In this video, Dr. Ho Presents a video case study in a patient with a retinal tear and vitreous hemorrhage. He demonstrates the use of fibrin glue and scleral patch graft to maintain globe integrity and discusses the postoperative results of this patient.
Lecturer: Dr. Jason Ho
DR HO: Hello. My name is Jason, and it’s very nice to be here. So I’m just gonna present a very quick video case of something interesting that I saw a few years ago. So this was a 43-year-old Pakistani gentleman. 20 years previously, he had lost his left eye to trauma. So in his only right eye, he came with sudden onset of floaters and photopsia. So this gentleman was a high myope, -11. With glaucoma. And he also had Ehlers-Danlos syndrome, which is a connective tissue disorder. When I saw him, he had a retinal tear, which we treated with laser. And his vision at that time was about 6/12, 6/18. But then he kept on coming back, day after day, for the next two weeks, complaining that his vision was getting worse and worse. And it dropped from 6/60, got better to 6/24, and then it dropped again to counting fingers. Even though he had an adequately lasered tear, he had a bridging vessel, and that continued to bleed. So we scanned his eye and said: You don’t have a retinal detachment. You just have vitreous hemorrhage. I’m sure all of you have seen something similar to this, and you just reassure the patient and wait for the blood to clear. But because this was his only eye, he wanted surgery, and so we offered him an operation. A vitrectomy. So this was halfway through the vitrectomy that my colleague was doing. As you can see, this was the vitrectomy port. And he was trying to close it at the end of the operation. I’ve never heard so many swear words used, because the hole is pretty big. As you can see, this patient has scleral fragility. And even though inside there was no retinal detachment, you can see it was continuously leaking. And he put many, many sutures, but they kept on cheesewiring. The only solution we had was to close the eye by doing a fluid-air exchange. Putting glue on top. And then a scleral patch. Also called Tutoplast. It’s called Tutoplast or Tutopatch. Artificial scleral graft. Sclera. The white… And then closing the conjunctiva over this. But basically he had a big hole that we couldn’t close. And it’s very hard to cover this, unless the eye is nice and dry. We filled the eye with a 25% sulfur hexafluoride gas tamponade, to keep it flat. We filled the eye with gas. But as you can see from the video, it’s still quite soft. And then hope for the best. So… Just to recap, he had very friable, very fragile sclera. When we put the ports in, this hole just kept getting bigger and bigger and bigger. Very thin sclera. Yeah.
>> Because of the myopia?
DR HO: High myopia and Ehlers-Danlos. And he also had some uveal prolapse, which was very worrying. That’s about 20 sutures. But they couldn’t close it. I don’t know if anybody else here has any experience with similar cases, but you don’t see that very often. Glue was very useful. Unfortunately, at day 1… His pressure was 25. He couldn’t see anything. Vision was hand movements. And he had some hyphema. So we sent him home. He came back at day 3. And the ultrasound showed a very big suprachoroidal hemorrhage. So obviously overnight his eye must have become a bit soft, and when we saw him, although the eye was formed and the anterior chamber was formed, and the pressure was still about 12 to 20 at that time, he still had a large bleed. And this was something that had happened postoperatively. This bleed persisted for the first two weeks. Continued for two weeks. But we did nothing. And his vision remained at hand movements. And he was very unhappy, because this was his only eye. This case was more of a demonstration, to show that sometimes it’s better not to intervene. Sometimes it is better not to do anything. But fortunately he recovered vision to 6/24. Over three months. With conservative management. And he had successful cataract surgery. I understand he’s seeing 6/12 today. Today he’s 6/12. 20/40. So what I just wanted to highlight was that this was a form of treatment for an acute scleral rupture. In a case where the sclera cannot be repaired, fibrin glue and scleral graft can be used. In the published literature, less than half of these patients get better vision than 6/60. Less than half. And sometimes it’s better to counsel these patients before the operation that it may be unnecessary to do it, and especially since there’s a very high risk, only eye, Ehlers-Danlos, systemic risk factors, high myopia, it may be better to leave it alone.