;75:178.
• Yoshizumi MO, Friberg T. Erosion of implants in retinal detachment surgery. Ann Ophthalmol 1983;15:430-4.
• Nguyen QD, Lashkari K, Hirose T, Pruett RC, McMeel JW, Schepens C, L. Erosion and intrusion of silicone rubber scleral buckle. Presentation and management. Retina 2001;21:214-20.
• Deramo VA, Haupert CL, Fekrat S, Postel EA. Hypotony caused by scleral buckle erosion in Marfan syndrome. Am J Ophthalmol 2001;132:429-31.
• Regan CD, Schepens CL. Erosion of the ocular wall by circling polyethylene tubing: a late complication of scleral buckling. Am J of Opthalmol 1964;57:79-83.
• Schepens C, L. Postoperative complications: III. Implant erosion without and with retinal detachment. In: Schepens C, ed. Retinal detachment and allied diseases. First Ed. Philadelphia:W.B. Saunders 1983:1053-86.
• Dark AJ, Rizk SNM. Untoward sequels of Arruga encirclement for retinal detachment. Report of 29 cases. Brit J Ophthalm 1965;49:259-63.
• Birgul T, Vidic B, El S, Yosuf. Intrusion of an encircling buckle after retinal detachment surgery. Am J Ophthalmol 2003;136:942-4.