Autogenous

Fascial Grafts for

Steven C. Dresner, MD; David S.

Exposed

Retinal Buckles

Boyer, MD; Robert E. Feinfield, MD

\s=b\ Three patients with exposed scleral buckling elements received autogenous fascial grafts as an alternative to buckle removal. All three patients had success-

ful coverage of their scleral buckles. There were no redetachments or infections. One patient had a postoperative ptosis that required repair. Autogenous fascial grafts are useful procedures in patients with exposed retinal buckles who have a significant risk of retinal redetachment with buckle removal.

(Arch Ophthalmol. 1991;109:288-289) ~U* xposure of retinal buckles occurs infrequently and necessitates the removal of the buckling elements.14

Retinal redetachment, however, is a definite risk and in some patients re¬ moval of the buckle may be undesir¬ able. We describe a technique to cover exposed buckling elements with autog¬ enous fasciai grafts. This technique has been used in three patients with excel¬ lent results. SURGICAL PROCEDURE

procedure can be performed under general or local anesthesia. Adequate fascia The

be harvested from the fascia lata femoris or temporal fascia. The temporal fascia is readily accessible from the same operative site and is our preferred method. The incision is marked behind and paral¬ lel to the hairline in the temporal scalp (Fig 1). A3- to 4-cm incision is made through the skin and subcutaneous tissue. The temporal fascia is then easily encountered (Fig 2). A No. 15 blade is used to incise the fascia; a piece four to five times the size of the defect to be covered is usually adequate. The fascia is harvested using scissors, and the incision is closed with staples. The conjunctiva adjacent to the extruded area is undermined for 360° with Westcott scissors under the operating microscope. Any exposed suture material is removed. Relaxing incisions are made in the conjunc¬ tiva anterior to the buckle to allow better exposure to place the fasciai graft. The graft is placed over the exposed buckle and sewn into place posteriorly with doublearmed absorbable sutures through the con¬ junctiva deep in the fornix. Anteriorly, the graft is sewn onto the sclera. The conjunct!can

Accepted for publication August 28, 1990. From the Division of Ophthalmic Plastic and Reconstructive Surgery, Jules Stein Eye Institute, UCLA (Dr Dresner), and the Department of Ophthalmology, Estelle Doheny Eye Institute, University of Southern California Medical Center, Los Angeles (Dr Boyer). Reprint requests to 2222 Santa Monica Blvd, Suite 101, Santa Monica, CA 90404 (Dr Dresner).

va

is then advanced

together if possible.

over

the

graft and sewn

REPORT OF CASES

CASE 1.—A 53-year-old woman who had had three retinal detachments in her right eye presented with an inferior temporal detachment in the same eye. A superior buckle exposure was present from the 10-o'clock to 11-o'clock positions (Fig 3). At the time of surgery, a No. 277 silicone tire and a No. 240 band were in place. The patient underwent repair of the retinal de¬ tachment and a primary closure of the conjunctival defect. The retina remained attached. However, the buckle remained exposed in the same area. Because of the patient's history of multiple detachments, we decided not to remove the buckle and to place a bank sclera patch graft and perform conjunctivoplasty to cover the defect. Ini¬ tially, the buckle remained covered; howev¬ er, 10 weeks after surgery the buckle was reexposed. An autogenous fascia lata graft was then placed over the defect and a conjunctivoplasty was performed. At the 19-month follow-up, the buckle remained covered. Case 2.—A 64-year-old man underwent cataract surgery in the left eye; 8 months later the retina detached and was repaired at another institution. The retina redetached and the patient was referred for repair. On examination, the patient was in

stage

D2

proliferative vitreoretinopathy.

The buckle was exposed superiorly from the 11- o'clock to 12-o'clock positions. A pars plana vitrectomy, endolaser photoeoagulation, and air-fluid exchange were per¬ formed. The patient had a previously placed No. 281 tire and a No. 40 band. The tire was trimmed and the conjunctiva was mobi¬ lized to close the defect. The retina re¬ mained flat. However, the buckle remained exposed between the 10-o'clock and 11o'clock positions. An autogenous temporal fasciai graft was placed over the defect and a conjunctivo¬ plasty was performed. A postoperative ptosis was repaired by an aponeurotic ap¬ proach. Sixteen months after surgery, the buckle remained covered. CASE 3.—A 53-year-old diabetic woman presented with a phakic retinal detachment involving the fovea in the right eye. Trac¬ tion at the vitreous base, associated with hemorrhage, was noted during surgery. A No. 277 silicone segment was placed from the 4-o'clock to 11 o'clock positions and a No. 240 band was placed in the groove and secured circumferentially. Seven months later, she underwent a routine phacoemulsification cataract extraction in the same eye. Three months after the cataract extraction, the buckle was noticed to be extruding superotemporally between the 10-o'clock and 11 o'clock positions. Because of contin-

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ued vitreoretinal traction, an autogenous temporal fasciai graft was performed with a conjunctivoplasty. The buckle remained well covered 8 months after surgery. RESULTS

Three patients received autogenous fasciai grafts for exposed retinal buck¬ les. All three patients had solid silicone buckling elements in place. One pa¬ tient also had a bank sclera patch graft for an exposed buckle that resorbed. Two patients underwent primary conjunctivoplasties to cover the defect at the time of retinal detachment sur¬ gery. All three patients had braided polyester fiber sutures placed in the area of the buckle exposure. There were no infections and all buckling elements remained covered after sur¬ gery. One patient had a postoperative ptosis that required repair. COMMENT

of scierai buckling ele¬ known, although infrequent,

Exposure

ments is

a

complication of retinal detachment sur¬

The exposure may be a result oversized buckling element or acute and chronic infection.3 Removal of the buckle is usually recommended rather than attempts to cover the ex¬

gery.12 of

an

posed elements.2

The associated problems with chron¬ ic exposure of the buckle must be weighed against the possibility of rede¬ tachment after its removal. In a study of 600 consecutive retinal detach¬ ments, Hilton and Wallyn4 noted a redetachment rate of 4% after removal of the buckles. Schwartz and Pruett" found that 14.5% of their patients' retinas redetached after removal of the buckling elements. Ulrich and Burton'; described 37 infected eyes after de¬ tachment requiring removal of the buckles. Eight (22%) of these 37 reti¬ nas redetached within 1 month of removal. Extruding and exposed implants may be either clinically or subclinically infected. Infection may also increase the risk of redetachment and the de¬ velopment of proliferative vitreoretinopathy. A substantially higher rede¬ tachment rate also follows removal of buckling elements that have been in place less than 6 months.'' Two of the patients in this study underwent multiple detachment proce¬ dures and one patient had persistent

operative ptosis that required repair, This may have occurred because the conjunctiva was advanced from the superior fornix to cover the graft, shortening the fornix and restricting the eyelid. To avoid this, the conjuncti¬ va can be mobilized inferiorly and ro¬ tated up over the graft. Not all exposed or infected buckles need to be grafted and left in place. Once a firm chorioretinal adhesion de¬ velops, the buckle may be removed. Norton1" has suggested that a buckle may be safely removed 3 weeks after placement, and Lincoff et al14 believe that they can be removed in 2 weeks. Schwartz and Pruett, however, stated that buckles, removed less than 6 months after placement have a signifi¬ cantly greater risk of redetachment. However, patients with exposed buckles whose retinas have been at¬ tached for short periods may be candi¬ dates for fasciai grafting instead of buckle removal. In addition, patients with a history of multiple detachment procedures or those who have continu¬ ing vitreoretinal traction may also ben¬ efit. Autogenous fasciai grafting is a useful technique that allows flexibility in the treatment of extruding solid '

Fig 1.—The incision is marked behind and parallel to the hairline in the temporal aspect of the scalp.

Fig 3.—Top, Preoperative appearance of the exposed buckle. Bottom, Postoperative ap¬ pearance after an autogenous fasciai graft has been placed.

silicone

Autogenous fascia has been used successfully for many years to correct eyelid and orbital deformities."'1 It has also been used as a buckling element

Fig 2.—The incision is made through the skin and subcutaneous tissue to the temporal

fascia.

vitreous traction and was believed to be at increased risk of redetachment, necessitating an alternative approach to buckle removal. Two of the patients had primary conjunctivoplasties at the time of their last detachment surgery. Since these procedures were not effec¬ tive, a grafting procedure was consid¬ ered. Extrapolating from our experi¬ ence with extruding orbital implants, we believed that conjunctival grafts or conjunctivoplasty alone would not be curative. The first patient had a preserved scierai graft with a conjunctivoplasty. The graft subsequently melted and the buckling elements were left exposed at the same location. Scierai grafts are nonautogenous and résorption of these grafts varies. In addition, there is a theoretical risk of the transmission of viral diseases with this tissue.' Autog¬ enous fasciai grafts were performed thereafter to avoid the problems of graft résorption and to eliminate the risks of nonautogenous materials.

and to reinforce the sclera and cornea in various ocular conditions.1"12 Fascia is composed of a collagen matrix with fibroblasts and elastic tissue. Its rela¬ tive acellularity and low nutritional requirements make it suitable for grafting." Its use as a patch graft for extruding buckling elements has not

been

previously reported, to our knowledge. Two of the three patients in our study had large buckling elements and had undergone more than one retinal procedure prior to grafting. One other patient had a cataract extraction on

the same eye after retinal detachment surgery. In all areas grafted, there were also exposed braided polyester fiber sutures with unburied knots. The multiple procedures may have contrib¬ uted to conjunctival tissue loss, thin¬ ning of tenons, and subsequent buckle exposure. The braided configuration of the polyester fiber suture as well as the unburied knots may also have con¬ tributed to conjunctival thinning and fistulization. All the patients in this study had exposed buckling elements superiorly. It is possible that mechani¬ cal irritation on the buckle from the upper lid contributed to the tissue loss in these areas. One patient had a post-

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buckling elements. References

1. Regan CDJ, Schepens CL. Erosion of the ocular wall by circling polyethylene tubing: a late complication of scleral buckling. Trans Am Acad

Ophthalmol Otolaryngol. 1963;67:335-339. 2. Schmidt CW, Cohen HB. Exposed

buckle:

a case

report in

an

eleven year

scleral course.

Ophthalmic Surg. 1983;14:238-239.

3. Yoshiumi MO. Exposure of intrascleral im-

plants. Ophthalmology. 1980;87:1150-1154.

4. Hilton GF, Wallyn RA. The removal of scleral buckles. Arch 1978;96:2061-2063. 5. Schwartz PL, Pruett RC. Factors influencing retinal detachment after removal of buckling elements. Arch Ophthalmol. 1977;95:804-807. 6. Ulrich RA, Burton TC. Infections following scleral buckling procedures. Arch Ophthalmol. 1974;92:213-215. 7. McCarthy RW, Swann ES. Autogenous scleral graft in implant surgery. Ophthalmic Surg. 1980;11:686-687. 8. Flanagan JF, Campbell CB. The use of autogenous fascia lata to correct lid and orbital deformities. Trans Am Ophthalmol Soc. 1981;79:227-240. 9. Neuhaus RW, Shorr RN. Use of temporal fascia and muscle as an autograph. Arch Ophthalmol. 1983;101:262-264. 10. Chilaris G, Liaricos S. Fascia of the temporalis muscle in scleral buckling and keratoprosthesis operations. Am J Ophthalmol. 1973;76:35-37. 11. Nesterov AT, Libenson NB, Suirin AV. Early and late results of fascia lata transplantation in high myopia. Br J Ophthalmol. 1976;60:271-272. 12. Taffett S, Carter GZ. The use of fascia lata graft in the treatment of scleromalacia perforans. Am J Ophthalmol. 1961;52:693. 13. Norton EWD. Complications of retinal detachment surgery. Trans New Orleans Acad

Ophthalmol.

Ophthalmol.

1969:222-234.

A, O'Connor T. The changing character of the infected scleral implant. Arch Ophthalmol. 1970;84:421-426. 14. Lincoff H, Nadel

Autogenous fascial grafts for exposed retinal buckles.

Three patients with exposed scleral buckling elements received autogenous fascial grafts as an alternative to buckle removal. All three patients had s...
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