with the vitreous cutter at a low cutting rate (about 200 cuts/min). Finally, the underlying choroid is cauterized with diathermy or laser.

7. Apply laser at the impact site

After successful retinectomy and cauterization of the choroid, you must photocoagulate the retina around the impact site. If the retina is detached in the area of laser treatment, you must Þrst inject PFCL in order to ßatten the retina.

8. Tamponade: Silicone oil

In almost all cases of penetrating and perforating eye injuries, silicone oil should be chosen as a tamponade, even if no signiÞcant retinal detachment is present. This is due to the extremely high risk of developing PVR postoperatively.

11.2Suprachoroidal Haemorrhage

DVD

Video 17a, b 2× open globe injury with suprachoroidal haemorrhage

The expulsive haemorrhage is a haemorrhage in the suprachoroidal space (Diagram 11.1). Sometimes, the term ÒsuprachoroidalÓ is used synonymously to ÒsubchoroidalÓ. As a basic rule, these haemorrhages are removed from the scleral side and not trans-retinal. In the case of an open globe injury without signiÞcant retinal pathology, close only the rupture during the Þrst operation. Perform a limbal peritomy and suture the central corneal wound with a continuous Ethilon 10-0 suture (Figs. 11.1 and 11.2) and the sclera with Vicryl 8-0 cross sutures.

Then wait about 1Ð2 weeks with the vitrectomy until the blood liqueÞes, always monitoring for a retinal detachment that may develop which should be treated immediately. The surgery should be performed under general anaesthesia. Preoperative ultrasound is necessary to determine the shape and location of the choroidal haemorrhage. You have to perform a sclerotomy in the area of the highest choroidal detachment.

We describe the surgical procedure of a suprachoroidal haemorrhage without expulsion of intraocular tissue.

Instruments

1. 4-port trocar

2. BIOM

Fig. 11.1 Eye with a perforating trauma from a screw driver. The cornea is perforated; the anterior capsule is open; and lens material prolapses into the anterior chamber

Fig. 11.2 Same eye 3 weeks later. The central wound was sutured with a continuous Ethilon 10-0 suture, which creates a stable cornea. The perforation close to the limbus is preferably sutured with a one-stitch suture. The scleral rupture was sutured with a Vicryl 8-0 cross suture

3.Anterior chamber maintainer

4.Vitreous cutter

One needs instruments from the detachment set and the PPV set. The anterior

chamber maintainer is an infusion cannula for the anterior chamber.

Tamponade

PFCL, 1,000 cSt silicone oil

Individual steps

1. Limbal peritomy

2. Place traction sutures beneath all four rectus muscles 3. Insert an anterior chamber maintainer

Fig. 11.3 Eye with a perforating trauma from a stick. In a Þrst operation, the temporal limbus was sutured with Ethilon 10-0, and the sclera at 5 oÕclock from the limbus to the insertion of the inferior rectus muscle was sutured with Vicryl 8-0. Prior to the second operation, a 360¡ suprachoroidal haemorrhage was detected. Now, four traction sutures were placed beneath the four horizontal muscles. An anterior chamber maintainer was inserted to stabilize the eye

4. 3-mm sclerotomies between insertion of the muscle and the equator

5.Insertion of trocars

6.Core vitrectomy

7.Injection of PFCL

8.Trimming of vitreous base

9.Exchange of PFCL against silicone oil

1.Limbal peritomy

2.Place traction sutures beneath all four rectus muscles

Perform a 360¡ peritomy and place traction sutures underneath all horizontal muscles.

3. Insert an anterior chamber maintainer

An inferotemporal paracentesis is performed; the anterior chamber maintainer is inserted; and the infusion line is opened (Fig. 11.3). Now, the eyeball becomes normotensive. An infusion of the anterior chamber works particularly well when there is a pseudophakia. If the patient is phakic, try to insert the infusion cannula in an area of the pars plana where there is no choroidal detachment (ultrasound). When in doubt, place a 20-gauge sclerotomy using a long (6 mm) 20-gauge infusion port is of vital importance that the inner opening of the infusion port is in the vitreous cavity and not in the subretinal/suprachoroidal space.

Fig. 11.4 Due to the choroidal detachment, it is really difÞcult to place trocar cannulas. With the help of a light pipe, which is inserted through a paracentesis, the situation in the posterior segment is explored

Fig. 11.5 A 3-mm sclerotomy is performed between the insertion of the straight eye muscle and the equator

4. 3-mm sclerotomies between insertion of the muscle and the equator

Before performing a sclerotomy, you should ascertain the location of the SCH in the eye. You can conÞrm your ultrasound examination by inspecting the vitreous cavity with a light pipe (Fig. 11.4). Search for the quadrant with the highest bullous choroidal detachment.

The sclerotomy should be 3Ð4 mm in length and extend in a radial direction (Fig. 11.5). Concerning the location of these sclerotomies, there are different preferences. Some surgeons perform the sclerotomies 4 mm posterior to the limbus, other place the sclerotomies equatorial, since there is more suprachoroidal blood. We place the sclerotomies between the insertion of the muscle and the equator. For example, if a temporal and nasal choroidal detachment is present, you should perform a temporal and nasal sclerotomy. Once the sclerotomy is performed, liqueÞed blood (Fig. 11.6) and blood clots (Fig. 11.7) will ßow out the sclerotomy.

Fig. 11.6 LiqueÞed blood ßows out of the second sclerotomy on the other side of the globe. Extract the blood by compressing the globe with a forceps or cotton swabs

Fig. 11.7 Thick blood clots can be pressed through a larger 4-mm incision. If the sclerotomy is too small, you cannot extract thicker blood clots. This sclerotomy needs to be sutured with 1Ð2 Vicryl 8-0 cross sutures

If only liqueÞed blood ßows out and no clots, you should gently massage the eyeball with two cotton swabs or a squint hook in the direction of the sclerotomies and enlarge the sclerotomy to 4 mm. With this technique, you can often extract larger blood clots.

Depending on the intraocular pressure, the sclerotomies may or may not be sutured at the end of the surgery.

5. Insertion of trocars

When no more blood ßows out of the sclerotomy, you should try to insert the trocars at the pars plana if you have not done this before. Due to the detachment of the pars plana epithelium, this is a difÞcult procedure. Choose an area with little choroidal detachment and select a sutureable, longer infusion cannula (see above). Check if the trocar is located in the vitreous cavity. Remove the anterior chamber maintainer and insert a pars plana infusion line. Then insert a second trocar opposite to the