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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 57  |  Issue : 3  |  Page : 237-239

Intraoperative ciliary body inflammation as a masquerade for postoperative wound leak following manual small-incision cataract surgery


Cataract and IOL Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Puducherry, India

Date of Submission13-Feb-2019
Date of Decision17-May-2019
Date of Acceptance09-Jun-2019
Date of Web Publication11-Nov-2019

Correspondence Address:
Dr. Bharat Gurnani
Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Puducherry - 605 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_18_19

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  Abstract 


This case highlights the postoperative management of a patient with hypotony who masqueraded as wound leak following manual small-incision cataract surgery (MSICS). A 66-year-old male patient underwent uneventful MSICS in the left eye. He developed postoperative hypotony following surgery. B-scan revealed a small peripheral shallow serous choroidal detachment. There was a mild conjunctival retraction which masqueraded as postoperative wound leak. Postoperative hypotony resolved after conservative management.

Keywords: Hypotony, masquerade, wound leak


How to cite this article:
Gurnani B, Kaur K, Nath M, Gireesh P. Intraoperative ciliary body inflammation as a masquerade for postoperative wound leak following manual small-incision cataract surgery. TNOA J Ophthalmic Sci Res 2019;57:237-9

How to cite this URL:
Gurnani B, Kaur K, Nath M, Gireesh P. Intraoperative ciliary body inflammation as a masquerade for postoperative wound leak following manual small-incision cataract surgery. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Dec 12];57:237-9. Available from: http://www.tnoajosr.com/text.asp?2019/57/3/237/270687




  Introduction Top


Wound construction is critical in modern-day cataract surgery because this initial step of the surgery serves as the foundation on which the rest of the surgical steps are built. A poorly constructed wound will make subsequent steps more difficult and increase the risk of complications.[1] A properly constructed wound not only facilitates the surgery but also more importantly ensures a self-sealing, watertight wound. Intraoperative manipulation during surgery can invite ciliary body inflammation which can present as postoperative hypotony.[2] Unfortunately, this can masquerade as wound leak postoperatively. Here, we report a case of a patient who underwent surgery in our hospital and presented similarly on postoperative day (POD) 1.


  Case Report Top


A 66-year-old male patient presented to our hospital with defective vision in the left eye (OS) for the past 2 years. There was a history of right eye (OD) cataract surgery done 3 years back. Past history and systemic history were not significant. Anterior segment (AS) examination for OD was within the normal limits with pseudophakia and OS examination was also normal except mature cataract, and no phacodonesis was noted. Fundus examination in OD revealed clear media with normal disc, vessels and macula and in OS media was hazy and no other details were clearly seen. Visual acuity was a perception of light with an accurate perception of rays in OS and 6/18 in OD. Intraocular pressure (IOP) by noncontact tonometry was 11 mmHg in OD and 9 mmHg in OS. The patient was advised manual small-incision cataract surgery (MSICS) in OS which was completed uneventfully on subsequent day.

Biometry was recorded by IOLMaster (Carl Zeiss Meditec, Jena, Germany):

  • Axial length – 22.48 mm
  • K1 – 47.0 at 180°
  • K2 – 46.0 at 90°
  • IOL power of + 20.0D.


There was iris prolapse and the pupil was miosed as a result of excessive manipulation during nucleus proplapse. Eventually the surgery was completely within 8 minutes. Uncorrected visual acuity in OS was 6/12 which was improving to 6/6 with pinhole and IOP was 2 mmHg in OS POD 1. Slit-lamp examination on POD 1 revealed mild conjunctival retraction [Figure 1] over the section; the cornea showed few Descemet membrane folds involving the visual axis, and the anterior chamber depth was Van Herick Grade 4 and 4+. Anterior chamber cells were present with fibrinous membrane (FM) [Figure 2]; intraocular lens was centered stable, and posterior capsule was intact. SeIdel's test was negative. On fundus examination, the disc was normal and the rest of the details were hazy. The patient was advised an urgent B-scan ultrasonography; cataract and retina clinic opinions were advised for postoperative hypotony following surgery. Fundus evaluation with indirect ophthalmoscope in retina clinic was grossly within the normal limits. Ultrasound B-scan showed a small peripheral shallow serous choroidal detachment (CD) [Figure 3] which confirmed postoperative hypotony. Ultrasound biomicroscopy (UBM) of OS was not done because of nonavailability at our center. AS examination in cataract clinic confirmed the above findings. The eyeball was soft with Seidel test negative as confirmed again by a senior ophthalmologist. Suspecting postoperative ciliary body inflammation, patient was advised injection dexamethasone 1cc intravenous stat, tab ciprofloxacin 750 mg bd (as a prophylaxis), tab diclofenac + seratiopeptidase bd, tab rantidine bd, e/d gatifloxacin + dexamethasone 6 hourly, e/d homatropine bd and tight pad and bandage to the OS. On examination POD 2, AS examination revealed clear cornea with evidence of retracting FM, and IOP increased to 9 mmHg. POD 3, IOP raised to 11 mmHg and AC reaction completely resolved, and the patient was discharged after retina evaluation. The patient was advised for review visit after 1 week.
Figure 1: Postoperative slit-lamp image of the left eye showing mild conjunctival retraction, but the section is not exposed

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Figure 2: Slit-lamp image of the left eye showing fibrinous membrane over the pupillary area and intraocular lens

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Figure 3: B-scan of the left eye showing small peripheral serous choroidal detachment

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  Discussion Top


The basis of MSICS is the proper wound construction for entry to the anterior chamber. The parameters important for the structural integrity of the tunnel are the self-sealing valved effect of the tunnel with return of normal IOP postoperatively, the location of the wound on the sclera with respect to the limbus, and the shape of the wound.[3] Suturing becomes necessary in a leaking tunnel, premature entry, in cases of combined surgery (trabeculectomy with SICS), in a scleral tunnel of >6.5 mm to avoid irregular astigmatism, and in cases of pediatric cataract.[4] Postoperative hypotony can lead to serous CD which can be picked up on B-scan. Our case had postoperative hypotony following cataract surgery which was suspected as wound leak. Surprisingly, the patient's Seidel test was negative and had shallow peripheral CD. He was managed conservatively, and no surgical intervention was done again. POD 3, the patient's IOP improved and CD resolved confirming our suspicion of ciliary body inflammation. To the best of our knowledge, this is the first case report of postoperative hypotony masquerading as wound leak.


  Conclusion Top


This article aims at recreating an awareness among cataract surgeons that ciliary body inflammation can masquerade as postoperative hypotony. A high index of clinical suspicion and a thorough conceptual examination to rule out wound leak will help in such cases and will avoid resurgery in the form of wound resuturing and anterior chamber reformation. A meticulous AS slit-lamp examination, fundus evaluation, and Seidel test are must before taking the patient for resurgery. Although UBM is the gold standard imaging for ciliary body pathologies, it cannot be done in all cases due to high cost and nonavailability at most of the tertiary eye care centers. Moreover, after good clinical evaluation, UBM can be avoided. Hence, all patients may not undergo wound reconstruction in suspected postoperative hypotony.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Haldipurkar SS, Shikari HT, Gokhale V. Wound construction in manual small incision cataract surgery. Indian J Ophthalmol 2009;57:9-13.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Colvard DM, Kratz RP, Mazzocco TR, Davidson B. Clinical evaluation of the terry surgical keratometer. J Am Intraocul Implant Soc 1980;6:249-51.  Back to cited text no. 2
    
3.
Girard LJ, Hofmann RF. Scleral tunnel to prevent induced astigmatism. In: Emery JM, Jacobson AC, editors. Current Concepts in Cataract Surgery: Proceedings of the Eight Biennial Cataract Surgical Congress. Norwalk: Appleton-Century-Crofts; 1984. p. 101-2.  Back to cited text no. 3
    
4.
Aravind Eye Hospital and Postgraduate Institute of Ophthalmology. Manual Small Incision Cataract Surgery an Alternative Technique to Instrumental Phacoemulsification. Madurai, India: Aravind Eye Hospital and Postgraduate Institute of Ophthalmology;2007. p. 20-2.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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