Management

As a general rule, the retina should not be excised but reposited. Even if it appears that the eye's condition is hopeless, successful retinal reposition may be accompanied by functional improvement.

• A small prolapse^ is dealt with by first removing any vitreous from the retinal surface, then gently introducing the suture into one of the edges of the scleral wound, having the assistant hold/push the retina back with a spatula, putting the needle through the opposing edge of the wound, and tying the suture while the spatula is still underneath the suture, preventing a retinal reprolapse.

• If the prolapse is large, its underlying cause must be addressed first: the IOP is high, presumably due to a hemorrhage, which is pushing the retina forward. Patience is needed - waiting for tens of minutes if necessary. The intraocular bleeding must stop first/3 and the IOP may have to be lowered.M Once the IOP is low, the material behind the

11 This statement is another example reflecting a proactive, rather than reactive, treatment philosophy (see Chap 1.8).

12 Small implies small area and small elevation.

13 The anesthesiologist should be asked to lower the patient's systemic blood pressure as much as possible.

14 This contradicts what is said about ECH in Chap. 2.8; however, a retinal prolapse requires special treatment. Usually, it is retinal prolapse that needs to be prevented if an intraocular hemorrhage occurs; once a retinal prolapse has occurred, the situation changes dramatically, and a different logic takes over.

Fig. 2.4.2 Retinal prolapse in a ruptured eye. The retinal extrusion is caused by an ECH. Fresh blood is visible on the right side of the image. Although the prognosis is poor, the eye is not necessarily unsalvageable; primary enucleation is not justified (see the text for management details)

retina (may be vitreous or blood) can be slowly removed, through a retinotomy if necessary. The wound is then gradually closed, using the technique described above.

• If the retina cannot be completely pushed back, it should be cauterized in as small an area as possible, sacrificed, and the scleral wound closed, saving most of the retina.

o Pearl

Incarcerating a prolapsed retina in the scleral wound is the lesser of "two evils." Retinal incarceration can be addressed in subsequent surgeries; only enucleation takes away the anatomical and functional hopes (see Chap. 1.8).

• The retina may be incarcerated despite the best efforts by surgeon and assistant [3]. The incarceration may be caused by the retina (a) being caught by the needle/suture, (b) prolapsing into the wound while the wound is being closed, and (c) subsequently being captured by the developing scar.

Regardless of the mechanism of incarceration, the choroid and retina must soon be liberated (i.e., excised) in this area (see Chap. 2.14).

try to salvage as much of the uvea and retina as possible try to remove as much of the prolapsed vitreous as possible

enucleate an eye just because there is retinal prolapse; in most cases, the retina can be reposited and the retinal incarceration dealt with later

Summary

Tissue prolapse is a common consequence of open globe injury. Knowledge of a few simple rules of how to deal with the prolapsed tissue greatly increases the eye's chances of anatomical and thus functional recovery.

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