|Year : 1983 | Volume
| Issue : 7 | Page : 997-1000
Management of the extruded explant
Manoj Shukla, OP Ahuja, J Chaturvedi
Institute of Ophthalmology, Aligarh Muslim University, Aligarh, India
Institute of Ophthalmology, AMU, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shukla M, Ahuja O P, Chaturvedi J. Management of the extruded explant. Indian J Ophthalmol 1983;31, Suppl S1:997-1000
|How to cite this URL:|
Shukla M, Ahuja O P, Chaturvedi J. Management of the extruded explant. Indian J Ophthalmol [serial online] 1983 [cited 2020 May 24];31, Suppl S1:997-1000. Available from: http://www.ijo.in/text.asp?1983/31/7/997/29728
Extrusion of the explant is a common complication of retinal detachment surgery and is often responsibel for recurrence of retinal detachment. In this paper, various factors responsible for extrusion of explant are analysed and management of extruded explant is discussed.
| Materials and methods|| |
This study includes ten patients of rhegmatogenous retinal detachment, operated in one eye by an episcleral buckling procedure. These patients developed extrusion of the explant following surgery from periods varying form 18 days to 3th years [Table - 1]. Six out of ten eyes had an extruded local explant while in the remaining eyes, encircling silicone band (2 eyes) and silicone sponge (2 eyes) was extruded. In six eyes, the explant was preoperatively placed naterior to the equator. Mild to severe infection was present in seven eyes [Figure - 1] and was responsible for granuloma formation in the region of extruded explant in two eyes [Figure - 2] . Staphylococcus pyocyaneus was the commonest pathogen isolated from the infected eyes.
In four eyes the retina was completely settled as seen after extrusion of the explant while in four eyes advanced massive periretinal proliferation (M.P.P.) was present (three eyes had mild form of M.P.P. before retinal surgery). The remaining two eyes had recurrence of retinal detachment following extrusion of the explant and in both cases, secondary buckling by a local radial explant with drainage of subretinal fluid was carried out. The retinal subsequently settled in both the eyes.
The infection associated with explant was treated with subconjunctival gentamicin injection (I ml) daily, neosporin drops, chloromycetin ointment, local betamethasone drops and broad spectrum systemic antibiotics, The explant was removed in all eyes after making a conjunctival incision and every effort was made to remove every fragment of the silicone sponge which was most frequentlv unused as a buckling material, After removal of the explant, the area was thoroughly irrigated with gentamicin solution and sprinkled with chloromycetin succinate powder. In two eyes during surgical removal of explant, it was seen covered by a thick fibrovascular membrane which bled profusely making removal difficult. These eyes had a relatively longer duration of extrusion of explant after retinal surgery (case 2 & 8). In one eye (case NO.9) after removal of the infected encirclage, the conjunctiva could not be approximated because of chemosis and a conjunctival graft was taken from the other eye to close the wound [Figure - 2]. After removal of the infected explant, the eyes behaved very well in the postoperative period as infection gradually subsided and all eyes were more or less quite after a week [Figure - 3].
Six out of ten eyes which were available for follow up (6 months to 3 years) revealed settled retina with good functional results.
| Discussion|| |
Episcleral buckling procedures are most commonly employed surgical procedures in the treatment of rhegmatogenous retinal detachment. A frequent complication of these procedures is infection of the explant 1 which in most of the cases is responsible for its extrusion. Early extrusion of the explant is nearly always due to infection as removal of explant alongwith its sutures invariably controls the infection. In such cases depending upon the severity and duration of the infection, conjunctivitis, granulaoma, scleral abscess and endophthalmitis may develop.
Silicone sponge which is most commonly used as an explant material is composed of compactly placed cells which do not have any communication between each other and external environment. These cells are broken following surgical compression by anchoring sutures and as a result, interconnecting cavities are formed within the sponge which are filled with plasma and other fluids and provide a nidus for the growth of micro-organisms.
Russo & Ruiz believe that extrusion of explant can also occur in the absence of infection as was also seen in three of our cases. In such cases the eye remains relatively free from congestion and extrusion occurs more commonly with anteriorly placed explants. The reason for extrusion of explant is an inadequate anchorage of the explant by anchoring sutures which are too superficial in the sclera and secondly a failure to cover the explant properly by Tenon's capsule and conjunctiva As a result, with movement of the eye the explant can readily shift its position and can get exturded.
Therefore, a good anchoring suture and a proper coverage of explant by tenon's capsule and conjunctiva would be very beneficial in preventing extrusion of explant and would consequently have a direct bearing on the surgical results.
One of the most significant aspect in the management of extruded explants is the control of associated infection by local and systemic broad spectrum antibiotics and local sterioids followed by removal of the explant The removal of explant may often pose three problems.
1. Localisation of the explant may be difficult in those patients where record of retinal surgery is not available.
2. The explant specially the silicone sponge in the presence of infection may necrose and break down into smaller fragments making removal difficult.
3. The explant may be covered by a fibrovascular silicone membrane which may hinder with the localisation of explant and also bleed profusely during dissection.
Alogical approach to prevent infection and extrusion of explant would be to keep the explant immersed in genta misin solution half an hour before surgery and to constantly irrigate it with the same solution during surgery. The importance of a perfect aseptic surgical technique in the managemer: t of retinal detachment can not be over emphasised.
It is usually believed that if extrusion of the explant occures 2-4 weeks after surgery, no secondary buckling is needed as strong chorioretinal adhesions have already developed in region of retinal break. On the other hanLd, two eyes in the present study developed recurrence of retinal detachment after three and four months respectively following retinal surgery due to extrusion of the explant. We would therefore, recommend that every case should be managed on its own merits after careful assessment of the retinal condition at the time of extrusion of the explant and thereafter. If secondary buckling is needed, it can safely be under taken within a few days after the eye 'is relatively free from infection and inflammation.
| Summary|| |
Our experience of the management of extruded explants in ten eyes operated for rhegmatogenous retinal detachment by episcleral buckling procedures is desribed. The various factors responsible for extrusion are analysed and discussed.
| References|| |
L.incoff, H. Nadel, A., and 0 connor. P., 1970, Arch. Ophthalmol., 84: 421.
Russo, C.E., and Ruiz, R..S., 1971, Arch. Ophthalmol., 85: 6.47.
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]