About us |  Subscription |  Top cited articles |  e-Alerts  | Feedback |  Login   
  Home | Ahead of print | Current Issue | Archives | Search | Instructions Celebrating 60 Years   Print this article Email this article   Small font sizeDefault font sizeIncrease font size
 
 Official publication of All India Ophthalmological Society   Users Online: 43
  Search
 
  
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (1,307 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1157    
    Printed31    
    Emailed0    
    PDF Downloaded63    
    Comments [Add]    
    Cited by others 4    

Recommend this journal

 


 
  Table of Contents  
BRIEF COMMUNICATION
Year : 2011  |  Volume : 59  |  Issue : 3  |  Page : 238-239
 

Extrusion of hydrogel exoplant into upper eyelid 16 years after a scleral buckle procedure


1 Ophthalmic Consultants of Boston, 50 Staniford Street, Suite 600, Boston, MA;MidAtlantic Retina, The Retina Service of Wills Eye Institute, Thomas Jefferson University, Suite 1020, Philadelphia, PA, USA
2 MidAtlantic Retina, The Retina Service of Wills Eye Institute, Thomas Jefferson University, Suite 1020, Philadelphia, PA, USA
3 Oculoplastics Service, Wills Eye Institute, Philadelphia, PA, USA

Date of Submission02-Dec-2009
Date of Acceptance22-Mar-2010
Date of Web Publication13-May-2011

Correspondence Address:
Chirag P Shah
Ophthalmic Consultants of Boston, 50 Staniford Street, Suite 600, Boston, MA 02114
USA
Login to access the Email id


DOI: 10.4103/0301-4738.81047

PMID: 21586850

Get Permissions

 

   Abstract 

Sixteen years after scleral buckle surgery with a hydrogel episcleral exoplant, a 43-year-old woman presented with progressive binocular diplopia, ptosis, and an expanding mass in her upper eyelid. She underwent surgical removal of the hydrogel exoplant through an anterior approach. The exoplant proved to be friable, fragmented, and encapsulated in a fibrous tissue; the exoplant was removed in its entirety. Postoperatively, the eyelid mass resolved, while her diplopia and ptosis improved slightly.


Keywords: Eyelid, Miragel, retinal detachment, scleral buckle


How to cite this article:
Shah CP, Garg SJ, Penne RB. Extrusion of hydrogel exoplant into upper eyelid 16 years after a scleral buckle procedure. Indian J Ophthalmol 2011;59:238-9

How to cite this URL:
Shah CP, Garg SJ, Penne RB. Extrusion of hydrogel exoplant into upper eyelid 16 years after a scleral buckle procedure. Indian J Ophthalmol [serial online] 2011 [cited 2014 Apr 18];59:238-9. Available from: http://www.ijo.in/text.asp?2011/59/3/238/81047 DOI:10.4103/0301-4738.81047


Hydrogel episcleral exoplants (MIRAgel, MIRA Inc., Waltham, Massachusetts) were approved for use in the 1980s, for scleral buckle surgery. These exoplants were soft and elastic and were thought to have the advantage of decreased erosion. Furthermore, the small pores of the hydrogel exoplants were thought to be impenetrable to bacteria, while allowing the gradual release of antibiotics, thus minimizing the risk of infection. [1]

While hydrogel exoplants were well-tolerated in the short-term, several authors have described the late complication of exoplant extrusion requiring explantation. [2],[3],[4],[5] Roldan-Pallares and colleagues described buckle swelling from the hydrolytic degradation of MIRAgel exoplants. At an average of 15.5 years follow-up, they noted that 6.5% (27 of 415) required removal. [2] Le Rouic and colleagues reported an average duration of 7.7 years between MIRAgel implantation and necessary explantation. [3] Kawano and colleagues reported a case of hydrogel exoplant extrusion and fragmentation into the eyelid; only part of the exoplant could be removed due to fibrous encapsulation. [4] Kearney and colleagues reported that 5 of 17 eyes (29%) developed recurrent retinal detachment after MIRAgel explantation. [5]

Herein we describe a case of progressive diplopia and upper eyelid mass many years after placement of a hydrogel exoplant. Hydrogel expansion and extrusion is often difficult to manage due to the friability of the material. The patient underwent successful surgical removal of the entire hydrogel exoplant, however, some diplopia persisted.


   Case Report Top


A 43-year-old woman described a three-year history of progressive left upper lid swelling and ptosis. Her primary ophthalmologist treated her for a presumed chalazion with warm compresses and various ointments. She sought a second opinion at Wills Eye Institute. She denied loss of visual acuity, but noted progressive diplopia with eccentric gaze over the last several years. Sixteen years prior to presentation (1992) she had undergone placement of a scleral buckle for repair of rhegmatogenous retinal detachment, associated with high myopia. On examination, visual acuity measured 20/100 in the right eye and 20/400 in the left eye. External examination of the left upper eyelid revealed a firm, non-mobile subcutaneous lesion split into two pieces [Figure 1]. Extraocular motility of the left eye was limited in all gazes, most notably in upgaze and abduction [Figure 2]. An ocular examination revealed normal anterior segments and attached retinas with moderate myopic degeneration bilaterally. Of note, there was no buckle indentation in the left eye.
Figure 1: Preoperative photograph revealing a firm, non-mobile, subcutaneous mass split into two pieces in the left upper eyelid. Note the buckle break centrally where the buckle split, allowing it to migrate anterior to the superior rectus (arrow)

Click here to view
Figure 2: Montage revealing limited extraocular motility of the left eye in all positions of gaze, with the greatest limitation in upgaze and abduction

Click here to view


We diagnosed an anteriorly extruded scleral buckle, probably one composed of hydrogel. The patient underwent surgical removal of the buckle via an anterior orbitotomy. A lid crease incision was made with care to dissect into the orbit. The extruded hydrogel exoplant was located posterior to the orbital septum and was encased in a fibrotic capsule. The buckle proved to be a friable MIRAgel exoplant [Figure 3] that was found in situ to be fragmented into two large pieces, which enabled it to migrate anterior to the superior rectus. It is possible that the hydrogel element migrated directly through the superior rectus. Dehiscence of the levator palpebrae allowed further migration anteriorly into the eyelid. The superior rectus and levator palpebrae were fibrotic, explaining the patient's decreased upgaze and ptosis. The hydrogel exoplant was removed in its entirety along with much of its fibrous capsule. Postoperatively, the patient no longer had an eyelid mass. Her ptosis and diplopia improved slightly, and her retina remained attached one year after surgery.
Figure 3: The friable hydrogel exoplant fragmented into several additional pieces during explantation

Click here to view



   Discussion Top


We describe a case of an extruded hydrogel episcleral exoplant manifesting as a large subcutaneous upper eyelid mass with diplopia and ptosis. The hydrogel exoplant required surgical explantation 16 years after initial scleral buckle surgery. The exoplant appeared to have migrated around the superior rectus and dehisced the levator palpebrae, leaving both muscles fibrotic; the exoplant remained encapsulated posterior to the orbital septum. The hydrogel exoplant was removed in its entirety via anterior orbitotomy through the upper eyelid crease. Although the retina remained attached, the patient's diplopia and ptosis persisted. Given the relatively high incidence of complications associated with the MIRAgel exoplants, they were discontinued by the manufacturer around 1994. [5]

 
   References Top

1.Ho PC, Chan IM, Refojo MF, Tolentino FI. The MAI hydrophilic implant for scleral buckling: A review. Ophthalmic Surg 1984;15:511-5.  Back to cited text no. 1
    
2.Roldán-Pallarés M, Hernández-Montero J, Llanes F, Fernández-Rubio JE, Ortega F. MIRAgel: Hydrolytic degradation and long-term observations. Arch Ophthalmol 2007;125:511-4.   Back to cited text no. 2
    
3.Le Rouic JF, Bettembourg O, D'Hermies F, Azan F, Renard G, Chauvaud D. Late swelling and removal of Miragel buckles: A comparison with silicone indentations. Retina 2003;23:641-6.   Back to cited text no. 3
    
4.Kawano T, Doi M, Miyamura M, Esaki K, Sasoh M, Uji Y. Extrusion and fragmentation of hydrogel exoplant 11 years after scleral buckling surgery. Ophthalmol Surg Laser 2002;33:240-2.  Back to cited text no. 4
    
5.Kearney JJ, Lahey JM, Borirakchanyavat S, Schwartz DM, Wilson D, Tanaka SC, et al. Complications of hydrogel explants used in scleral buckling surgery. Am J Ophthalmol 2004;137:96-100.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Mucus Extravasation Into the Orbit During Frontal Sinus Irrigation
Nicholas Andrew,Adnan Pirbhai,David Moffat,Suresh Rajapaksa,Peter-John Wormald,Michael Reid,Dinesh Selva
Ophthalmic Plastic and Reconstructive Surgery. 2013; 29(1): e29
[Pubmed]
2 Hydrogel Explant Extrusion Masquerading as a Malignant Eyelid Lesion
Craig N. Czyz,Thomas P. Petrie,Kelly R. Everman,Kenneth V. Cahill,Jill A. Foster
Ophthalmic Plastic and Reconstructive Surgery. 2013; 29(1): e25
[Pubmed]
3 MULTIMODALITY IMAGING OF HYDROGEL SCLERAL BUCKLES
Daniel T. Ginat,Arun D. Singh,Gul Moonis
Retina. 2012; 32(8): 1449
[Pubmed]
4 Late Complications of Hydrogel Scleral Buckle Implants and a Technique for Effective Removal
Ayo-Lynn Richards,Dale R. Meyer
Ophthalmic Plastic and Reconstructive Surgery. 2012; 28(6): 455
[Pubmed]



 

Top
Print this article  Email this article
 

    

2005 - Indian Journal of Ophthalmology
Published by Medknow

Online since 1st April '05