International Journal of Ophthalmic PathologyISSN: 2324-8599

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Case Report, Int J Ophthalmic Pathol Vol: 3 Issue: 1

Silicone Rubber Scleral Buckle Implant Simulating Conjunctival Tumor

Daniel Lee*, Sheila Garcia-Santana and John J. Huang
Yale School of Medicine, Department of Ophthalmology and Visual Science, New Haven CT, USA
Corresponding author : Daniel Lee
Ophthalmology Resident, Yale School of Medicine, Department of Ophthalmology and Visual Science, New Haven CT, USA
Tel: 203-785-2020; Fax: 203-785-7090
E-mail: [email protected]
Received: January 16, 2014 Accepted: February 24, 2014 Published: February 28, 2014
Citation: Lee D, Santana SG, Huang JJ (2014) Silicone Rubber Scleral Buckle Implant Simulating Conjunctival Tumor. Int J Ophthalmic Pathol 3:1. doi:10.4172/2324-8599.1000128

Abstract

Silicone Rubber Scleral Buckle Implant Simulating Conjunctival Tumor

We report a unique case of a silicone rubber scleral buckle implant simulating a conjunctival tumor. The patient had remote scleral buckling procedure for a retinal detachment and subsequent removal secondary to implant extrusion. Slit lamp examination revealed a large conjunctival mass with a papillomatous surface and overlying corkscrew vessels. Radiologic imaging revealed a septated fluid collection corresponding with the lesion.

Keywords: Conjunctival Tumor; Scleral buckling; Silicone rubber

Keywords

Conjunctival Tumor; Scleral buckling; Silicone rubber

Introduction

Scleral buckling is a technique that has been employed for the treatment of rhegmatogenous retinal detachments for more than fifty years [1]. A number of materials have been used in the past, however silicone is most widely used for its advantages of being easily obtainable, sterile and pliable [2]. Hydrogel implants have largely been abandoned and are no longer commercially available due to late complications caused by implant expansion [3]. Post-operative complications with silicone scleral buckles include increased intraocular pressure, altered refractive error, strabismus, scleral abscess, endophthalmitis, implant extrusion and implant intrusion [1]. We report a unique presentation of silicone rubber scleral buckle simulating a conjunctival tumor.

Case Report

A 71-year-old man presented with six months of progressively enlarging mass of his right eye. His ocular history included a pars planavitrectomy, endolaser and scleral buckle for a macula-off retinal detachment eighteen years prior. The scleral buckle was then removed ten years ago due to extrusion. Symptoms first presented as a dull aching sensation associated with itching and erythema. Four months prior, he noted a tender nodule underneath his right lower lid and began having intermittent irritation and foreign body sensation associated with mild amounts of thick yellow discharge. No medical attention was sought at this time and symptoms were allowed to progress. Four weeks prior, patient noted a slowly progressive decrease of vision in his right eye associated with an enlarging mass, worsening pain and purulent discharge. Patient was finally persuaded to seek medical attention by his family.
On presentation, his vision was hand motion in his right eye and 20/50 in the left. A right relative afferent pupillary defect was noted. Intraocular pressure was determined to be 22 in the right eye and 16 in the left eye by handheld tonometer. There was right eye hyperglobus and limitation of down gaze. Slit-lamp biomicroscopic of his right eye revealed purulent discharge, lower-lid ectropion, and diffuse papillary reaction. There was a large 25x10 mm conjunctival mass on the inferior globe surface and in the inferior fornix. The mass had overlying corkscrew vessels and papillomatous surface. Foreign body material was noted on the temporal aspect of the conjunctiva (Figure 1). His anterior segment was notable for a clear cornea, deep and quiet anterior chamber, a posterior chamber intraocular lens, and quiet vitreous. The optic nerve had advanced glaucomatous cupping. The macula and retinal vessels were within normal limits. Laser scars were noted 360 degrees in the retinal periphery. The left eye was pseudophakic and otherwise unremarkable.
Figure 1: External photographs at presentation. (A) Photograph demonstrates a 2.5 cm x 1 cm conjunctival mass of the right eye with associated purulent exudates. (B) A close-up photograph of the right eye with lower lid retracted with cotton swab.
Patient was admitted for intravenous antibiotics which included piperacillin/tazobactam and vancomycin. CT scan of the head and orbits with contrast revealed a 2.6x2.2x1.5 cm complex septated fluid collection in the preseptal right inferolateral orbit with mass effect that displaced the globe superiorly (Figure 2). The following day, patient was taken to the operating room for removal of possible infected residual scleral buckle material, conjunctival biopsy and exploration of the right orbit. A conjunctival peritomy was created. We found a large amount of yellow translucent gelatinous material which extended to the posterior orbit (Figure 3). The material was removed piecemeal and submitted for pathologic evaluation. An incisional biopsy of 5 x 5 mm was obtained from the conjunctival tumor and sent for histopathological evaluation. Tissue gram stain revealed gram negative rods, gram positive rods, and gram positive cocci in pairs; with cultures yielding streptococcus viridans. H&E staining of the specimen was described as “a globular and pseudocrystalline foreign material with massive bacterial overgrowth” (Figure 4). The conjunctival tumor was read as granulation tissue with marked acute and chronic inflammation (Figure 5). The patient’s prior retinal surgeon was contacted who indicated that a Silicone buckle 279 solid component and 240 band was utilized (DORC; Zuidland, The Netherlands).
Figure 2: Radiologic Imaging. A coronal section of the CT scan demonstrates a fluid collection inferior to the right globe. The globe is displaced by mass effect superiorly.
Figure 3: Intra-operative findings. (A) A large amount of yellow, translucent, gelatinous material was encountered. (B) Close-up image of a portion of the unknown material.
Figure 4: External photographs at presentation. (A) Photograph demonstrates a 2.5 cm x 1 cm conjunctival mass of the right eye with associated purulent exudates. (B) A close-up photograph of the right eye with lower lid retracted with cotton swab.
Figure 5: Post-operative photograph. Photograph demonstrating complete resolution on first post-operative week.

Discussion

Foreign bodies simulating orbital tumors are exceedingly uncommon. In an analysis of 1264 patients with orbital tumors and simulating lesions by Shield et. al., only 2 were caused by a foreign body [4]. Another study performed by the same group analyzed 1643 patients presenting with conjunctival tumors where 11 were caused by a foreign body [5]. Similar presentations have been reported almost exclusively in patients who had received MIR Agelscleral buckles [3,6,7]. MIRAgel is a hydrogel-based material that was widely used in the 1980s and early 1990s for its lower risk of infection and minimal early complications. However, late complications due to excessive implant swelling and difficult removal put MIRAgel out of favor among most vitreoretinal surgeons [8].
Despite our patient’s remote history of scleral buckle removal, his clinical picture most likely represents retained silicone rubber due to incomplete removal of the buckle. A super infection developed and was allowed to progress untreated for nearly six months, giving the unique presentation simulating a conjunctival tumor. Pathologic analysis revealed a globular pseudo-crystalline material, most likely representing the silicone rubber, with an adjacent conjunctival tumor made up of massive granulomatous overgrowth. The infection was polymicrobial, but cultures predominantly grew Streptococcus viridans.
The gelatinous material encountered during exploration did not retain the shape of the original material used (279 solid component and 240 band; DORC). It appeared to mold to the contour of the globe without invasion of the sclera. It was present in the most dependent areas of the orbit inferiorly and extending posteriorly behind the globe. The mechanism of this unique finding is unclear and may represent a breakdown of the silicone rubber as a consequence of chronic exposure to a relatively acidic inflammatory and infectious environment.

Acknowledgment

The authors indicate no financial support or financial conflict of interest. Involved in the conduct of study (D.L, S.G, J.J.H); collection of data, typing and editing of manuscript and preparation, review, or approval of manuscript (D.L, S.G, J.J.H).

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