Management

All vitreous must be thoroughly excised. If the prolapse is through a corneal wound, the surgeon is advised to also remove the vitreous from the AC (see Chap. 2.5).

O Cave

Although it is technically possible to thoroughly remove the prolapsed vitrectomy at the wound using Wechsler sponges9 and scissors, this is not without risk. The vitreous first needs to adhere to the sponge and then be lifted from the eye before it is cut. The traction exerted on the extruded vitreous is unavoidably transmitted to the peripheral retina and may cause a break.

8 A healthy vitreous requires more force to extrude than one that has lost most of its gel properties.

9 The surgeon should avoid touching the corneal endothelium with the sponge.

Fig. 2.4.1 Rupture of a cataract wound with iris prolapse and vitreous "streaks". The iris has prolapsed into the limbal wound and tamponaded it. The running suture has been severed. It is not possible to determine whether there is extraocular vitreous prolapse, but the vitreous has prolapsed into the AC and has a few dots of blood on its anterior surface. The vitreous configuration is such that it points the examiner toward the wound (Courtesy of V. Mester, Abu Dhabi, U.A.E.)

Fig. 2.4.1 Rupture of a cataract wound with iris prolapse and vitreous "streaks". The iris has prolapsed into the limbal wound and tamponaded it. The running suture has been severed. It is not possible to determine whether there is extraocular vitreous prolapse, but the vitreous has prolapsed into the AC and has a few dots of blood on its anterior surface. The vitreous configuration is such that it points the examiner toward the wound (Courtesy of V. Mester, Abu Dhabi, U.A.E.)

The vitrectomy probe is the preferred instrument for removing vitreous from the wound, irrespective of whether the wound is corneal^ or scleral. It is possible that the higher incidence in the USEIR of retinal detachment associated with scleral compared with corneal wounds (23 vs 11%, respectively; see Tables 2.2.1, 2.3.1) is due not only to the injury itself but also to inappropriate management of vitreous prolapse. This assumption is supported by the finding that the retinal detachment rate is 78% if the scleral wound is at the ora serrata but only 16% the wound is posterior [4] as well as by the clinical experience that the breaks causing the retinal detachment are typically found either at the wound or a 180° away. Failure to fully excise the prolapsed vitreous greatly increases the risk of retinal detachment [2].

10 Unlike the sponge-scissors combination, the vitrectomy probe also allows removing the vitreous from the internal aspect of the wound (see Chap. 2.5).

If vitreous is found to have extruded through a wound posterior to the ora serrata, the retina must also have been injured,11 and this must be taken into consideration when the management plan is designed. If the scleral wound is very posterior, it may be impossible to remove the vitreous prolapse completely, and management of the condition must be addressed ab interno (see Chap. 2.14).

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