Author: Ilias Gkizis (Greece)
Co-authors: Georgios Bontzos, Georgios Smoustopoulos, Christina Garnavou-Xirou, Stamatina Kabanarou, Tina Xirou
Purpose
We present a case of hypotony in a young, high myopic male after silicone oil removal (SOR) and we highlight the importance of knowledge the concomitant risk factors.
Setting/Venue
Korgialeneio-Mpenakeio General Hospital of Athens, Hellenic Red Cross
Methods
Case presentation: A 35-year-old , high myopic male, presented in our Emergency Department complaining of floaters and vision deterioration in his right eye for the last few days. The patient had a history of refractive surgery (LASIK) for myopia correction. On examination his best corrected visual acuity (BCVA) was found less than 1/20 on Snellen Chart and on fundoscopy a retinal detachment with a giant retinal tear (GRT), extended 6 clock hours temporally, was revealed. Furthermore, a vitreous haemorrhage was present and the posterior edges of the tear were rolled. The axial length of his right eye was 29,14 mm. Subsequently a 20 G pars plana vitrectomy was performed with intraoperative use of perfluorocarbon liquid (PFCL), laser across to the retinal tear, silicone oil 5000-cs as a tamponade agent and scleral buckling 3600. Follow up period was uneventful and 16 months after the operation, the retina was attached, his BCVA was 0,12logMAR with +4.00 sph correction and the intraocular pressure (IOP) was 10 mmHg. SOR was decided and a 20 G pars plana approach was performed while sclerotomies were closed with of 7-0 vicryl sutures at the end of surgery
Results
On the first postoperative day after SOR, the patient presented with BCVA barely hand movements, a substantial hypotony (IOP< 5mm), optic disc swelling and chorioretinal folds. Patient was in close follow up for immediate intervention in case of prolonged hypotony. A significant improvement of his clinical situation was noted 2 weeks after SOR, on fundoscopy optic nerve swelling and chorioretinal folds were reversed back to normal. His BCVA was 0.42logMAR and his IOP was 12 mmHg. The patient, subsequently, underwent an uneventful phacoemulsification because of a dense posterior capsular cataract. On his last review appointment, BCVA was 0.26logMAR, his IOP was 14 mmHg and his retina was flat.
Conlusions
Postoperative ocular hypotony after SOR in complex retinal detachment surgery is a complication that can occur in about 20% of cases. It can be transient or permanent and can prevent the successful outcome of a posterior segment surgery. The exact mechanism is not completely understood. Leakage from sclerotomies, structural changes of the ciliary body, inflammation damage to the anterior uveal vasculature, several vitreoretinal procedures , anterior PVR and rerouting of aqueous outflow to the absorbing compartment of the RPE and choriocapillaries through large retinal breaks or retinectomies are possible mechanisms of transient hypotony after SOR. In some studies, the occurrence of transient hypotony increased with large axial length, due to a thinner sclera in longer eyes, which might be more susceptible to mechanical stress. In these cases, the sclera could be unstable to maintain the ciliary body in position during surgical manipulation and IOP fluctuation which occurs during SOR. Hypotony is a severe problem which can provoke irreversible tissue changes and phtisis bulbi. Accordingly, it is of primary importance to be aware of the mechanisms of hypotony and the possible treatments to avoid such a complication. Further research into the pathophysiology of uncontrolled IOP is required.
Financial Disclosure
I HAVE NO FINANCIAL DISCLOSURES
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