Ординатура / Офтальмология / Английские материалы / Strabismus Surgery and Its Complications_Coats, Olitsky_2007

of the sclera), was reported in 728 of almost 554,000 strabismus procedures performed by 223 surgeons responding to the survey. Thus the estimated incidence of scleral perforation was 1.37 for every 1000 strabismus operations performed. While surveys such as this that depend on the surgeon’s memory may over or under estimate the true occurrence of scleral perforation, the study contains some potentially valuable information. Perforations were twice as likely to occur when residents and fellows were operating than when an attending surgeon was operating. Perforations were reported at several stages during surgery. Most occurred during muscle reattachment to the ­sclera with sutures, which accounted for 633 (87%) of the 728 reported perforations. Twenty-four (3.3%) perforations occurred during muscle disinsertion, six (<1%) during muscle dissection, five (<1%) during passage of traction sutures, and five (<1%) occurred during pre-placement of muscle sutures prior to muscle disinsertion.

Morris and coworkers [3] noted a single case of globe perforation during surgery on 100 eyes of 67 patients, 22 (44 eyes) of whom had undergone previous strabismus surgery. They recommended that all strabismus surgery should be performed under magnification, suggesting that magnification could help prevent scleral perforation. In a retrospective review of 4886 strabismus procedures performed at King Khalid Eye Specialist Hospital in Saudi Arabia, Awad and coworkers [4] reviewed recognized scleral perforations, which were noted in only 15 cases. Five of these perforations occurred during muscle reattachment to the sclera, four during placement of traction sutures at the limbus, three during muscle disinsertion, and three occurred during pre-placement of sutures in the muscle prior to disinsertion. In the study by Awad and coworkers [4] 11 (73%) of 15 perforations occurred while surgery was being performed by a supervised resident. The authors readily admitted that they could have underdiagnosed the number of perforations that actually occurred in this retrospective study. A summary of the findings of selected studies is presented in Table 21.1.

Retrospective studies and surveys are likely to greatly underestimate the number of scleral perforations and deep passes that actually occur. Dang and coworkers [5] conducted a prospective study of resident and fellow strabismus surgeons for the purposes of identifying “scleral penetrations and perforations,” and to identify associated risk factors. They evaluated 217 operated eyes of 114 patients. Each patient was dilated preoperatively. At the conclusion of surgery, each underwent indirect ophthalmoscopy with scleral depression over the operative site. Though these authors’ intention was to study scleral penetrations and perforations, they actually defined penetration and perforation using the eye wall, consisting of the sclera, choroid, retinal pigmented epithelium, and the retina as their reference. A penetration was defined as a “full thickness scleral pass with the presence of retinal hemorrhage or edema in the area of the muscle surgery but without the presence of a visible retinal break.” A perforation, on the other hand, involved the entire eye wall and was defined as a “full thickness scleral pass with a visible retinal break with or without hemorrhages or retinal edema.” Patients who experienced eye wall perforations were followed for at least 1 year after surgery for complications. Of their patients, 11 (5.1%) experienced eye wall penetrations, which by their definition involved the full thickness of the sclera, while 6 (2.8%) patients experienced an eye wall perforation. When calculated based on the number per muscle operated, eye wall penetrations with scleral perforation occurred in 4.3% of muscles operated while eye wall perforations occurred in 1.9% of muscles operated.

Goldstein and coworkers [6] studied the characteristics of scleral tunnels created by 40 needle passes in the sclera of rabbits by evaluating histologic sections of the involved sclera. They reported that a needle with an acute curve produced a shorter pass through similar depth compared with a shallow curve needle. A needle with a cutting surface located on the inferior aspect tended to produce a pass that was deeper than a needle with its cutting surface on the superior aspect of the needle.

We studied the characteristics of scleral passes created by several spatulated needles commonly used during strabismus surgery in eye bank eyes (unpublished data). Scleral tunnels simulating those made during strabismus surgery were created using S14, S24, S28, and TG 100 needles at the rectus muscle insertions, 6 mm posterior to the rectus muscle insertions and 10 mm posterior to the rectus muscle insertions. Ultrasound biomicroscopy was performed to evaluate the characteristics of each scleral tunnel before removal of the suture (>Fig. 21.2). A perforation was considered present when the pass depth equaled or exceeded scleral thickness. A near perforation was considered present when the pass depth equaled or exceeded 90% of the scleral thickness but was less than 100% thickness.

Each of the needle passes met published recommendations for minimal acceptable length and depth (2 mm in length and 200 µm in depth) [7], regardless of which needle was used. Only one perforation occurred, this using an S28 needle. Four near perforations occurred, twice by an S24 needle and once each by an S28 and S14 needle. The combined incidence of scleral perforation and near perforation in this study was 0.038%. The average depth of the scleral tunnels created with each needle varied (>Fig. 21.3). With the S14, S24 and the S28 needles, there was a linear trend of increasing depth of pass as the length of the pass increased, a trend that was greatest for the S14 needle. The opposite trend was found with the TG100 needle, where the pass depth tended to decrease slightly as the length of the pass increased (>Fig. 21.4). This finding may be

Fig. 21.2. Ultrasound biomicroscopy demonstrating a scleral penetration (right), and a scleral perforation (left)

Fig. 21.3. Average depth of needle pass in the sclera of eye bank eyes using four spatulated needles

related to differences in needle characteristics, including wire diameter, curvature, and length (Chap. 7). The larger S14 needle is more visible as it is passed through the sclera compared with the S28 needle, for example. Figure 21.5 demonstrates the greater visibility of the S14 needle compared with the S28 needle when each is placed in the same scleral tunnel. The ability to visualize the needle as it is passed through the sclera, combined with its shallow curve, may encourage the surgeon to pass larger needles more deeply into the sclera. Likewise, limited ability to see smaller needles during the scleral passes may act to discourage deeper passes.

21.1 Risk Factors

Most of the factors that purportedly increase the risk of scleral perforation during strabismus surgery are unproven, though most are intuitive and probably correct. Thin sclera almost certainly increases the risk of scleral perforation. While difficult, if not impossible to prove this in a scientific study, it is logical to believe this is true and the use of extra caution when performing strabismus surgery on patients with thin sclera is advisable. The risk of scleral perforation appears to be greatest during reattachment of a muscle to the sclera, where the needle must carefully penetrate the sclera, but only deep enough to secure the muscle to the globe. The margin of error may be very small in eyes with a thin sclera. Patients who may have thin sclera include, but are not limited to, those with high axial myopia, a history of previous scleritis, and a history of previous ocular surgery. Haugen and Kjeka [8] reported the sudden rupture of the globe in a 78-year-old woman without myopia. During attempts to recess the superior rectus muscle, a large, radial rupture of the sclera occurred with prolapse of a large amount of vitreous. This occurred without undue traction on the globe. Following the rupture, the sclera in this area was noted to be extremely thin. The laceration was repaired, and retinal cryopexy, scleral buckling, and injection of intravitreal gas were performed by a retina surgeon. The patient subsequently developed a blind, painful eye and underwent evisceration.

We experienced rupture of the sclera in one patient, but the setting was quite different than that described by Haugen and Kjeka [8]. We had a patient who experienced a 1-cm rupture of the sclera adjacent to the inferior rectus muscle. Surgery was being performed to recess the inferior rectus muscle in a patient with congenital fibrosis syndrome. The rupture occurred during traction on the globe to expose the muscle, traction that was well in excess of what is required for standard surgery. The intraocular contents did not prolapse and the patient did well with simple closure of the defect. We also experienced rupture of an old scleral cataract incision during surgery on the superior rectus muscle of an elderly man, which was repaired without sequelae.

Surgical techniques have been devised to mitigate the risk of scleral perforation in eyes with thin sclera. Rectus muscle recessions and resections can be performed without the need to pass sutures through the sclera, and may be of use in selected patients [9, 10]. Coats and Paysse [9] described a procedure that allows a surgeon to perform a rectus muscle recession or resection without the need to pass sutures through the sclera, greatly reducing the risk of scleral perforation. The technique is outlined below.

To perform a rectus muscle recession, two double-arm 6.0 Polyglactin sutures are secured in the rectus muscle, one near its insertion and the other 2 mm posterior to the muscle insertion into the sclera (>Fig. 21.6a). To help minimize bleeding, a hemostat is placed across the muscle between these two sutures and removed after 30–60 s. The muscle between the two sutures is then cut on the crush marks left by the hemostat (>Fig. 21.6b). The suture remaining in the muscle insertion is tied to the suture in the muscle, creating a hang-back recession without the need to penetrate the sclera with a needle (>Fig. 21.6c).

To perform a rectus muscle resection, two double-arm 6.0 Polyglactin sutures are secured in the rectus muscle, one near its insertion and a second posteriorly, at the desired resection position (>Fig. 21.7a). The muscle between the two sutures is removed (>Fig. 12.7b) and the two sutures are tied together to bring the resected muscle back to the muscle insertion, without the need to penetrate the sclera with a needle (>Fig. 12.7c).

Fig. 21.6a–c. Rectus muscle recession without the need to penetrate the sclera with a needle. a An absorbable suture is secured in the muscle near the insertion and a second suture is placed 2 mm posterior to the insertion. b The muscle between the two sutures is then cut, and c the sutures are tied together to create a hang-back recession

Fig. 21.7a–c. Rectus muscle resection without the need to penetrate the sclera with a needle. a An absorbable suture is secured in the muscle near the insertion and a second suture is placed posteriorly in the desired resection position. b The muscle between the two sutures is removed, and c the two sutures are tied together to bring the resected muscle back to the muscle insertion

In their prospective study of scleral perforation and penetration during resident and fellow surgery, Dang and coworkers [5] found three factors to be statistically associated with eye wall perforations and penetrations. These three factors were younger age, use of the S24 needle, and rectus muscle recession surgery (as opposed to resection surgery). Interestingly, and in contrast to other studies, the skill level and experience of the learner surgeon was not statistically associated with an increase in the rate of scleral perforation and penetration. Dang and co-workers [5] were not able to determine why younger patients were more likely to suffer scleral perforations and penetrations, but postulated that younger patients were more likely to have a standard recession (instead of a hang-back procedure) compared with older patients, or that the sclera might have been less rigid in younger patients, increasingly the propensity toward scleral penetration and perforation. We suggest an alternative explanation may be the fact that exposure of the operative site is typically more difficult in the smaller eyes and orbits of younger children, especially when surgery is performed through a fornix incision. Limited exposure, in our experience, significantly increases the risk of scleral perforation.

Other authors have also suggested that scleral perforation occurs more commonly during recession surgery than during resection surgery [3]. This is presumably the result of two factors: (1) the fact that the sclera is thinner behind the insertion where recession sutures frequently must be placed (>Fig. 21.8) and (2) because exposure of the surgical site is more difficult with recession surgery compared to resection surgery. Expo-

sure is usually excellent at the insertion where resection sutures are placed compared with exposure more posteriorly for a recession, especially a large recession. The use of a hang-back recession technique (Chap. 9) in patients believed to be at higher risk for scleral perforation should be considered. To our knowledge, the report by Dang and coworkers [5] represents the only study to prospectively and statistically demonstrate an increase in the risk of scleral perforation during rectus muscle recession compared with rectus muscle resection surgery.

Posterior fixation sutures are generally placed well behind the limbus, where surgical exposure can be difficult. Alio and Faci [11] evaluated 187 eyes by indirect ophthalmoscopy following placement of posterior fixation sutures and followed abnormal eyes over time. While they did not detect any retinal perforations, they did detect fundus abnormalities in 29 (15.5%) of these 187 eyes. The lesions primarily consisted of chorioretinal scars, though a triangular-shaped area of choroidal ischemia was noted in one patient (>Fig. 21.9). These authors hypothesized to that ophthalmoscopically visible fundus changes might be more common following the poster fixation sutures technique because the technique itself is difficult and/or because the lesions are easier to visualize than lesions that might occur more anteriorly during routine strabismus surgery. A technique reported by Clark and coworkers [12, 13] involving placement of a nonabsorbable suture in the medial rectus muscle and its associated pulley may be considered in order to minimize or eliminate the risk of scleral perforation for appropriate patients (>Fig. 21.10).

21.2 Clinical Evidence of Perforation

Scleral perforation probably goes unrecognized in many cases. We have occasionally been surprised to find evidence of a scleral perforation that was not suspected at the time of surgery, but detected on indirect ophthalmoscopy immediately after surgery (>Fig. 21.11) or through detection of a chorioretinal scar in the area of muscle reattachment in the late postoperative period. Intraoperative signs of a scleral perforation may vary depending on the patient and the severity of the perforation, but in general we have noted that one or more of the following usually occurs during recognized scleral perforation. First, the experienced and even the inexperienced surgeon often feels a “gestalt” that the needle pass was too deep and is immediately suspicious that a perforation may have occurred. Recognized scleral perforations are often heralded by small piece of uveal or a bead of vitreous on the tip of the suture needle [14]. A small amount of dark red, deoxygenated blood from the choroidal circulation may be seen following a scleral perforation, but external bleeding is generally very mild when it occurs.

If a retinal perforation has occurred, liquid vitreous may be seen exiting from either the scleral entrance or exit wound, though it is more commonly seen at the exit wound. We operated on an elderly woman who suffered a 5-mm scleral laceration during a Harada–Ito procedure while the superior oblique tendon was being sutured to the sclera above the lateral rectus muscle. Vitreous was seen to extend through the scleral laceration. The vitreous was excised and the scleral laceration was closed with 6.0 Polyglactin suture. Interestingly, examination of the retina underlying the site of the laceration failed to demonstrate the presence of a retinal break, underscoring the fact that scleral perforation can easily go undetected during postoperative evaluation of the retina. The patient recovered without sequelae. Finally, even without obvious loss of blood or fluid from the eye, the globe may become softer immediately following a scleral perforation.

Indirect ophthalmoscopy to inspect the retina underlying the surgical site should be performed when a scleral perforation is suspected. We generally administer dilating drops as soon as a perforation is suspected and perform indirect ophthalmoscopy at the conclusion of the surgery. Some surgeons, including us, place neosynephrine drops into the eyes of strabismus patients prior to surgery to produce vasoconstriction of the conjunctival blood vessels during surgery and this often results in sufficient papillary dilation that further dilation of the pupil may not be needed to inspect the retina. If a perforation is suspected, the suture is withdrawn and replaced in an alternative location before proceeding with surgery. Even when a perforation is present, there may be no obvious sign of perforation during indirect ophthalmoscopy, thus we reposition the suture before inspecting the retina for evidence of perforation. If a retinal break is detected, treatment is initiated as discussed below in Sect. 21.3.

Fig. 21.11. Retinal perforation seen immediately after strabismus surgery. Note the absence of associated hemorrhage. In this case, the perforation was obvious at the time it occurred

In a study of eye wall perforations in rabbit eyes, Sprunger and coworkers [1] were unable to verify the site of a known scleral­ perforation in three of four rabbit eyes in which a needle had been “thrust into the eye and removed,” despite knowing both that a perforation had occurred and its exact location. Inability to identify the site of a retinal break may be less likely in cases of human retinal breaks occurring during surgery where the perforation is more likely to have been oblique to the retina, resulting in greater disruption of intraocular structures compared to a needle that has been thrust directly into the eye, as was done in the aforementioned study. While hemorrhages in an experimental setting have been reported to be small [1], large preretinal hemorrhages have been reported. All five patients experiencing retinal perforation at the time of muscle reattachment reported by Awad and coworkers [4] had evidence of retinal perforation, including localized vitreous hemorrhage noted at the time of intraoperative fundus examination.

21.3Potential Sequelae of Scleral and Eye Wall Perforation

21.3.1 Retinal Detachment

Retinal detachment has been reported as a complication of both incisional strabismus surgery and from inadvertent intraocular injection of botulinum toxin to treat strabismus. Liu and coworkers [15] reported a patient who was noted to have a retinal tear and a bullous retinal detachment following botulinum injection in which inadvertent eye wall perforation occurred. The detachment spontaneously resolved and the patient was treated with prophylactic laser retinopexy. Awad and coworkers [4] reported a patient who underwent a medial rectus muscle recession who suffered a 4×3 mm defect in the sclera during disinsertion of the muscle. The defect was closed with a scleral patch graft and the medial rectus muscle was reattached posterior to the patch graft. The patient subsequently developed a vitreous hemorrhage and a retinal detachment, requiring a pars plana vitrectomy and gas–fluid exchange with endolaser. The final visual acuity at 68 months following surgery was 20/50, two lines worse than the preoperative visual acuity. The child had high myopia with a refractive error of

–­ 8.50 diopters and a thin sclera, which was thought to have predisposed the child to this complication. Wolf and coworkers [16] reported the development of anterior segment ischemia and retinal detachment due to an unsuspected perforation that occurred during vertical rectus muscle surgery. The patient’s vision at the time of the report was 20/400 due to a cataract.

The fact that scleral perforation can occur and can go unrecognized is highlighted by reports of retinal detachment following strabismus surgery in patients in whom a perforation of the global was not suspected intraoperatively [17]. Retinal cryopexy has often been recommended as a prophylactic measure in the event of an eye wall perforation [17]. However, retinal cryopexy, a procedure known to disrupt the blood–retinal barrier, has been shown to stimulate development of traction

Chapter 21

retinal detachment in eyes with an ocular wound in an experimental setting through development of epiretinal membranes [18]. A common intraocular finding in many cases of strabismus surgery that led to retinal detachment was the presence of later developing fibrous tissue emanating from the perforation site and extending into the vitreous [17, 19]. Retinal detachment may occur months to years after surgery [19].

Mittleman and Bakos [20] found that the incidence of retinal detachment was higher if the sclera over a perforation site had been treated with heavy retinal cryotherapy, in a study they performed on rabbit eyes. This complication was less likely to occur if only mild cryotherapy was administered [21]. These authors suggested that unless significant vitreous hemorrhage was present or the patient had a predisposing risk factor for retinal detachment, that prophylactic treatment to prevent a retinal detachment was probably not warranted. This has also been our experience and our general recommendation. The purpose of retinal cryotherapy or laser retinopexy is to stimulate adjacent retinal pigment epithelial cells so that a scar develops between the retina and retinal pigment epithelium, thus closing the retinal break and preventing access of liquid vitreous to the subretinal space, which can result in a progressive retinal detachment. It has been our belief that direct stimulation of the retinal pigment epithelium with a surgical needle during unintentional eye wall perforation provides enough stimulation of the retinal pigmented epithelium to initiate this process, and that administration of prophylactic measures may produce more harm than benefit in many cases.

Sprunger and coworkers [1] demonstrated using a rabbit retinal perforation model that cryotherapy often resulted in the release of pigmented cells into the vitreous, whereas laser retinopexy did not (>Fig. 21.12). They were concerned that these released pigment cells had the potential to stimulate contraction of the vitreous, leading to distortion of retinal anatomy. They suggested that observation alone or laser retinopexy were reasonable options if a retinal perforation occurred during surgery. We agree with this philosophy, and do not generally recommend prophylactic laser retinopexy if a small retinal break without associated retinal fluid is seen. On the other hand, if a large retinal break is seen, especially if associated with subretinal fluid, we will apply a double row of laser retinopexy to surround the break in an attempt to reduce the risk of progressive retinal detachment, though we recognize that there is no sound scientific evidence available to support this position. For patients with a high risk for retinal detachment, such as patients with high axial myopia and aphakia, we have a lower threshold for recommending prophylactic laser retinopexy. We do not recommend use of prophylactic cryotherapy in any setting.

21.4Vitreous and Anterior Chamber Hemorrhage

Vitreous hemorrhage can occur as a result of eye wall perforation during strabismus surgery. Vitreous hemorrhage is generally mild and localized [1, 4], though it can be more pro-

nounced [14] and late onset of severe hemorrhage thought to be related to previous strabismus surgery has been reported [19]. Arnold and coworkers [22] reported a patient who experienced a scleral-choroidal perforation who suffered vitreous hemorrhage during and after strabismus surgery. The perforation was felt to have been caused by altered surgical conditions related to the patient’s asymptomatic and unrecognized rigid cervical spine. The patient’s head did not make contact

Fig. 21.12a,b. Histopathology of retinal break in a rabbit eye induced by eye wall perforation. a Dispersion of pigmented cells is seen in the vitreous of cryo-treated eyes, but not in b laser-treated, or in untreated eyes (not shown). (Reprinted with permission from Sprunger DT, and coworkers. Management of experimental globe perforation during strabismus surgery. J Pediatr Ophthalmol and Strabismus 1996; 33:140–143. Copyright © 1996, Slack, Inc.)

with the operating table and was noted to shift up and down by several centimeters when the patient coughed during surgery. Vitrectomy and intraocular lens implantation was required to restore the patient’s vision and binocularity. Anterior chamber hyphema has been reported as a consequence of perforation of the eye wall when placing traction sutures near the limbus [4].

21.5 Endophthalmitis

Endophthalmitis [23] and even phthisis bulbi [24] can occur as a consequence of scleral perforation during strabismus surgery. Some authors have argued that scleral perforation must have occurred if endophthalmitis develops. The lack of recognition of scleral perforation in patients who have developed a retinal detachment after strabismus surgery has been cited as supportive of the fact that scleral perforation can go unrecognized [17, 19] and therefore was most likely present in patients who develop endophthalmitis despite lack of recognition of a perforation. Parks [25] believed that endophthalmitis could occur as a result of postoperative cellulites over the operative site and routinely recommended a 5-day course of oral antibiotics after strabismus surgery. We do not believe that scleral perforation is a prerequisite for endophthalmitis; instead believing that penetration of the sclera alone, especially deep penetration, may be sufficient to allow access of microbes into the eye. Endophthalmitis is discussed in detail in Chap. 22.

21.6 Anterior Chamber Perforation

The fact that a perforation of the eye can occur at any time during strabismus surgery has been stressed. Even seemingly simple surgical maneuvers, such as the passage of traction sutures, can result in penetration of the eye wall [2, 4]. We once had the unfortunate experience of passing a conjunctival closure suture through the cornea and into the anterior chamber during the simple process of suture closure of a limbal incision. No further complications developed and the patient did well, but the potential for a more serious problem was certainly recognized. Awad and coworkers [4] reported four patients who experienced collapse of the anterior chamber and hyphema following placement of traction sutures at the limbus. They abandoned surgery on these patients until the hyphema had cleared. The patients underwent uneventful strabismus surgery at a later date. None of the patients experienced a loss of best-corrected visual acuity, or developed cataract, glaucoma, or other anterior segment complications.

21.7 Prevention

Careful surgical planning and technique are both important in preventing scleral and eye wall perforation during strabismus surgery. Assuring adequate surgical exposure, taking

special precautions on patients with thin sclera, and selection of a spatulated needle that is appropriate for the specific surgical task required are the major methods available to reduce the risk of perforation. Perforations are less likely to occur as a surgeon gains experience. The surgeon should avoid the tendency to believe that scleral perforation only occurs during muscle reattachment to the globe, but instead should be vigilant throughout the procedure, because scleral perforation can occur at virtually any time during surgery. For patients who are at particularly high risk for scleral perforation, such as patients with high myopia, or for monocular patients undergoing strabismus surgery on their sound eye, techniques that allow strabismus surgery to be performed without the need to penetrate the sclera with a needle should be considered (>Figs. 21.6, 21.7). Methods to reattach muscles to the sclera with adhesives have been studied, but are not yet a viable tool for use in strabismus surgery.

21.8 Treatment

Most scleral perforations are small, even microscopic. Lacerations of the sclera and even unintentional block resections of the sclera can occur during strabismus surgery and the surgeon must be prepared to manage this complication or have ready access to a consultant surgeon. Awad and coworkers [4] reported placement of a scleral patch graft at the time of strabismus surgery to repair a large scleral defect with uveal prolapse that occurred during muscle detachment in a patient with high myopia. We believe that retinal cryopexy should be avoided. If a large retinal tear is noted, or if a small retinal tear is noted in a patient at high risk for retinal detachment, laser retinopexy may be a reasonable consideration. Laser can be applied in two rows to surround the retinal break and the patient should be following closely during the postoperative period for evidence of endophthalmitis and/or retinal detachment.

In addition to measures to identify and manage a retinal break, our general practice when a perforation is suspected is to withdraw the needle and suture and reposition it in an alternative location. We do this because of available evidence which demonstrates not only that needles and sutures used during strabismus surgery are commonly contaminated during surgery [26, 27], but also experimental evidence that contaminated needles are capable of transferring live bacteria into the eye during experimental eye wall perforation [28].

We empirically apply antibiotic drops and/or 5% povo- dine-iodine solution to the operative site if a perforation has occurred or is strongly suspected. We will consider administration of subconjunctival antibiotics and often administer a dose of intravenous antibiotics and/or prescribe prophylactic oral antibiotics postoperatively. Though recognizing that this protocol has not been scientifically validated or shown to be necessary, we wish to make every effort possible to reduce the risk of endophthalmitis, though we have no quarrel with the surgeon who chooses an alternate approach.

Probably the most important step to take after a scleral perforation has been identified is to inform and educate the pa-

Chapter 21

tient and/or family so that they are aware of the potential for a serious complication and understand the signs and symptoms of endophthalmitis and retinal detachment in the rare event that one of these complications occurs. We follow patients with known scleral perforations more frequently then routine postoperative patients, usually seeing them on postoperative days 1, 3, and 7, and as guided by examination findings and our level of concern. It is our practice to dilate the pupil and examine the retina at each of these early postoperative visits.

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