CASE OF THE MONTH: September 2023

Decreased Vision After A Fall

By Haley S. D’Souza, MD, MS and Matthew R. Starr, MD

A 59-year-old male presented to the Emergency Department due to decreased vision in his left eye two days after sustaining a fall in which he struck his left eye on a door handle. Visual acuity was 20/30 in the right eye and hand motion in the left. The left pupil was minimally reactive but without an afferent pupillary defect, and intraocular pressures were 16 and 10 mmHG in the right and left eye, respectively. Examination of the left eye was remarkable for chemosis with subconjunctival hemorrhage, anterior chamber cell, and a dense vitreous hemorrhage with no view to the posterior pole. B-scan demonstrated an area suspicious for choroidal hemorrhage nasally. The patient was started on Pred Forte six times per day and atropine twice per day. The patient followed up in Retina clinic two days later, where B-scan demonstrated an area of vitreoretinal traction concerning for tear or detachment and the decision was made to proceed with early pars plana vitrectomy.

At the start of the case, a standard 3-port pars plana vitrectomy setup was achieved. A pre-tested infusion line was inserted and turned on after verification of positioning with the light pipe. Initial visualization revealed an extremely dense vitreous hemorrhage obscuring the view to the posterior pole. A posterior vitreous detachment was then carefully induced and then a core vitrectomy was performed. At this point, sure enough, a nasal macula involving rhegmatogenous retinal detachment was noted. After prolonged scleral depression to identify the retinal break, we were surprised to find the fluid was guttering from a superior scleral rupture site and not a retinal tear. The decision was then made to proceed with scleral buckling and repair of the open globe.

After a 360-degree conjunctival peritomy and dissection was carried out, the scleral rupture was noted to extend from 9-3 o’clock. The superior rectus was imbricated and disinserted, and the rupture was closed with interrupted 8-0 nylon sutures. The superior rectus was then tied down in its original position. The rectus muscles were individually isolated and cleaned and no additional rupture was noted. A 41 band was placed around the eye with a Watzke sleeve in the superonasal quadrant. On returning attention to the vitreous cavity, further careful shave of the vitreous base was performed. Superiorly from approximately 10-2 o’clock, there was retinal incarceration into the scleral rupture site. The cutter was then used to remove the incarcerated retina superiorly and immediate relaxation of the retina was noted. Perfluorocarbon was instilled and used to re-attach the retina. Endolaser was performed to the superior retinectomy. Fluid air exchange was carried out followed by filling of the eye with 1000 centistoke silicone oil.

The patient tolerated the procedure well and remained attached. Four months later he underwent cataract extraction and removal of the silicone oil. At that time, inferior proliferative vitreoretinopathy was resting on and just posterior to the buckle, but the retina remained attached. During the oil removal, the internal limiting membrane was peeled and used as a scaffold to peel the posterior PVR. Now, 10 months following his oil removal his, best corrected visual acuity in the left eye is 20/50 and the retina remains attached.