The changing character of the infected scleral implant

Scleral Buckling: A Review of Clinical Aspects and Current Concepts

Scleral buckling represents a valuable treatment option for rhegmatogenous retinal detachment repair. The surgery is based on two main principles: the closure of retinal breaks and the creation of a long-lasting chorioretinal adhesion. Buckles are placed onto the sclera with the purpose of sealing retinal breaks. Cryopexy is usually performed to ensure a long-lasting chorioretinal adhesion. Clinical outcomes of scleral buckling have been shown to be more favorable in phakic eyes with uncomplicated or medium complexity retinal detachment, yielding better anatomical and functional results compared with vitrectomy. Several complications have been described following scleral buckling surgery, some of which are sight-threatening. Expertise in indirect ophthalmoscopy is required to perform this type of surgery. A great experience is necessary to prevent complications and to deal with them. The use of scleral buckling surgery has declined over the years due to increasing interest in vitrectomy. Lack of confidence in indirect ophthalmoscopy and difficulties in teaching this surgery have contributed to limiting its diffusion among young ophthalmologists. The aim of this review is to provide a comprehensive guide on technical and clinical aspects of scleral buckling, focusing also on complications and their management.

Scleral buckle induce orbital cellulitis and scleritis – A case report and literature review

We report a case of a young healthy patient who developed orbital cellulitis and scleritis after retinal detachment surgery that was repaired with a scleral buckling procedure. Once scleral implant infection occurs, orbital infection results requiring removal of the implant in all previous reported cases. However, our patient was treated with systemic antibiotic and steroids without the need for removal of the scleral buckle.

Extrusion and Infection Incidence in Scleral Buckling Surgery with the use of Silicone Sponge: To Soak or not to Soak? An 11-Year Retrospective Analysis

PURPOSE

To assess the incidence of extrusion and infections of encircling silicone sponges in scleral buckling surgery for retinal detachment with and without the use of an intraoperative antibiotic soaking procedure.

METHODS

The authors performed a retrospective analysis reviewing the charts of 1127 patients who underwent episcleral buckling surgery operated by the same surgeon in three different institutions during a period of 11 years. The authors reviewed the charts of patients treated with a single episcleral silicone sponge (Labtician) indentation in three different models. The infection prophylaxis on the operating field was the same in all cases and only since February 1997 was the silicone sponge preoperatively treated with an antibiotic soaking procedure.

RESULTS

No immediate postoperative infections were reported in the operated eyes. Three eyes had an implant extrusion and in all these cases silicone sponge removal was performed. All three extrusion cases developed when sponge soaking was not adopted.

CONCLUSIONS

The data indicate that the soaking procedure does not decrease extrusion and infection incidence in scleral buckling surgery when both accurate surgical technique and disinfection prophylaxis are performed.

Postoperative Complications of Scleral Buckling

Scleral buckling has an important role in the repair of certain categories of rhegmatogenous retinal detachments. These include detachments in young phakic patients, detachments associated with dialysis, and also in conjuction with vitrectomy in patients who have sustained trauma or have developed proliferative vitreoretinopathy. However, it can be associated with significant postoperative complications. The most important ones are refractive change, intrusion or extrusion, infection, globe ischemia, and choroidal detachments, amongst others. Careful planning, appropriate patient selection, and good intraoperative technique can reduce the rate of these complications.

Scleral buckle infections: microbiological spectrum and antimicrobial susceptibility

BACKGROUND

The purpose of the present study was to evaluate the microbiological spectrum and antimicrobial susceptibility in patients with scleral buckle infection. Medical records of all the patients diagnosed as buckle infection at L. V. Prasad Eye Institute between July 1992 and June 2012 were reviewed in this non-comparative, consecutive, retrospective case series.

FINDINGS

A total of 132 eyes of 132 patients underwent buckle explantation for buckle infection during the study period. The incidence of buckle infection at our institute during the study period was 0.2% (31 out of 15,022). A total of 124 isolates were identified from 102 positive cultures. The most common etiological agent isolated was Staphylococcus epidermidis (27/124, 21.77%) followed by Mycobacterium sp. (20/124, 16.13%) and Corynebacterium sp. (13/124, 10.48%). The most common gram negative bacilli identified was Pseudomonas aeruginosa (9/124, 7.26%). The median interval between scleral buckling surgery and onset of symptoms of local infection was 30 days. All eyes underwent buckle explantation and median time interval between primary SB surgery and explantation was 13 months. Recurrent retinal detachment was observed in two cases at 7 and 48 months, respectively, after buckle explantation. Gram positive, gram negative, and acid-fast organisms isolated from 2003 to 2012 were most commonly susceptible to vancomycin (100%), ciprofloxacin (100%), and amikacin (89%). Susceptibility to ciprofloxacin during the same time period was observed in 75% (15/20), 100% (13/13), and 87% (7/8) of gram positive, gram negative, and acid-fast isolates, respectively.

CONCLUSION

Scleral buckle infection is relatively rare and has a delayed clinical presentation. It is most commonly caused by gram positive cocci. Based on the current antimicrobial susceptibility, ciprofloxacin can be used as empirical therapy in the management of scleral buckle infections.

Orbital cellulitis following silicone-sponge scleral buckles

Background

Acute or chronic infection of the scleral explant is rare. We report seven cases of scleral explant infections that caused orbital cellulitis.

Materials and methods

This was a retrospective chart review of oculoplastics at oculoplastics and vitreo-retinal units in a secondary referral hospital. All subjects had orbital cellulitis secondary to scleral buckle in the range of January 1990 to March 2010. Demographics, imaging studies, and pathology specimens were reviewed.

Results

A total of 841 silicone-sponge scleral buckle implants for rhegmatogenous retinal detachment were performed. Forty were extracted (4.75%; annual rate of 1.9 cases). Seven (0.83%) had orbital cellulitis. The mean time from implantation to presentation was 5.7 years. There was bacterial growth in all specimens, with Staphylococcus aureus in four.

Conclusions

Patients who are operated on with silicone-sponge scleral buckling for rhegmatogenous retinal detachment sometimes require removal of the implant because of infection. However, the infection rate is low. Patients should be followed in the long term for possible complications.

Scleral buckle removal: indications and outcomes

Primary scleral buckling has been an effective means to reattach the retina for over 50 years. After surgery, complications may arise that require scleral buckle (SB) removal. The most common indications for SB removal are extrusion, infection, and pain. I review the pertinent literature in an effort to develop guidelines for when to remove a SB.

Transpalpebral extrusion of solid silicone buckle

Explants used in retinal reattachment surgery occasionally extrude. Cheese-wiring of the suture through the sclera consequent to raised intraocular pressure allows the buckle to loosen and/or unfold. Subsequent infection, often with Staphylococcus albus, accelerates the process of extrusion. Commonly, such explants are of silicone sponge. The reported case is unusual in that the extrusion occurred through the upper lid, and involved a solid silicone explant.

Infectious scleritis after retinal surgery

PURPOSE

To report a series of patients in whom infectious scleritis developed after vitreoretinal surgery.

DESIGN

Interventional case series of four patients.

METHODS

Medical records of patients at a single institution in whom infectious scleritis developed after vitreoretinal surgery were reviewed.

RESULTS

In three patients, infectious scleritis developed after 20-gauge pars plana vitrectomy, and in one patient, infectious scleritis developed after a scleral buckling procedure. Three cases were had positive culture results; the identified organisms were Pseudomonas aeruginosa in two cases and methicillin-resistant Staphylococcus aureus in one. The fourth patient did not have culture results but responded rapidly to empiric treatment with moxifloxacin. In one patient, surgically induced necrotizing scleritis subsequently developed.

CONCLUSIONS

Although infectious scleritis is an uncommon complication after vitreoretinal surgery, it should be a considered cause in patients with persistent postoperative pain and inflammation.

Radiologic findings in infected and noninfected scleral buckles

PURPOSE

To present the radiologic findings in scleral buckle infections and in the early postoperative period after scleral buckling.

METHODS

Retrospective multicenter orbital computed tomography (CT) study of 14 patients and brain magnetic resonance (MR) in one patient with scleral buckle infections, some with the referring diagnosis of endophthalmitis, proliferative vitreoretinopathy, orbital cellulitis, or unilateral headache. The control population consisted of early postoperative prospective CT study of 38 consecutive patients with scleral buckle without clinical infection.

RESULTS

Diffuse scleral thickening and preseptal soft tissue swelling were noted in acute scleral buckle infections. Scleral thickening decreased radiologically following prompt antibiotic therapy in five patients with acute infections. Silicone sponge had low attenuation without infection and high attenuation with infection. In chronically infected scleral buckle, the sclera was thickened around the buckle, with scleral melt under the buckle. MR showed increased signal intensity in the preseptal region in one patient with chronic fungal infection. In the controls, two had thickening of the sclera without soft tissue swelling.

CONCLUSIONS

CT or MR can assist in the early diagnosis and management of scleral buckle infections.

LONG-TERM STABILITY OF CIRCUMFERENTIAL SILICONE SPONGE SCLERAL BUCKLING EXOPLANTS

PURPOSE

The historical extrusion/explantation rate of silicone sponge scleral buckle exoplants is 3.5 to 24.4%. This contrasts with the published 0.6 to 1.2% explantation rate of solid silicone elements. Previously reported silicone sponge exoplants studies were noncircumferential (quadrantic or multiple). This study was undertaken to assess the long-term stability of 360 degrees circumferentially placed 3 x 5 mm silicone sponge exoplants.

METHODS

Interventional case series of 840 consecutive circumferentially placed 3 x 5 mm silicone sponge exoplants. A retrospective review of operative reports and patient charts was performed.

RESULTS

A total of 552 patients had documented follow-up over 1 year. Median follow-up was 32.8 months. Six patients underwent removal of the scleral buckling element (two for diplopia, one acute postoperative infection, and three for extrusion). Median time to removal was 7.3 months. Extenuating circumstances contributed to two of the three extrusions. Of the entire series, fewer than 1% of patients required removal of the silicone sponge implant. Excluding patients with less than 1 year of documented follow-up, the long-term infection/extrusion rate was 0.7%.

CONCLUSIONS

Circumferentially placed silicone scleral buckling sponge elements are very stable and are well tolerated. The explantation/extrusion rate is comparable to published solid silicone element series.

Effect of vancomycin on Staphylococcus epidermidis adherence to poly(methyl methacrylate) intraocular lenses

PURPOSE

To study the adherence of Staphylococcus epidermidis in variable loads (10(8) cfu/mL and 10(3) cfu/mL) to poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) and to evaluate the effect of vancomycin treatment on S epidermidis adherence to the IOL.

SETTING

L.V. Prasad Eye Institute, Hyderabad, India.

METHODS

The study was designed in 2 parts. Phase I: Twelve PMMA IOLs were soaked in a solution of S epidermidis, randomized to 10(8) cfu/mL or 10(3) cfu/mL. They were rinsed or rinsed and vortexed and cultured. Phase II: Twelve IOLs were treated with vancomycin (10 mg/mL), randomized to before and after treatment with S epidermidis.

RESULTS

Staphylococcus epidermidis adhered to all portions of the IOL with 10(8) cfu/mL and 10(3) cfu/mL bacterial loads. Treatment with vancomycin reduced S epidermidis adherence.

CONCLUSION

Pretreatment of an IOL with vancomycin or a suitable antibiotic agent appears to reduce bacterial adherence to the IOL. Placement of a sustained-release device that could release an antibiotic agent over a specific period, reducing the incidence of postcataract endophthalmitis, should be studied.

Methicillin-resistant Staphylococcus aureus infections after scleral buckling procedures for retinal detachments associated with atopic dermatitis

OBJECTIVE

To determine the incidence and the clinical course of methicillin-resistant Staphylococcus aureus as a cause of acute-onset infections in patients with atopic dermatitis after a scleral buckling procedures.

DESIGN

A retrospective chart review.

PARTICIPANTS

Two hundred eighty-seven patients (293 eyes) who underwent scleral buckling procedures to treat rhegmatogenous retinal detachments at either Osaka Rosai Hospital or Osaka University Medical School between July 1, 1995, and June 30, 1997, participated. Of these, 32 eyes (10.9%) were associated with atopic dermatitis.

INTERVENTION

Demographic and clinical data were abstracted from patients' medical records.

MAIN OUTCOME MEASURES

The incidence, clinical features, and management of postoperative infections associated with methicillin-resistant S. aureus were studied.

RESULTS

Methicillin-resistant S. aureus infection after scleral buckling procedures was identified in 6 (18.8%) of 32 eyes of patients with atopic dermatitis but in only 1 (0.4%) of the other 261 cases without atopic dermatitis (P < 0.001). The average interval from the scleral buckling procedures to the initial onset of infection was 8.3 +/- 9.1 days (range, 2-28 days). Bacterial infection and inflammation were controlled in four eyes by prompt removal of the infected buckle in combination with vancomycin administration. In the other three eyes, however, repeat intravitreous injections of vancomycin or emergent vitrectomies were required because of the development of endophthalmitis.

CONCLUSIONS

Methicillin-resistant S. aureus is an important causative pathogen of scleral buckling infections, particularly in patients with retinal detachment associated with atopic dermatitis. Preoperative evaluation and intraoperative attention to contamination are recommended to prevent methicillin-resistant S. aureus infections in these patients.

In vitro adhesion of Pseudomonas aeruginosa and Staphylococcus aureus to surface passivated poly(methyl methacrylate) intraocular lenses

Bacterial attachment to intraocular lenses (IOLs) can be a cause of infectious endophthalmitis following cataract surgery. In this study, Pseudomonas aeruginosa and Staphylococcus aureus adhered in vitro to untreated poly(methyl methacrylate) (PMMA) and to surface passivated PMMA lenses. The IOLs were placed in bacterial suspensions (1 x 10(7) cfu/ml) in vitro. Significantly fewer S. aureus attached (P < .05) to the normal PMMA IOLs (4,535 +/- [SD] 3,052 bacteria/mm2) and to passivated PMMA IOLs (8,720 +/- 10,040 bacteria/mm2) than did P. aeruginosa (normal PMMA: 67,808 +/- 45,070 bacteria/mm2, passivated PMMA: 85,795 +/- 70,647 bacteria/mm2). The differences in bacterial attachment to surface passivated IOLs and to untreated PMMA lenses were not significant.

Results of a temporary balloon buckle in the treatment of 500 retinal detachments and a comparison with pneumatic retinopexy

Five hundred detachments with a single break or a group of breaks close together were treated with parabulbar balloon and cryopexy in Tübingen between November 1980 and September 1986. Follow-up ranged from six to 91 months. Primary attachment was achieved in 466 eyes (93%). Twelve (2.4%) redetached after the balloon was removed. After a second operation, 490 eyes (98%) were attached and after a third, 493 (99%) were attached. The results with the extraocular balloon were compared with results of a similar group of detachments treated with an intraocular gas bubble. The primary attachment rate with the expanding gas operation was 91%; 11% of these eyes redetached. Although the final attachment rate was 99%, the complications after gas were much more frequent and of serious consequence.

Preoperative antibiotic soaking of silicone sponges. Does it make a difference?

A prospective randomized trial was carried out during the years 1974 to 1981 to determine whether preoperative antibiotic soaking of silicone sponges used in retinal detachment surgery would reduce the incidence of postoperative infection and extrusion. During this period 2972 consecutive primary scleral buckles were performed and in 921 (31%) of the cases an episcleral sponge was utilized either alone or in conjunction with a hard silicone encircling band. In alternate cases the sponge was soaked in an antibiotic solution for at least 30 minutes prior to insertion. In the remaining cases the sponge was not soaked. Overall, a statistically significant (P = 0.00018) seven-fold reduction in the rate of infection or extrusion was observed in cases where the silicone sponge was soaked preoperatively in antibiotics. An additional result of the study showed the rate of sponge removal was significantly increased by the use of multiple episcleral sponges (P = 0.00002).

Removal of solid silicone rubber exoplants after retinal detachment surgery

A prospective study of 255 eyes undergoing scleral buckling procedures with solid silicone rubber elements as exoplants disclosed a 1.2% incidence (three of 255 eyes) of buckling element removal after a minimum follow-up period of two years. This rate was lower than that reported in series using solid silicone rubber implants or sponge silicone rubber exoplants.

Current status of biomaterials in ophthalmology

The artificial materials currently used in ophthalmology are reviewed. Those include poly(methyl methacrylate) in contact lenses, keratoprostheses, and intraocular lenses; cellulose acetate butyrate and the siloxane-containing polymethacrylates in contact lenses; the silicones in contact lenses, scleral buckling materials, and drainage implants in glaucoma; the hydrogels for contact lenses and retinal surgery implants; and the cyanoacrylate adhesives for corneal perforations and ulcers. The properties of the materials and their relationship to ocular tissues, as well as the advantages and disadvantages of their use in the eye are discussed. Probable future advances of biomaterials in ophthalmology are also discussed.

Surgical management of retinal detachment without cryopexy

A clinical study of eyes with rhegmatogenous retinal detachment compared the reattachment rate in two groups of eyes: in the control group, cryopexy was applied over the retinal breaks during surgery; in the test group, cryopexy was not applied. There was a similar rate of retinal reattachment in the two groups in the immediate postoperative period. However, during the long follow-up period (36 months) there was a considerable difference in the two groups. Eyes that had undergone cryopexy had a lower rate of redetachment than eyes that had not. The rate of operative and postoperative complications was low in both groups, except for periretinal proliferation, which was more frequent in the test group. These results suggest that cryopexy may lower the incidence of redetachment after retinal detachment surgery.

Infection after sponge implantation for scleral buckling

In one series of 900 explant scleral buckling procedures, 31 had to be removed over seven years because of contamination. Of 1,000 explants from a parallel series, 27 had to be removed. In the second series, requirement of a sterile conjunctiva preoperatively and the use of prophylactic antibiotics postoperatively did not significantly reduce the rate of infection.

A predictive model for visual recovery following retinal detachment surgery

By multiple regression analysis we have identified 26 out of 200 observations which significantly affect the visual acuity following retinal detachment surgery. In addition, we have developed a highly significant mathematical model, which is able to predict in rather broad ranges of visual acuity to approximately 67% accuracy. There is still a large percentage of patients for whom we cannot account for the variability in final vision, a problem requiring future investigation. Potentially important factors which were not analyzed in this study include duration of macular detachment, afferent pupil defect, drainage of subretinal fluid, extent of the scleral-buckling procedure, and postoperative follow-up longer than six months. While most of the variables are fixed and cannot be alterd, such as age, senile cataract, and refractive error, improved knowledge of influential factors may allow us to manipulate some of them and provide mechanisms for improving results in recovery or maintenance of macular function after retinal detachment surgery.

A case of late pseudomonas ocular infection following scleral buckling

Two and half years after a circling buckle operation in which two Supra-mid sutures and a solid silicone explant were employed, a Pseudomonas infection developed around the explant and progressed to the inner eye. Removal of all implanted foreign material and treatment with Rifamicin saved the eye. The relevant literature on infection following sclero-plastic procedures is reviewed, and the pathogenesis of the late infections is discussed.

Penetration of cephaloridine into the subretinal fluid

Images

Pigment fallout and uveitis after cryotherapy

Images