EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
Elshafei et al
ULTRASOUND BIOMICROSCOPIC EVALUATION OF THE
SCLEROTOMY SITES AFTER VITRECTOMY.
By
Ahmed M K Elshafei MD FRCS, Hossam Moharram MD,
Khalid Mourad MD and Ezz Eldin Galal MD.
Department of Ophthalmology, Minia Faculty of Medicine
ABSTRACT:
Purpose: To use the ultrasound biomicroscopy (UBM) to evaluate the the sclerotomy
sites and their related structures in vitrectomatized eyes.
Methods: UBM was used for examining the sclerotomy sites in 20 vitrectomized eyes
to treat advanced proliferative diabetic retinopaty (PDR), endophthalmitis and
rhegmatogenous retinal detachment. All patients were subjected to 20 gauge three
ports pars plana vitrectomy. Vitreous was completely shaved from the internal
sclerotomies and sclerotomies were closed by 6/0 vicryl stitches. The patients were
examined six weeks to six months after vitrectomy using ultrasound biomicroscopy
(UBM).
Results: On UBM examination the following findings were noted:
1. Shadowing caused by the stitches material was noted in 12 eyes.
2. Thinning of the sclera at the sclerotomy sites was noted in 2 eyes.
3. Proliferations related to the inner aspect of the sclerotomy sites in 10 eyes.
4. Emulsified silicon bubbles were imaged in the anterior chamber of six eyes.
Conclusion: Ultrasound biomicroscopy is useful in detecting changes that may occur
at sclerotomy sites in vitrectomized eyes. UBM findings correlate well with the
clinical situations and may aid in reoperative planning when needed.
KEY WARDS:
Vitrectomy
Sclerotomy
UBM
close the sclerotomy site at the end of
the case. Another option for
sclerotomy site closure is to use a 9-0
or 10-0 synthetic monofilament suture,
such as nylon or Prolene. Monofilament nylon sutures are elastic, and
close wounds that have opened as a
result of undue pressure on the globe 2.
INTRODUCTION:
The sclerotomy created by a
20-gauge MVR blade is approximately
1.4 mm long. A sclerotomy of this size
must be sutured at the completion of
the surgery. This incision can be closed
with a variety of techniques. A survey
of 380 surgeons by the American
Society of Retina Specialists in 2003
showed that 72% of surgeons close
with a single figure-of-eight stitch,
14% use a figure-of-eight with one or
more additional passes and 11% use a
single interrupted pass1. 7-0 Vicryl
suture can be placed in a figure-ofeight fashion to secure the infusion
cannula. If temporarily tied, this same
suture can be loosened and used to
Recently,
the
25-gauge
vitrectomy system was developed by
Fujii, de Juan and colleagues3,
followed by the similar innovation of
the 23-gauge system developed by
Eckardt4. The specific features of Fujii
et al.,’s system include instruments
with the 25-gauge, transconjunctival
trocar system and sutureless wounds.
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
The new instruments used in the new
25-gauge vitrectomy system are much
smaller than the regular 20-gauge
instruments. The advantage of smallgauge vitrectomy is the small wound
size, which is expected to be less
invasive.
Elshafei et al
All patients were subjected to
complete history taking, anterior
segment examination using slit-lamp
biomicroscopy, measurement of the
intraocular pressure, indirect ophthalmoscopy and dynamic in vivo
examination using ultrasound biomicroscopy (UBM) using ParadigmTm
UBM Unit. UBM examination technique included:
1- Axial scanning through the centre
of the cornea, anterior chamber and
pupil
2-Radial scanning in the meridia of
the sclerotomies (upper termporal,
upper nasal and lower temporal
quadrants) to image sclera, pars plana,
and the area related to the inner aspect
of the pars plana,
3- Transverse scanning concentric
with the limbus in the areas of the
sclerotomies to image the pars plana
and more posteriorly to image the
peripheral retina together with their
related anterior vitreous cavity
Late postoperative hemorrhages
may occur because of fibrovascular
ingrowth from the sclerotomy incisions
or anterior hyaloidal fibrovascular
proliferation.
Hemorrhage
from
fibrovascular ingrowth begins several
months after vitrectomy, although it
can be variable and may occur several
years later5. A useful finding in making
the diagnosis of fibrovascular ingrowth
is
the
presence
of
dilated
subconjunctival blood vessels entering
the sclerotomy sites. Ultrasound
biomicroscopy is useful in detecting
fibrovascular
proliferation
at
6
sclerotomy sites .
PATIENTS AND METHODS:
Ultrasound biomicroscopy was
used for examining the sclerotomy
sites in 20 vitrectomized eyes of 18
patients in
the Ophthalmology
Department in Minya University
Hospital between April and July 2008.
Eight patients were subjected to
vitrectomy to treat advanced proliferative diabetic retinopaty (PDR), four
patients for endophthalmitis and six
patients for rhegmatogenous retinal
detachment.
The UBM images were stored,
printed and carefully studied in
correlation with the clinical data.
RESULTS:
The patients were eighteen in
number, eleven males and seven
females with age ranging from 42 to 66
years. Eight patients had proliferative
diabetic retinopathy. Four patients had
endophthalmitis and six patients had
rhegmatogenous retinal detachment.
Two patients with proliferative diabetic
retinopaty had vitrectomy in both eyes.
Eleven patients had silicon oil injection
and three patients had prior scleral
buckling.
All patients were subjected to
20 gauge three ports pars plana
vitrectomy. Ten patients had silicon oil
injection and eight patients had
endolaser panretinal photocoagulation.
Vitreous was completely shaved from
the internal sclerotomies by cotton-tip
depressed vitrectomy. Sclerotomies
were closed by 6/0 vicryl stitches.
The patients were examined six weeks
to six months after vitrectomy.
On UBM examination the following
findings were noted:
1- Shadowing caused by the
stitches material was noted in
12 eyes [fig.2,3,4], seven eyes
of diabetic vitrectomy and three
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
2-
3-
a)
b)
eyes of endophthalmitis and
two eyes of reghmatogenous
retinal detachment . The
shadowing was noted to be
more evident in the more recent
cases and absent in old cases
Thinning of the sclera at the
sclerotomy sites was noted in 2
eyes [fig.3,7,9], one eye of
diabetic vitrectomy and one eye
of
vitrectomy
after
endophthalmitis.
Proliferations related to the
inner aspect of the sclerotomy
sites in 10 eyes. Proliferation
were detected in six eyes of
diabetic vitrectomy, three eyes
with
vitrectomy
after
endophthalmitis and only one
eye with vitrectomy after
reghmatogenous
retinal
detachment. These proliferation
were categorized into groups:
Thin membranous proliferation
attached to the inner aspect of
the sclerotomy sites in 2 eyes
[fig.4], one eye of diabetic
vitrectomy, and one eye with
vitrectomy after reghmatogenous retinal detachment.
Irregular
heterogeneous
proliferation attached to the
Elshafei et al
inner aspect of the sclerotomy
sites in 5 eyes [fig.5], all of
them had diabetic vitrectomy.
c) Irregular
heterogeneous
proliferation not attached but
related to the inner aspect of the
sclerotomy sites in 3 eyes
[fig.6].
This
type
of
proliferation was imaged in
cases of vitrectomy after
endophthalmitis.
The proliferations were imaged at
more than one sclerotomy site in
seven eyes and at only one
sclerotomy site in three eyes. As a
general, proliferations were noted
to be more common and denser in
relation to the upper temporal
followed by the upper nasal and
finally
the
lower
temporal
sclerotomies.
4- Emulsified silicon bubbles
were imaged in the anterior
chamber of six eyes [fig.8]. In
four of them emulsified silicon
bubbles were imaged in relation
to the inner aspect of the
sclerotomy sites [fig.9], three
eyes of diabetic vitrectomy and
one eye with vitrectomy after
endophthalmitis.
16
14
12
10
8
6
4
2
0
Sh
ad
ow
in
g
Pro
life
rat
ion
s
findings
DR
endopthalmitis
RD
T
Em
ul s hinni
n
i fie
ds g
i lic
on
Figure 1: Echographic findings detected on UBM examination of the sclerotomy sites
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
Elshafei et al
Fig (2)
Fig (3)
Fig (4)
Fig (5)
Fig (6)
Fig (7)
Fig (8)
Fig (9)
Figure 8: demonstrates the echographic findings detected on UBM
examination of the sclerotomy sites
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
Elshafei et al
DISCUSSION:
Ultrasound
biomicroscopy
(UBM) is a painless and non-invasive
diagnostic technique that offers high
resolution imaging. It is a useful
diagnostic tool not only in pathologies
of the anterior segment but also of the
posterior part of the ciliary body and of
the
peripheral
retina7.
Clinical
examination can not detect changes
that may occur in relation to the inner
aspect of the sclerotomy sites. This
area can be clearly imaged using
UBM.
diabetic eyes with recurrent vitreous
hemorrhage. They classified the
proliferations
detected
in
the
Ultrasound biomicroscopy images at
each sclerotomy site into 3 categories:
none (grade 0), minor (grade 1), and
major (grade 2). Grade 1 or 2
fibrovascular ingrowth (FVIG) was
detected in 85% of cases, and grade 2
FVIG was identified in >/=1
sclerotomy site in 58% of cases. Grade
1 or 2 FVIG was detected in 56% of
microvitrector sites, 41% of infusion
sites, and 61% of light port sites8.
In this study the most common
finding was shadowing caused by the
stitch material. Although this could be
of little clinical importance and it may
hinder imaging of the underlying
structures, it confirms that imaging is
exactly at the sclerotomy site.
Shadowing could not be detected in
cases subjected to vitrectomy long time
before UBM examination probably due
to absorption of the stitch material.
Kazuki et al., examining the
sclerotomy sites in 13 eyes of 11
patients with PDR experiencing
postoperative vitreous hemorrhage by
UBM. They classified the UBM
images proliferations into four
categories: A, tent; B, spheroid; C,
trapezoid; and N, none. The findings
were distributed as follows in the PDR
group: category A, 18%; B, 5%; C,
56%; and N, 21%; and as follows in
the control group: category A, 28%; B,
5%; C, 5%; and N, 62%6.
The second most common
finding was the presence of
proliferations attached to or related to
the inner side of sclerotomies. This
was specially noted in eyes with
diabetic vitrectomy. This was noted in
six eyes with diabetic vitrectomy (60%
of diabetic vitrectomy eyes and 30% of
all vitrectomized eyes). The presence
of irregular heterogeneous proliferation
not attached but related to the inner
aspect of the sclerotomy sites in 50%
of vitrectomized eyes due to
endophthalmities may reflect the
inflammatory nature of the condition
or caused by incomplete removal of the
peripheral cortical vitreous due to
performing core vitrectomy rather than
complete vitrectomy in this condition.
The presence of emulsified
silicon bubbles in relation to the inner
aspect of the sclerotomy sites in four
eyes out of six eyes with emulsified
silicon bubbles imaged in the anterior
chamber may indicate predilection of
the presence of emulsified silicon
bubbles in the anterior chamber rather
than adjacent to the inner aspect of the
sclerotomy sites in the supine position
during UBM examination.
The presence of scleral thinning at the
sclerotomy sites was detected only by
UBM imaging and had no detected
clinical importance.
CONCLUSION:
Ultrasound biomicroscopy is
useful in detecting changes that may
occur at sclerotomy sites in
vitrectomized eyes. UBM findings
Hershberger et al., used UBM
to study the fibrovascular ingrowth at
sclerotomy sites in vitrectomized
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
correlate well with the clinical
situations and may aid in reoperative
planning when needed.
Elshafei et al
sclerotomy. Arch Ophthalmol 95:235,
1977.
6- Kazuki H, Hirakata, Yoshiko
O et al,: Ultrasound biomicroscopy for
examination of the sclerotomy site in
eyes with proliferative diabetic retinopathy after vitrectomy. Retina. 20(1):
52, January 2000.
7- Mannino G, Malagola R,
Abdolrahimzadeh S, et al., Ultrasound
biomicroscopy of the peripheral retina
and the ciliary body in degenerative
retinoschisis associated with pars plana
cysts. Br J Ophthalmol; 85:976-982,
2001.
8- Hershberger VS, Augsburger
JJ, Hutchins RK, Raymond LA, Krug
S: Fibrovascular ingrowth at sclerotomy sites in vitrectomized diabetic
eyes with recurrent vitreous hemorrhage: ultrasound biomicroscopy findings. Ophthalmology. Jun; 111(6):
1215-21,2004.
REFERENCES:
1- Pollack JS and Packo KH,
Preferences and Trends (PAT) Annual
Survey, American Society of Retina
Specialists, 2003.
2- Charles S: Principles and
techniques of vitreous surgery. In:
Ryan S, Wilkinson C P (eds) Retina.
Mosby, St. Louis, pp 2121–2141,2001.
3- Fujii GY, de Juan E, Humayun
MS, et al., A new 25-gauge instrument
system for transconjunctival sutureless
vitrectomy surgery. Ophthalmology
109:1807–1813,2002.
4- Eckardt C. Transconjunctival
sutureless23-gauge vitrectomy. Retina
25:208–211, 2005.
5- Tardif YM, Schepens CL:
Closed vitreous surgery. XV. Fibrovascular ingrowth from the pars plana
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‫‪Elshafei et al‬‬
‫‪EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008‬‬
‫تقييم أماكن شق الصلبة بعد استئصال الجسم الزجاجى باستخدام التصوير‬
‫المجهرى الحيوى بالموجات فوق الصوتية‬
‫أحمد محمد كمال الشافعي ‪ ,‬حسام محرم‪ ,‬خالد مراد ‪ ,‬و عز الدين جالل محمد‪.‬‬
‫قسم الرمد – كلية طب المنيا‬
‫الغرض من البحث‬
‫استخدام التصوير المجهرى الحيوى بالموجات فوق الصوتية فى تقييم أماكن شق الصلبة فى‬
‫العيون التى خضعت لجراحة استئصال الجسم الزجاجى‪.‬‬
‫الوسائل‬
‫تم استخدام التصوير المجهرى الحيوى بالموجات فوق الصوتية فى فحص عشرين عينا لثمانية‬
‫عشر مريضا خضعوا لجراحة استئصال الجسم الزجاجى‪ .‬و قد خضع ثمانية مرضى للجراحة‬
‫لعالج التهاب شبكى سكرى مترعرع‪ ،‬و أربعة مرضى لعالج التهاب صديدى داخل العين‪ ،‬و‬
‫ستة مرضى لعالج انفصال شبكى قطعى‪.‬‬
‫و قد خضع جميع المرضى الستئصال الجسم الزجاجى من خالل الجزء المسطح باستخدام ثالثة‬
‫مداخل‪ .‬و قد تم حقن زيت السيليكون فى عشر مرضى‪ ،‬و اجراء التخثر الضوئى الكلى للشبكية‬
‫باستخدام الليزر الداخلى فى ثمانية مرضى‪ .‬و قد تمت ازالة الجسم الزجاجى كلية من السطح‬
‫الداخلى لشق الصلبة‪ ،‬كما تم اغالق شق الصلبة باستخدام خيط فكريل ‪. 0\6‬‬
‫تم فحص المرضى بعد ستة أسابيع الى ستة أشهر من تاريخ اجراء الجراحة‪.‬‬
‫و قد خضع جميع المرضى ألخذ التاريخ المرضى بالكامل‪ ،‬و فحص الجزء األمامى من العين‬
‫باستخدام المصباح الشقى‪ ،‬و قياس ضغط العين الداخلى‪ ،‬و الفحص غير المباشر لقاع العين‪ ،‬و‬
‫التصوير المجهرى الحيوى بالموجات فوق الصوتية‪.‬‬
‫النتائج‬
‫تمت مالحظة المشاهدات االتية باستخدام التصوير المجهرى الحيوى بالموجات فوق الصوتية ‪:‬‬
‫‪ ‬وجود ظالل بالجسم الزجاجى بسبب المادة المكونة للغرز فى اثنى عشر عينا‪.‬‬
‫‪ ‬ترقق الصلبة فى أماكن شق الصلبة فى عينين‪.‬‬
‫‪ ‬وجود تكاثر وعائى ليفى على السطح الداخلى لشق الصلبة فى عشرة أعين‪.‬‬
‫‪ ‬وجود فقاعات مستحلبة من زيت السيليكون فى الخزانة األمامية لستة أعين‪.‬‬
‫االستنتاج‬
‫يعتبر التصوير المجهرى الحيوى بالموجات فوق الصوتية مفيدا فى تشخيص التغيرات‬
‫التى تحدث فى أماكن شق الصلبة بعد جراحة استئصال الجسم الزجاجى‪.‬‬
‫وترتبط نتائج التصوير المجهرى الحيوى بالموجات فوق الصوتية جيدا ً بالفحص‬
‫االكلينيكى‪ ,‬وقد تساعد في إعادة التخطيط لعملية عند الحاجة اليها‪.‬‬
‫‪69‬‬