Scleral rupture is one of the intraoperative complications of scleral buckle and cryotherapy (SB/C). Jeong et al. [1] reported that globe rupture occurred in one eye out of 180 eyes (0.6%) that underwent scleral buckle for retinal detachment (RD). Risk factors for scleral rupture during RD surgery include reoperation following previous RD surgery and preexisting scleral pathology [2]. We report a case in which retinal reattachment and good vision were achieved without reoperation by applying scleral allograft to scleral rupture during SB/C in a patient without prior RD surgery or scleral pathology. Informed consent for publication of the research details and clinical images was obtained from the patient.

A 22-year-old female patient presented with visual field defect in her right eye that started 1 week ago. She had a history of laser epithelial keratomileusis 3 years ago. Uncorrected visual acuity (UCVA) was 20/20. Anterior segment was unremarkable. Fundus showed macular-on superior bullous RD extending from 11 to 1.5 o’clock. There was a retinal hole at 12.5 o’clock (Fig. 1A-1C). The axial length was 24.6 mm. On the same day, SB/C was planned. After conjunctival peritomy and isolation of rectus muscles, retinal hole was marked at 12.5 o’clock, 15 mm posterior from limbus and near equator. During rotation of eyeball for cryotherapy, cryoprobe kept slipping from the hole marking location. A total of five to six times of 1-second application of cryotherapy were applied just before eyeball rotation to prevent slippage. A total of four sessions of a-few-second cryopexy were performed around the marking location. Due to bullous RD, cryopexy was applied with high indentation using cryoprobe. During the fourth session of cryopexy, L-shaped 4 × 4-mm scleral rupture appeared (Fig. 1D). Multiple 10-0 nylon sutures were tried. Due to the irregular margin of defect and leak, scleral allograft using cryo-preserved donor sclera was performed. The 6 × 6-mm sized patch graft was secured over the defect with multiple interrupted 10-0 nylon sutures (Fig. 1E). Intravitreal injection of balanced salt solution was performed to reform the eyeball. Conjunctiva was sutured with 8-0 Vicryl (Ethicon). Indirect ophthalmoscopy showed residual subretinal fluid (SRF) and mild vitreous hemorrhage. Three months after surgery, UCVA was 20/20 and fundus showed decreased residual RD and cryo-markings (Fig. 1F). One year and 7 months after surgery, UCVA was 20/20 and fundus was flat (Fig. 1G).

To the best of our knowledge, this is the first report of scleral rupture during SB/C successfully repaired with scleral patch graft in South Korea. Previous reports of scleral rupture during SB/C were rare. Johnson et al. [3] reported a scleral rupture during SB/C in a patient with microspherophakia (MSP). MSP is a congenital condition with small crystalline lens. During cryotherapy, a 4-mm scleral rupture occurred. Sclera was closed with interrupted nylon sutures and reinforced with pericardium allograft. Considering that MSP is associated with multiple connective tissue disorders, the authors speculated that MSP may increase the risk of scleral rupture. Carpineto et al. [4] also reported a scleral rupture during cryotherapy after removal of previous buckle in recurrent RD. Scleral sutures, patch graft using human fascia, encircling band, and scleral explant were applied. Both of these two reports were about cases with risk factors for scleral rupture.

In contrast, in our case, the patient had no scleral pathology nor previous surgery. Retinal hole was located near the equator. The equator has the second thinnest scleral thickness [5]. It is presumed that scleral thinning and rupture were caused by multiple cryotherapies applied while pressing hard on the sclera around the equator, where the sclera is thin. It is speculated that scleral rupture occurred in the area of bullous RD resulted in the external SRF drainage (SRFD). Scleral buckle was not applied as we planned to monitor the progress of SRF after surgery. Fortunately, the residual SRF gradually decreased and was completely absorbed one year after surgery.

In conclusion, to avoid scleral rupture during SB/C, number of cryotherapy should be minimized and the strength of pressing the probe should also be adjusted. In bullous RD, external SRFD appears to be more suitable than pressing hard on the sclera. As the sclera of the equator is thin, more caution is needed during SB/C around the equator. To repair the scleral rupture, scleral sutures can be insufficient and scleral graft can be a good alternative.