ABSTRACT
A 56-year old female patient presented to our clinic with a complaint of low vision in her right eye. Twenty-two years earlier she had undergone a scleral buckling operation in her right eye because of retinal detachment. She indicated that vision in her right eye was good after the surgery but had recently been gradually declining. Best-corrected vision acuity was counting fingers at 1 meter in the right eye and 8/10 in the left eye. Anterior segment examination revealed stage 3 nuclear cataract in the right eye. Examination of the right eye was blurred and revealed an area of chorioretinal atrophy posterior to the equator, approximately 3 disc diameters in the peripapillary zone and about 2 disc diameters in the nasal papilla zone. Anteriorly of the equator there was an area of chorioretinal atrophy as well as a narrow, sharply demarcated, shiny 360⁰ suture with high buckling pressure, situated intraretinally but extending into the vitreous in some places. The structure was thought to be made of polyethylene. Around the suture there were retinal atrophic changes. After detailed explanation of the possible surgical complications and after obtaining informed consent, the right eye cataract was removed by phacoemulsification and a foldable intraocular lens was placed into the capsule. During the operation, we worked under low fluid pressure and as atraumatically as possible due to the possibility of intraocular pressure changes and the risk of the suture causing retinal and blood vessel tears or passing completely into the eye and causing intravitreal hemorrhage. A month after an uncomplicated surgery, the posterior segment examination demonstrated a reattached retina and the patient’s best corrected visual acuity was 6/10.
Introduction
Scleral buckling was commonly used in the past and is still utilized today in the treatment of retinal detachment. Although in recent years silicone-based structures have been used as encircling bands, Arruga sutures were also applied in the past.
In this report, we aimed to present a patient whose retinal detachment was treated with an encircling Arruga suture which years later caused intraocular invasion and cataract, necessitating cataract surgery.
Discussion
All of the various techniques utilized in the management of retinal detachment aim to create an adhesion to prevent fluid exchange between the retinal pigment epithelium (RPE) and sensorial retina in the area surrounding the retinal tear, to thus enable RPE active transport and reabsorption of the subretinal fluid, to reduce the effects of vitreoretinal traction, and to prevent new tear formation.1,2,3,4
Schepens et al.5introduced the scleral buckling procedure for the treatment of retinal detachment. In the procedure, binocular indirect ophthalmoscopy and scleral buckle are used to localize retinal tears. Following lamellar scleral dissection, diathermy is applied to the area of the inner lamella corresponding to the retinal tear. A nonabsorbable, 1.25 mm-wide polyethylene tube is then fixed to the dissected area with a polyethylene/silk suture. After the subretinal fluid drains, the tube is tightened to provide sufficient pressure and the flap is closed over the tube. This lengthy procedure is usually performed under general anesthesia.
The Arruga technique is a dated surgical technique which has become obsolete in the treatment of retinal detachment. This technique, performed under local anesthesia, was used to simplify the scleral buckling method and reduce operation time. After localizing the tear, full-thickness scleral diathermy is applied to the area. In order to make an indentation, a 3-0 nylon, Supramid or Mersilen suture is placed posterior to the equator, stabilized in the four quadrants, and later tightened to provide adequate pressure after the subretinal fluid has drained.
The phenomenon observed in these patients of postoperative intraocular intrusion of the suture has been termed the ‘clothesline phenomenon’.6Intraocular invasion of the suture has been associated with various complications including recurrent retinal and vitreous hemorrhage, uveitis or recurrent retinal detachment.6,7,8,9
In our patient, it was clear that an Arruga suture which was placed 22 years earlier gradually invaded the sclera and choroid, eventually reaching the inner retinal layers and intravitreal space. However, despite the prolonged time since the surgery, our patient had not experienced any problems.
Conclusion
Although the Arruga suture is no longer used in contemporary practice, we may still encounter complications related to this technique in patients who underwent the procedure in the past. With this report we wished to highlight the need to be prepared when faced with complications due to Arruga sutures in patients undergoing ocular procedures for other reasons.
