SB removal leads to retinal re-detachment in 8-14.5% of patients, especially when done within six months of SB placement [6
]. Risk factors include a history of multiple retinal detachments, persistent vitreoretinal traction, proliferative vitreoretinopathy, aphakia with multiple posterior breaks, exposures with retina attached for a short duration, and lack of detecting retinal holes/tears at the time of the original RD repair [6
]. In our monocular
patient with Stickler Syndrome contributing to multiple retinal detachments and a recent SB placement of less than six months, there would have been high risk of retinal re-detachment upon SB removal. Therefore, repairing the defect with a graft became the safer choice. Despite the literature’s encouraging reports of successfully using various autologous and allogeneic grafts to repair exposed SBs, our patient encountered multiple graft failures, ultimately requiring a second thicker and larger dermis fat graft to achieve long-term coverage. Although dermis fat grafting stands as a novel technique for SB repair, it has long been used in the oculoplastics field in the repair of exposed orbital implants, socket reconstruction after enucleation, superior sulcus augmentations, and repair of enophthalmos [9
]. Autologous DFG not only bypasses the risks of disease transmission and immunologic rejection, but is thought to provide comfort and promote rapid wound healing. In addition, its robust nature reduces the risk of wound breakdown, desquamation and fistula formation. A disadvantage is the need of a donor surgical
site which may lead to increased morbidity.
In our patient, numerous risk factors contributed to grafting failure and SB re-exposure. The first is poor epithelialization over donor material. Our patient carried numerous risk factors that could interfere with the integrity of the ocular surface, thus compromising the epithelialization process. These potential factors included a history of glaucoma
, chronic use of topical brimonidine eye drops, collagenopathy from Stickler Syndrome, decreased wound healing from topical steroids, mechanical effect from the SB element itself, multiple past ocular surgeries including previous cataract extraction
and retinal surgeries, concurrent pars plana vitrectomy, and subsequent ocular procedures. Secondly, immunologic rejection may explain the mechanism of graft failure in the allogeneic grafts used in this patient. Additionally, our initial DFG may have simply been too thin and small. Fat atrophy of the thinner DFG may have led to further thinning resulting in SB re-exposure and may explain why the second, thicker DFG survived. If this technique is used, a generous size DFG with a relatively thick fat layer should be used, anticipating some postoperative fat atrophy. Care should be taken to suture the graft to allow for a tension free closure and to overlap the dermal and conjunctival edges to promote epithelialization. Finally, a subclinical infection may have been present; however, a culture of the SB was not obtained prior to the repair attempts.
In conclusion, DFG is a relatively robust material that can be successfully used to salvage an exposed SB, thus obviating the removal of an exposed SB and avoiding the increased risk of recurrent RD associated with SB removal in select patients.