Abstract
Purpose
To retrospectively report a case of complex retinal detachment secondary to an intraocular episcleral hydrogel explant (MIRAgel, MIRA Inc., Waltham, MA, USA) invasion.
Observations
The severe vitreous inflammation, shifting nature of the subretinal fluid, and absence of proliferative vitreopathy 2 months following multiple surgeries for removal of fragmented MIRA gel in the present case made the diagnosis of complex retinal detachment. With the assistance of the fragmatome and Perfluorocarbon, the subretinal MIRA gel, and turbid, yellowish subretinal fluid were removed successfully. The retina was re-attached without recurrence.
Conclusions and importance
By using the pars plana ultrasonic fragmatome, the intraocular MIRAgel was able to be removed while maintaining the integrity of the retina and globe.
Introduction
The episcleral hydrogel explant (MIRAgel, MIRA Inc., USA) was introduced in 1985 as an alternative to silicone explants for the treatment of rhegmatogenous retinal detachment (RRD). , It is no longer being chosen because of the associated late complications, which include but are not limited to extrusion, intrusion, eye motility disorder, cosmetic deformities, and periocular infections. ,
Here, we report a case of complex retinal detachment induced by the intraocular invasion of MIRAgel. The clinical course and the surgical procedures for implant removal are also presented.
Case report
This is a retrospective case report study. The study adheres to the tenets of the declaration of Helsinki. Ethical approval was obtained from the IRB of Changhua Christian Hospital.
A 45-year-old man presented to our clinic complaining of blurry vision and pain in the left eye. Reviewing the history, he had undergone MIRAgel scleral buckle implantation at 120° on the temporal side for RRD in the left eye approximately 26 years ago, and the retina had been successfully reattached. Ocular discomfort and chronic conjunctival congestion were noted 10 years later; he had experienced incomplete MIRAgel removal by the previous surgeon. Unfortunately, the ocular discomfort and chronic conjunctival congestion still bothered him, and the symptoms had recently worsened.
At his initial presentation, his best-corrected decimal visual acuity was 0.5 (OS). A congested, bulging conjunctiva with gel-like degraded MIRAgel extrusion on the temporal side was noted in the left eye. MIRAgel removal was performed. After dissecting the conjunctiva, the degraded, fragmented MIRAgel was removed with blunt-tipped forceps and scoop. A scleral perforation was noticed intraoperatively on the temporal lower aspect during mechanical extraction. MIRAgel was partially removed, and the wound was closed.
One day postoperatively, his vision decreased to light perception, while the intraocular pressure remained around 20–30 mmHg. The fundus was invisible with severe vitreous inflammation. B-scan showed choroidal detachment at the inferior aspect ( Fig. 1 -A). Since endophthalmitis could not be ruled out, intravitreal antibiotics were injected. Six days later, his vision was hand motion. Vitreous opacity, retinal detachment at the upper and nasal aspects, and choroidal detachment inferiorly were noticed via B-scan sonography ( Fig. 1 -B). As endophthalmitis and recurrent RRD were suspected, pars plana vitrectomy (PPV) was arranged. During the operation, the detached retina was noted to extend from the nasal upper to the inferior aspect, while the retina around the perforated site remained attached. No break was found after 360° of scleral indentation. Ceftazidime and teicoplanin were injected intravitreally. Under the suspicion of exudative retinal detachment, retinotomy and subretinal fluid drainage were not performed. Due to the fear of undetected break, the vitreous cavity was filled with silicone oil after the removal of vitreous fluid with gas-fluid exchange. He was admitted to our ward for intensive wound care and intravitreal and subconjunctival antibiotic treatment for one week, followed by frequent clinical appointments.
Two months later, the surgical wound became more stable, but the inferior peripheral retina remained detached ( Fig. 2 -A). In addition, an intruding, triangular whitish material located at the temporal upper aspect was noted ( Fig. 2 -A). Moreover, shifting of the subretinal fluid was noticed via B-scan sonography while the patient changed his position ( Fig. 3 ). PPV was arranged due to persistent retinal detachment. Subretinal MIRAgel at the temporal upper aspect was dislodged through retinotomy. MIRAgel was then removed with a fragmatome (video). When peeling the peripherally organized vitreous, an iatrogenic retinal break was made at the site of previous cryotherapy. Perfluorocarbon was injected into the vitreous cavity to drain the turbid, yellowish subretinal fluid, followed by air-fluid exchange and silicone oil tamponade. No re-detachment was noted during the follow-up period ( Fig. 2 -B).
