Diagnostic and Therapeutic Challenges
Edited by H. Richard McDonald
Drs. Lalit Verma, Arindam Chakravarti, Avnindra Gupta, Hem Kumar Tewari, and James C. Folk
T
A 29-year-old phakic woman presented with bilateral inferior rhegmatogenous retinal detachment partially involving the macula, with multiple inferior breaks in the periphery (Figure 1). The bestcorrected visual acuity was 6/12 in the right eye and 6/9 in the left eye. She underwent successful scleral buckling with modified needle drainage of subretinal fluid in both eyes. A 276 buckle was placed after applying buckle sutures with 240 encircling band. Modified needle drainage of subretinal fluid was performed using a perpendicular transscleral entry with a 26-gauge needle attached to a 2-mL syringe without the plunger. Appearance of subretinal fluid in the hub of the needle was considered as endpoint. The initial postoperative course was uneventful. After 24 days postoperatively, the patient developed blurring of vision in the left eye, the best-corrected visual acuity had dropped to 6/24, anterior
segment evaluation did not show any evidence of inflammation, and there was no localized tenderness and buckle or suture exposure (Figure 2). Fundus evaluation showed attached retina; however, a discrete, elevated yellowish subretinal lesion was seen in the inferotemporal quadrant on the buckle site along with Grade 2 vitritis, which was consistent with an infective lesion (Figure 3, A and B). The patient was immediately started on high dose systemic and topical antibiotics. After 3 days, the best-corrected visual acuity dropped to finger counting, and the lesion had extended into the vitreous (Figure 4). Patient was started on antifungals empirically and counseled about the need for vitrectomy with intravitreal antibiotics. She went for a second opinion where she initially underwent antibiotic lavage of the buckle with segmental peritomy and intravitreal antibiotics. Because her clinical course continued to deteriorate, she subsequently underwent vitrectomy with silicone oil injection along with intravitreal vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL). Postoperatively, after 4 weeks, the patient had a gradual improvement in the vision in the left eye, and fundus evaluation showed silicone oil–filled eye with reduction in the size of the subretinal abscess and vitritis. The retina remained attached (Figure 5, A and B). The best-corrected visual acuity improved to 6/12. Microbiological evaluation of vitreous sample including bacterial and fungal culture was negative. After six months, she remains stable with no recurrence of any feature of inflammation or infection.
Fig. 1. Color fundus photograph of the left eye showing chronic inferior retinal detachment involving macula.
Fig. 2. External photograph of the left eye on the 24th postoperative day after scleral buckling.
his case is submitted by Drs. Lalit Verma, Arindam Chakravarti, Avnindra Gupta, and Hem Kumar Tewari of the Department of Vitreo-Retina, Centre for Sight, New Delhi, India; commented by Dr. James C. Folk, Iowa City, Iowa. Case Report
1911
1912 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES
2014 VOLUME 34 NUMBER 9
Fig. 3. A. Color fundus photo of the left eye showing Grade 2 to 3 vitritis on the 24th postoperative day. B. Color fundus photo of the left eye showing subretinal abscess in inferotemporal quadrant posterior to buckle on the 24th postoperative day.
Dr. James C. Folk (Iowa City, Iowa): There are two types of scleral buckle infections. The less severe form usually presents months or even years after surgery as a breakdown of conjunctiva overlying the exoplant. The conjunctiva is mildly inflamed, and there is often a collection of mucous overlying the buckle. The patient has a foreign body sensation or intermittent blurring of vision. These patients can be watched but usually want to have the buckle removed for comfort or stabilization of vision. The authors are not claiming that their patient has this type of infection. The authors are presenting a second type of a scleral buckle infection that is more severe and acute. It typically appears within a month or even a week after surgery as did this case. I do not believe, however, that this patient had a buckle infection. Why not? All of the buckle infections that I have seen have presented with pain, erythema, and swelling over the exoplant. There is exquisite tenderness over the area of infected buckle. None of them have been cured without the removal of the buckle elements. Culture of the buckle elements
Fig. 4. Color fundus photo of the left eye on the 27th postoperative day showing extension of the subretinal abscess into the vitreous.
have always been positive for bacteria usually a Staphylococcus species or Pseudomonas. So how do we explain the author’s case? I believe that the drainage needle introduced a bacteria or fungus into the subretinal space. The authors state that Figure 3B shows that the subretinal abscess already extends posterior to the scleral buckle on day 24. Figure 4 shows a subretinal abscess that is widespread in the area previously occupied by subretinal fluid. The patient was cured by a vitrectomy and intravitreal antibiotics. It is doubtful, but perhaps not impossible, that the intravitreal antibiotics cured the extensive subretinal abscesses. But, then again, subretinal abscesses can resolve spontaneously if they are due to a lessaggressive bacterium or fungus. There is no way, however, that intravitreal antibiotics could have cured an infection in a scleral buckle on the outside of the sclera of the eye. This is an interesting case with a remarkably good outcome. Editor’s Note: Drs. Verma, Chakravarti, Gupta, and Tewari have presented a 29-year-old woman who developed a subretinal yellow lesion associated with a scleral buckle placed more than 3 weeks earlier. This lesion was felt to be an infection, and she underwent a series of interventions. Dr. James Folk has been asked to give his opinion on this case and reviews of the types of scleral buckle infections. The first type involves a breakdown of the conjunctiva overlying the buckle, and this usually leads, perhaps after months to years, to a removal of the buckle. The second type usually appears more quickly, with a more severe and rapidly progressive course. Dr. Folk feels that this patient did not have a buckle infection. In his experience, all buckle infections present with erythema, swelling, and tenderness. Importantly, none have been cured without the removal of the scleral buckle elements. The removed buckles are invariably positive for bacteria, usually Staphylococcus or Pseudomonas.
Diagnostic and Therapeutic Challenges VERMA ET AL
1913
Fig. 5. A. Color fundus photo of the left eye 4 weeks after vitrectomy with intravitreal antibiotics and silicone oil injection. B. Color fundus photo of the left eye 4 weeks after vitrectomy with intravitreal antibiotics and silicone oil injection showing regression of the subretinal abscess.
Dr. Folk believes that the drainage needle introduced an organism, bacteria, or fungus, into the subretinal space. The patient seemed to be cured by the vitrectomy and intravitreal antibiotics, but he feels that it is doubtful, though not impossible, that the intravitreal antibiotics cured the extensive subretinal abscesses. He states that it is possible, however, and that less aggressive bacterium or fungus can even resolve spontaneously. Dr. Folk unequivocally states that intravitreal antibiotics could not have cured an infection in a scleral buckle on the outside of the sclera of the eye.
We thank our presenters for this case, and Dr. Folk for his consultation. RETINAÒ, The Journal of Retinal and Vitreous Diseases, encourages readers to submit Diagnostic and Therapeutic Challenges to [email protected]. Cases for the Diagnostic and Therapeutic Challenges section should include a detailed history of the patient, the diagnosis, the workup, the management, and finally, the question or questions that the submitter wishes to have answered by the consultants.
Edited by H. Richard McDonald
Drs. Lalit Verma, Arindam Chakravarti, Avnindra Gupta, Hem Kumar Tewari, and James C. Folk
T
A 29-year-old phakic woman presented with bilateral inferior rhegmatogenous retinal detachment partially involving the macula, with multiple inferior breaks in the periphery (Figure 1). The bestcorrected visual acuity was 6/12 in the right eye and 6/9 in the left eye. She underwent successful scleral buckling with modified needle drainage of subretinal fluid in both eyes. A 276 buckle was placed after applying buckle sutures with 240 encircling band. Modified needle drainage of subretinal fluid was performed using a perpendicular transscleral entry with a 26-gauge needle attached to a 2-mL syringe without the plunger. Appearance of subretinal fluid in the hub of the needle was considered as endpoint. The initial postoperative course was uneventful. After 24 days postoperatively, the patient developed blurring of vision in the left eye, the best-corrected visual acuity had dropped to 6/24, anterior
segment evaluation did not show any evidence of inflammation, and there was no localized tenderness and buckle or suture exposure (Figure 2). Fundus evaluation showed attached retina; however, a discrete, elevated yellowish subretinal lesion was seen in the inferotemporal quadrant on the buckle site along with Grade 2 vitritis, which was consistent with an infective lesion (Figure 3, A and B). The patient was immediately started on high dose systemic and topical antibiotics. After 3 days, the best-corrected visual acuity dropped to finger counting, and the lesion had extended into the vitreous (Figure 4). Patient was started on antifungals empirically and counseled about the need for vitrectomy with intravitreal antibiotics. She went for a second opinion where she initially underwent antibiotic lavage of the buckle with segmental peritomy and intravitreal antibiotics. Because her clinical course continued to deteriorate, she subsequently underwent vitrectomy with silicone oil injection along with intravitreal vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL). Postoperatively, after 4 weeks, the patient had a gradual improvement in the vision in the left eye, and fundus evaluation showed silicone oil–filled eye with reduction in the size of the subretinal abscess and vitritis. The retina remained attached (Figure 5, A and B). The best-corrected visual acuity improved to 6/12. Microbiological evaluation of vitreous sample including bacterial and fungal culture was negative. After six months, she remains stable with no recurrence of any feature of inflammation or infection.
Fig. 1. Color fundus photograph of the left eye showing chronic inferior retinal detachment involving macula.
Fig. 2. External photograph of the left eye on the 24th postoperative day after scleral buckling.
his case is submitted by Drs. Lalit Verma, Arindam Chakravarti, Avnindra Gupta, and Hem Kumar Tewari of the Department of Vitreo-Retina, Centre for Sight, New Delhi, India; commented by Dr. James C. Folk, Iowa City, Iowa. Case Report
1911
1912 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES
2014 VOLUME 34 NUMBER 9
Fig. 3. A. Color fundus photo of the left eye showing Grade 2 to 3 vitritis on the 24th postoperative day. B. Color fundus photo of the left eye showing subretinal abscess in inferotemporal quadrant posterior to buckle on the 24th postoperative day.
Dr. James C. Folk (Iowa City, Iowa): There are two types of scleral buckle infections. The less severe form usually presents months or even years after surgery as a breakdown of conjunctiva overlying the exoplant. The conjunctiva is mildly inflamed, and there is often a collection of mucous overlying the buckle. The patient has a foreign body sensation or intermittent blurring of vision. These patients can be watched but usually want to have the buckle removed for comfort or stabilization of vision. The authors are not claiming that their patient has this type of infection. The authors are presenting a second type of a scleral buckle infection that is more severe and acute. It typically appears within a month or even a week after surgery as did this case. I do not believe, however, that this patient had a buckle infection. Why not? All of the buckle infections that I have seen have presented with pain, erythema, and swelling over the exoplant. There is exquisite tenderness over the area of infected buckle. None of them have been cured without the removal of the buckle elements. Culture of the buckle elements
Fig. 4. Color fundus photo of the left eye on the 27th postoperative day showing extension of the subretinal abscess into the vitreous.
have always been positive for bacteria usually a Staphylococcus species or Pseudomonas. So how do we explain the author’s case? I believe that the drainage needle introduced a bacteria or fungus into the subretinal space. The authors state that Figure 3B shows that the subretinal abscess already extends posterior to the scleral buckle on day 24. Figure 4 shows a subretinal abscess that is widespread in the area previously occupied by subretinal fluid. The patient was cured by a vitrectomy and intravitreal antibiotics. It is doubtful, but perhaps not impossible, that the intravitreal antibiotics cured the extensive subretinal abscesses. But, then again, subretinal abscesses can resolve spontaneously if they are due to a lessaggressive bacterium or fungus. There is no way, however, that intravitreal antibiotics could have cured an infection in a scleral buckle on the outside of the sclera of the eye. This is an interesting case with a remarkably good outcome. Editor’s Note: Drs. Verma, Chakravarti, Gupta, and Tewari have presented a 29-year-old woman who developed a subretinal yellow lesion associated with a scleral buckle placed more than 3 weeks earlier. This lesion was felt to be an infection, and she underwent a series of interventions. Dr. James Folk has been asked to give his opinion on this case and reviews of the types of scleral buckle infections. The first type involves a breakdown of the conjunctiva overlying the buckle, and this usually leads, perhaps after months to years, to a removal of the buckle. The second type usually appears more quickly, with a more severe and rapidly progressive course. Dr. Folk feels that this patient did not have a buckle infection. In his experience, all buckle infections present with erythema, swelling, and tenderness. Importantly, none have been cured without the removal of the scleral buckle elements. The removed buckles are invariably positive for bacteria, usually Staphylococcus or Pseudomonas.
Diagnostic and Therapeutic Challenges VERMA ET AL
1913
Fig. 5. A. Color fundus photo of the left eye 4 weeks after vitrectomy with intravitreal antibiotics and silicone oil injection. B. Color fundus photo of the left eye 4 weeks after vitrectomy with intravitreal antibiotics and silicone oil injection showing regression of the subretinal abscess.
Dr. Folk believes that the drainage needle introduced an organism, bacteria, or fungus, into the subretinal space. The patient seemed to be cured by the vitrectomy and intravitreal antibiotics, but he feels that it is doubtful, though not impossible, that the intravitreal antibiotics cured the extensive subretinal abscesses. He states that it is possible, however, and that less aggressive bacterium or fungus can even resolve spontaneously. Dr. Folk unequivocally states that intravitreal antibiotics could not have cured an infection in a scleral buckle on the outside of the sclera of the eye.
We thank our presenters for this case, and Dr. Folk for his consultation. RETINAÒ, The Journal of Retinal and Vitreous Diseases, encourages readers to submit Diagnostic and Therapeutic Challenges to [email protected]. Cases for the Diagnostic and Therapeutic Challenges section should include a detailed history of the patient, the diagnosis, the workup, the management, and finally, the question or questions that the submitter wishes to have answered by the consultants.
