25-GAUGE SUTURELESS VITRECTOMY IN OSTEOGENESIS IMPERFECTA TYPE I Yaprak Banu Unver, MD, Nur Acar, MD, Tug˘rul Altan, MD, Ziya Kapran, MD, Gamze Ozturk, MD
Purpose: To report a case with type I osteogenesis imperfecta (OI) with intravitreal opacities who underwent 25-gauge sutureless vitrectomy. Methods: A 2.5-year-old girl with OI type I who presented with intravitreal opacities underwent 25-gauge sutureless vitrectomy. Results: The 25-gauge sutureless vitrectomy system, which is less traumatic, was performed in a patient with OI type I. Nine months postoperatively, funduscopic examination under general anesthesia showed a healthy optic nerve and retina without detachment. Intraocular pressure by Tonopen was 10 mmHg. Conclusion: The use of 25-gauge sutureless vitrectomy to avoid scleral suturing and minimize surgical trauma is an option in pediatric patients with associated thin sclera. RETINAL CASES & BRIEF REPORTS 3:286 –287, 2009
From the Beyoglu Eye Research and Training Hospital, Istanbul, Turkey.
1 day later, repair was attempted again. Amnion membrane implantation was performed, and a contact lens was placed on the cornea. One week later, spontaneous opening of the corneal sutures was noted in RE, and penetrating keratoplasty with extracapsular cataract extraction was performed. Postoperative B-scan ultrasonography demonstrated midvitreal opacity caused by hemorrhage without retinal detachment. However, visual acuity assessment and biomicroscopic examination were unsuccessful because of the patient’s inability to cooperate; therefore, she underwent examination under general anesthesia. At that time we observed a clear corneal transplant, intact keratoplasty sutures, aphakia, and fibrin membrane in the pupillary area of her right eye at postoperative week 1 (Figure 1). The pupillary membrane dissolved in 2 weeks; however, the fundus could not be visualized with indirect ophthalmoscopy. After 1 month pars plana vitrectomy was planned because of persistent vitreous opacities. The patient had suffered corneal rupture in her left eye 4 months before, and had undergone primary corneal repair in another clinic. In the left eye, vascularized corneal scar formation was seen between 5 and 10 o’clock from limbus to limbus, along with total anterior synechia and loss of anterior chamber. The patient’s periocular skin was prepared with 5% povidoneiodine (Betadine, Purdue Frederick Co., Norfolk, CT). Pars plana vitrectomy with the 25-gauge transconjunctival sutureless vitrectomy system (Millenium, Bausch and Lomb, St Louis, MO) was performed. Utilizing the surgical technique described by LopezGuajardo et al.,4 oblique sclerotomy was used to avoid postoperative leakage. Vitreous opacities were removed with the 25-gauge vitrectomy. The peripheral retina was examined with scleral indentation utilizing the noncontact wide-angle viewing system (SDI/ BIOM 3, Oculus Inc, Lynnwood, WA). There was no retinal detachment or tear. The cannulas were removed and no leakage or bleb formation was observed. On postoperative day 1, the eye was
O
steogenesis imperfecta (OI) is an autosomal dominant disorder resulting from an abnormal quantity and/or quality of Type 1 collagen, and occurs in approximately 1/20,000 live births. Because Type 1 collagen comprises 85% of the human cornea, as well as the major portion of the collagen in the sclera, these tissues are very likely to be affected in patients with OI.1 In fact, low ocular rigidity and low intraocular pressure, frequent problems in patients with OI, are both directly attributed to abnormalities of collagen.2,3 In this case report, we present a child with OI who underwent 25-gauge sutureless vitrectomy for the treatment of posttraumatic vitreous opacity. Because of the likelihood of scleral thinning, we chose a sutureless technique for vitrectomy in this patient. Case Report A 2.5-year-old girl with OI Type 1 suffered blunt ocular trauma with her finger to her right eye (RE) and was referred to our hospital for repair of corneal rupture. However, at the first attempt at repair, the cornea was so fragile that tearing occurred during the attempt to suture it. Consequently, The authors have no proprietary interest in the material used in this study. Reprint requests: Yaprak Banu Unver, MD, Plaj Yolu, Mehtap Sok., Gencturk Apt., 31/10 Caddebostan, Istanbul, Turkey.
286
287
25G VITRECTOMY IN OSTEOGENESIS IMPERFECTA
Fig. 1. The right eye of a 2.5-year-old girl with OI type I after penetrating keratoplasty and cataract extraction. The picture demonstrates a clear corneal transplant with intact keratoplasty sutures and fibrin membrane in the pupillary area in an aphakic eye at postoperative week 1.
digitally normotonic and looked quiet, with the retinal reflex visible on indirect ophthalmoscopy. Topical antibiotics and corticosteroids were started, and the patient was examined under general anesthesia at weekly intervals. By the fourth postoperative week, the corneal transplant was clear, and the anterior chamber was formed; the optic nerve and retina looked normal by indirect ophthalmoscopy. Intraocular pressure by Tonopen was 10 mmHg. Cycloplegic refraction was measured with a hand-held autorefractometer. Refractive correction was prescribed, and the patient was observed at 2-week intervals for amblyopia treatment. At the 9-month examination, the ophthalmologic findings were normal.
sutureless technique without encountering any complications, and recommended the use of this technique in children. Although 25-gauge sutureless vitrectomy produces approximately 0.5-mm openings in the sclera, which can occasionally cause postoperative leakage, with modification of the technique and the use of oblique incisions, this leakage decreases significantly.9 In our case, we chose to perform 25-gauge sutureless vitrectomy to avoid scleral suturing, which we expected to be difficult in this patient with OI. The surgery was completed without difficulty. Because this case did not require extensive dissection, we did not observe any extension of sclerotomies, leakage, or postoperative hypotony. During follow-up, no complications such as vitreous hemorrhage, vitreous and/or retinal incarceration, hypotony, choroidal detachment/ fold, retinal detachment, endophthalmitis, or scleral pigmentation were seen. In conclusion, the use of 25-gauge sutureless vitrectomy to avoid scleral suturing and minimize surgical trauma is an option in pediatric patients with associated thin sclera. Key words: blue sclera, 25-gauge vitrectomy, osteogenesis imperfecta, transconjunctival sutureless vitrectomy.
References 1.
Discussion In patients with OI who have a defect in collagen Type 1, repair of any rupture in cornea or sclera is difficult. In fact, the tissues are sometimes so fragile that suturing is not possible. In our case, we encountered this problem when we attempted to suture the cornea of a young girl with a corneal rupture. Sutureless 20-gauge pars plana vitrectomy through self-sealing sclerotomies was first described by Chen.5 However, several complications have been reported, including wound leakage, extension, dehiscence, hemorrhage, vitreous and/or retinal incarceration, retinal tears, and dialysis.6 The use of 25-gauge sutureless vitrectomy has been reported to cause minimal surgical trauma. It decreases operating time, postoperative inflammation, patient discomfort, and the duration of convalescence.7 Fujii et al7 also postulated the benefit of 25-gauge sutureless vitrectomy in pediatric cases such as retinopathy of prematurity and Norrie’s disease. Lam et al8 operated on 8 eyes of 5 children with pars plana anterior vitrectomy using the 25-gauge
2.
3.
4.
5. 6.
7.
8.
9.
Marshall GE, Konstas AC, Lee WR. Immunogold fine structure localization of extracellular matrix components in aged human cornea. I. Types I-IV collagen and laminin. Graefess Arch Clin Exp Ophthalmol 1991;229:157–163. Berggren L, Wesser E, Wennerstroem J. Intraocular pressure and excretion of mucopolysaccharides in osteogenesis imperfecta. Acta ophthalmol 1969;47:122–128. Kaiser-Kufer MI, McCain L, Shairo JR, et al. Low ocular rigidity in patients with osteogenesis imperfecta. Invest ophthalmol Vis Sci 1981;20:807– 809. Lopez-Guajardo L, Pareja-Esteban J, Teus-Guezala MA. Oblique sclerotomy technique for prevention of incompetent wound closure in transconjunctival 25-gauge vitrectomy. Am J Ophthalmol 2006;141:1154 –1156. Chen JC. Sutureless pars plana through self-sealing sclerotomies. Arch Ophthalmol 1996;114:1273–1275. Milibak T, Suveges I. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies (letter). Arch Ophthalmol 1998;116:119. Fujii GY, de Juan E Jr, Humayun MS, et al. Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002;109:1814 –1820. Lam DSC, Chua JKH, Leung ATS, et al. Sutureless pars plana vitrectomy through self-sealing sclerotomies in children. Arch Ophthalmol 2000;118:850 – 851. Shimada H, Nakashizuka H, Mori R, et al. 25-gauge scleral tunnel transconjunctival vitrectomy. Am J Ophthalmol 2006; 142:871– 873.
Purpose: To report a case with type I osteogenesis imperfecta (OI) with intravitreal opacities who underwent 25-gauge sutureless vitrectomy. Methods: A 2.5-year-old girl with OI type I who presented with intravitreal opacities underwent 25-gauge sutureless vitrectomy. Results: The 25-gauge sutureless vitrectomy system, which is less traumatic, was performed in a patient with OI type I. Nine months postoperatively, funduscopic examination under general anesthesia showed a healthy optic nerve and retina without detachment. Intraocular pressure by Tonopen was 10 mmHg. Conclusion: The use of 25-gauge sutureless vitrectomy to avoid scleral suturing and minimize surgical trauma is an option in pediatric patients with associated thin sclera. RETINAL CASES & BRIEF REPORTS 3:286 –287, 2009
From the Beyoglu Eye Research and Training Hospital, Istanbul, Turkey.
1 day later, repair was attempted again. Amnion membrane implantation was performed, and a contact lens was placed on the cornea. One week later, spontaneous opening of the corneal sutures was noted in RE, and penetrating keratoplasty with extracapsular cataract extraction was performed. Postoperative B-scan ultrasonography demonstrated midvitreal opacity caused by hemorrhage without retinal detachment. However, visual acuity assessment and biomicroscopic examination were unsuccessful because of the patient’s inability to cooperate; therefore, she underwent examination under general anesthesia. At that time we observed a clear corneal transplant, intact keratoplasty sutures, aphakia, and fibrin membrane in the pupillary area of her right eye at postoperative week 1 (Figure 1). The pupillary membrane dissolved in 2 weeks; however, the fundus could not be visualized with indirect ophthalmoscopy. After 1 month pars plana vitrectomy was planned because of persistent vitreous opacities. The patient had suffered corneal rupture in her left eye 4 months before, and had undergone primary corneal repair in another clinic. In the left eye, vascularized corneal scar formation was seen between 5 and 10 o’clock from limbus to limbus, along with total anterior synechia and loss of anterior chamber. The patient’s periocular skin was prepared with 5% povidoneiodine (Betadine, Purdue Frederick Co., Norfolk, CT). Pars plana vitrectomy with the 25-gauge transconjunctival sutureless vitrectomy system (Millenium, Bausch and Lomb, St Louis, MO) was performed. Utilizing the surgical technique described by LopezGuajardo et al.,4 oblique sclerotomy was used to avoid postoperative leakage. Vitreous opacities were removed with the 25-gauge vitrectomy. The peripheral retina was examined with scleral indentation utilizing the noncontact wide-angle viewing system (SDI/ BIOM 3, Oculus Inc, Lynnwood, WA). There was no retinal detachment or tear. The cannulas were removed and no leakage or bleb formation was observed. On postoperative day 1, the eye was
O
steogenesis imperfecta (OI) is an autosomal dominant disorder resulting from an abnormal quantity and/or quality of Type 1 collagen, and occurs in approximately 1/20,000 live births. Because Type 1 collagen comprises 85% of the human cornea, as well as the major portion of the collagen in the sclera, these tissues are very likely to be affected in patients with OI.1 In fact, low ocular rigidity and low intraocular pressure, frequent problems in patients with OI, are both directly attributed to abnormalities of collagen.2,3 In this case report, we present a child with OI who underwent 25-gauge sutureless vitrectomy for the treatment of posttraumatic vitreous opacity. Because of the likelihood of scleral thinning, we chose a sutureless technique for vitrectomy in this patient. Case Report A 2.5-year-old girl with OI Type 1 suffered blunt ocular trauma with her finger to her right eye (RE) and was referred to our hospital for repair of corneal rupture. However, at the first attempt at repair, the cornea was so fragile that tearing occurred during the attempt to suture it. Consequently, The authors have no proprietary interest in the material used in this study. Reprint requests: Yaprak Banu Unver, MD, Plaj Yolu, Mehtap Sok., Gencturk Apt., 31/10 Caddebostan, Istanbul, Turkey.
286
287
25G VITRECTOMY IN OSTEOGENESIS IMPERFECTA
Fig. 1. The right eye of a 2.5-year-old girl with OI type I after penetrating keratoplasty and cataract extraction. The picture demonstrates a clear corneal transplant with intact keratoplasty sutures and fibrin membrane in the pupillary area in an aphakic eye at postoperative week 1.
digitally normotonic and looked quiet, with the retinal reflex visible on indirect ophthalmoscopy. Topical antibiotics and corticosteroids were started, and the patient was examined under general anesthesia at weekly intervals. By the fourth postoperative week, the corneal transplant was clear, and the anterior chamber was formed; the optic nerve and retina looked normal by indirect ophthalmoscopy. Intraocular pressure by Tonopen was 10 mmHg. Cycloplegic refraction was measured with a hand-held autorefractometer. Refractive correction was prescribed, and the patient was observed at 2-week intervals for amblyopia treatment. At the 9-month examination, the ophthalmologic findings were normal.
sutureless technique without encountering any complications, and recommended the use of this technique in children. Although 25-gauge sutureless vitrectomy produces approximately 0.5-mm openings in the sclera, which can occasionally cause postoperative leakage, with modification of the technique and the use of oblique incisions, this leakage decreases significantly.9 In our case, we chose to perform 25-gauge sutureless vitrectomy to avoid scleral suturing, which we expected to be difficult in this patient with OI. The surgery was completed without difficulty. Because this case did not require extensive dissection, we did not observe any extension of sclerotomies, leakage, or postoperative hypotony. During follow-up, no complications such as vitreous hemorrhage, vitreous and/or retinal incarceration, hypotony, choroidal detachment/ fold, retinal detachment, endophthalmitis, or scleral pigmentation were seen. In conclusion, the use of 25-gauge sutureless vitrectomy to avoid scleral suturing and minimize surgical trauma is an option in pediatric patients with associated thin sclera. Key words: blue sclera, 25-gauge vitrectomy, osteogenesis imperfecta, transconjunctival sutureless vitrectomy.
References 1.
Discussion In patients with OI who have a defect in collagen Type 1, repair of any rupture in cornea or sclera is difficult. In fact, the tissues are sometimes so fragile that suturing is not possible. In our case, we encountered this problem when we attempted to suture the cornea of a young girl with a corneal rupture. Sutureless 20-gauge pars plana vitrectomy through self-sealing sclerotomies was first described by Chen.5 However, several complications have been reported, including wound leakage, extension, dehiscence, hemorrhage, vitreous and/or retinal incarceration, retinal tears, and dialysis.6 The use of 25-gauge sutureless vitrectomy has been reported to cause minimal surgical trauma. It decreases operating time, postoperative inflammation, patient discomfort, and the duration of convalescence.7 Fujii et al7 also postulated the benefit of 25-gauge sutureless vitrectomy in pediatric cases such as retinopathy of prematurity and Norrie’s disease. Lam et al8 operated on 8 eyes of 5 children with pars plana anterior vitrectomy using the 25-gauge
2.
3.
4.
5. 6.
7.
8.
9.
Marshall GE, Konstas AC, Lee WR. Immunogold fine structure localization of extracellular matrix components in aged human cornea. I. Types I-IV collagen and laminin. Graefess Arch Clin Exp Ophthalmol 1991;229:157–163. Berggren L, Wesser E, Wennerstroem J. Intraocular pressure and excretion of mucopolysaccharides in osteogenesis imperfecta. Acta ophthalmol 1969;47:122–128. Kaiser-Kufer MI, McCain L, Shairo JR, et al. Low ocular rigidity in patients with osteogenesis imperfecta. Invest ophthalmol Vis Sci 1981;20:807– 809. Lopez-Guajardo L, Pareja-Esteban J, Teus-Guezala MA. Oblique sclerotomy technique for prevention of incompetent wound closure in transconjunctival 25-gauge vitrectomy. Am J Ophthalmol 2006;141:1154 –1156. Chen JC. Sutureless pars plana through self-sealing sclerotomies. Arch Ophthalmol 1996;114:1273–1275. Milibak T, Suveges I. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies (letter). Arch Ophthalmol 1998;116:119. Fujii GY, de Juan E Jr, Humayun MS, et al. Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002;109:1814 –1820. Lam DSC, Chua JKH, Leung ATS, et al. Sutureless pars plana vitrectomy through self-sealing sclerotomies in children. Arch Ophthalmol 2000;118:850 – 851. Shimada H, Nakashizuka H, Mori R, et al. 25-gauge scleral tunnel transconjunctival vitrectomy. Am J Ophthalmol 2006; 142:871– 873.
