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Department of Ophthalmology
Moch Hoesin Hospital
Palembang 2015
Case report
Wednestday June 14 2015
Neuro-ophthalmic Presentations and
Treatment of Cryptococcal Meninitis-related
!ncreased !ntracranial Pressure
"ndrian #uner$
Consultantdr% &'% (e)i "*ri Wahyuni+ #pM,.
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INTRODUCTION
CM is the most common manifestationof extra pulmonary cryptococcosis.
Intracranial hypertension occurs in upto 75% of patients ith CM an! isassociate! ith increase! mortality.
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INTRODUCTION
CM can present to the ophthalmolo"istas #ision loss$ papille!ema$ a!ucens
palsy$ an!&or other cranialneuropathies.
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'UR'O()
To illustrate three !i*erentophthalmic presentations ofcryptococcal menin"itis +CM,
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C-() R)'ORT +C-() ,
- /01year1ol! male as referre! to theneuro1 ophthalmolo"y clinic fore#aluation of ilateral optic atrophy. 2eha! een ell until 3 months prior henhe experience! #ision loss$ hea!ache$nausea$ an! fe#er. 2e presente! to hisprimary me!ical !octor an! his local
hospital emer"ency !epartment se#eraltimes an! as !ia"nose! ith an!treate! presumpti#ely for sinusitis.
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on hospitali4ationforma"neticresonanceima"in"+MRI, an!lumarpuncture+',.Contrast1enhance!MRIofthe rainasunremar6ale.'shoe!anele#ate!openin"pressure+O',of3/cm2O. Cererospinal 8ui! +C(9, ha!
:hiteloo!cells+;<C,&m +75%lymphocytes$ 5%monocytes$=%neutrophils,.CryptococcalC(9 anti"enaspositi#eatmorethan>:$an!culture"re C.neoformans. Cytolo"yan! 8o cytometryerene"ati#e formali"nancy.2I?1testin"aspositi#eithaCD/ count
of0cells&m an!a#iralloa!of3@$===copies&m. Thepatientasstarte!onamphotericin<an! 8ucytosine forCM.Repeat'sereperforme!torelie#eIC'an!monitoranti"entiters.
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On examination$ acuity as =&5OD an!=&== O(. -utomate! #isual Ael!s shoe!a ri"ht !ense superior arcuate an! inferior
altitu!inal Ael! !efect an! a left centralscotoma. Ishihara plates ere &/ on theri"ht an! =&/ on the left. There as a leftrelati#e a*erent pupillary !efect +R-'D,.
Ophthalmoscopy shoe! !i*use opticatrophy ilaterally. -ntifun"al treatmentas continue!.
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C-() R)'ORT
Case - /31year1ol!femalepresente!ith3ee6sofhea!1ache$ hori4ontal!iplopia$an!ilateral#isionloss.Me!icalhistory assi"niAcant forrenaltransplantationforcon1"enital 6i!ney!iseasein==5an!repeattransplantationfor
focal"lomerulosclerosisreBuirin"immunosuppressionfor @years.'ost1transplant6i!neyfunctionasstale.(heha! chronic$utstalesecon!aryreno#ascularhyper1tension$
hyperlipi!emia$anemiaofchronic!isease$an!prior !eep#enous thromosis e#ents in ==5 treate! itharfarin until her most recent transplant 0 monthsa"o.
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C-() R)'ORT
'hysical )xamination eneral (tatus > Normal
Ophthalmolo"y (tatus>
RE LE
VA N/P 100
IOP PN30 5 mm&
Eye ballPosititon
#ymetric
Eye BallMovement
ood to "ll a*e ood to "ll a*e
Palpebra Normal Normal
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C-() R)'ORTConjunctiva Normal Normal
Cornea Cicatri all o)er corneasurface
Clear
Anterior Chamber Moderate Moderate
Iris Posterior synechia ,3. Normal
Pupil 6)al+ /7 ,-. N 7ound+ Central+/7,3. +8 5 mm
Lens Can9t :e assessed Clear
Fundus e!le" Neati)e Positi)e
Papil Can9t :e assessed 7ound+ :lurred marin+ Normal 7edColour+ C(; Can9t :e assessed "<;2
Macula =o)eal refle,-.
etina 4 >uadrants detachment ,3.+ iant
retinal tear ,3. temporal reion%
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C-() R)'ORTLEF E!E F"#D"$ PHOO%R&PH
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C-() R)'ORTRE'#&L DR&('#%
RE
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)9T )E) U(
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RI2T )E) U(
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C-() R)'ORT
#ia$nosis %
7hematoenous 7etinal (etachment /? 3 Cornea
/eu@oma 7? 3 7etinal (etachment /?
Mana$ement% !nformed Consent
&ospitali*ed
/a:oratorium ?amination 3 Chest A-7ay
Pro consult "nesthesioloy (epartment Pro #cleral Buc@le 3 Pars Plana <itrectomy 3 ?ndolaser 3
#ilicone 6il /? ith eneral "nesthesia
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Pro$nosis %
Duo ad <itam ; Bonam
Duo ad =unctionam ; (u:ia ad :onam
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C-() R)'ORT
&ur$ical eport% '()*+*(,)-.1% Patient in supine position ith "
2% "septic E antiseptic performed+ surical field as narroed
% F00 con'uncti)al peritomy E etraocular muscle isolated
4% #ilicone :and inserted under rectus muscle+ #lee)e installed at
nasal inferior E :and sutured to sclera at 4 ith mersilene 5%0
5% #clerotomy site mar@ed at mm from lim:al and at G o9cloc@ filled
infusion cannula+ 10 o9cloc@-)itrector E 2 o9cloc@-endoilluminator
F% (etached retina and tear as identified+ proceed to performin
)itrectomy until optimal clearance
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C-() R)'ORT
H% &ea)y fluid in'ected to sta:ili*e retina and to do the endodrainaeG% fluid-air echane performed+ endolaser applied around tear and
F00 peripheral retina
I% #ilicone 6il in'ected to )itreal ca)ity
10% !nfusion cannula+endoilluminator E )itrector ere remo)ed fromca)ity E sclera sutured ith G%0 )ycril
11% (eamethason-entamycin in'ected su:con'uncti)al and eye
as closed ith sterile patch
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Post operti)e therapy CeAxime x == m" 'aracetamol 3 x 5= m" Metil pre!nisolon 3x / m" Toramycine F !exametason )D 0 x
"tt OD
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C-() R)'ORT +=6//6W P.
Right Eye 1st *ay post op +th *ay post op
?- 4F0 P&,-. FF0 ph ,-.
IO' 1+1 mm& 15+F mm&
9R +F, +F,
'apil 7ound+ =irm marin+ Normal 7ed Colour+C(;0+ "<;2
7ound+ =irm marin+ Normal 7edColour+ C(;0+ "<;2
Macula =o)eal refle ,3. =o)eal refle,3.
Retina Tiroid appearance+ /attice deeneration,3. + scar laser ,3.+ su:retinal hemorrhaic,3.
Tiroid appearance+ /atticedeeneration ,3.+ scar laser ,3.+su:retinal hemorrhaic ,3.
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C-() R)'ORT
1st *ay post op ,th *ay post op
Dia"nosis
'ost Buckle (6lera F parsplana #itrectomyF )n!olaser F(ilicon oil /?F corneal leucomaR) F Retinal !etachment R)
'ost Buckle (6lera F parsplana #itrectomyF )n!olaserF (ilicon oil /?F cornealleucoma R) F Retinal
!etachment R)
Therapy KCeAxime x == m"K'aracetamol 3 x 5= m"KMetil pre!nisolon 3x / m"K Toramycine F !exametason)D 0 x "tt OD
K Toramycine F !exametason)D 0 x "tt OD
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IT)R-TUR) R)?I);
It exten!s almost as far anteriorlyas the ciliary o!y
)n!in" point
The ora serrata The outer surface of the sensory
retina is appose! to the retinal
pi"ment epithelium an! thusrelate! to <ruchGs memrane$ thechoroi!$ an! the sclera.
RE'#
&
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Thic6ness =. mm at the ora
serrata an! =.50 mm at theposterior pole The macula lutea is !eAne!
anatomically as the 3 mm !iameterarea containin" the yello lutealpi"ment xanthophyll
RE'#&
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FO-E&
The retinal a)ascular *one of
fluorescein anioraphy% L 1%5 mm
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- !epression that creates a
particular re8ection hen #iee!ophthalmoscopically.
In the center of the macula /mm lateral to the optic !is6
H =.5 mm
FO-EOL&
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K In the mi!!le of K The thinnest part of area of the
retina =.5 mmK Only cone photoreceptors.K 'ro#i!in" optimal #isual acuity.
FO-EOL&
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IT)R-TUR) R)?I);
Retinal !etachment> separation of thesensory retina from the pi"ment epithelium
hich occur at potential space.
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IT)R-TUR) R)?I);
Normally$ sensoryneural attach to R') maintaine!y alance hy!rostatic. R') preser#e the potentialspace free from 8ui! y osmotic "ra!ient an!acti#e1pump mechanism.
3 maJor factor of RD> full1thic6ness retinal !efect +rea6, Traction of retina
(uretinal 8ui!
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IT)R-TUR) R)?I);
'otential space in RD Alle! ithsuretinal 8ui!. 9lui! came from
syneretic #itreous throu"h retinal rea6an! separate the sensory retina fromR')
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IT)R-TUR) R)?I);
7is@ factor; Myopic eye
Trauma
/attice deeneration
&istory of surery =amily history
“Lattice degeneration is a predisposing factor of RRD. 8 % of
population have lattice and 40% case of RD associated withlattice”
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(EM'TOM( Metamorphopsia 'hotopsia
(ha!o or curtain o#er a portion of#isual Ael!
<lur in #ision
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IT)R-TUR) R)?I);Management of RRD. An! an! close the rea6 Reattachment retina
Post operati)e o/tcome *epen* on. Macular in#ol#ement !uration of separation until sur"ical mana"ementapply
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IT)R-TUR) R)?I);
$/rgical echni/e1 $cleral /c3ling
Retinope4y
(90 C39:
5 h o r i o r e t i n a l a * h e s i o n
Cryo aser
$ c l e r a l i n * e n t a t i o n(ilicone
an!
Tyre
Performed ; sinle :rea@ E peripheral
ood )isuali*ation
only in 1 >uadrant I0 ood result
(rainae
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IT)R-TUR) R)?I);
#C/?7"/ BC/!N C6MP/!C"T!6N
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IT)R-TUR) R)?I);
2 -itrectomyRationally$ #itrectomy is a proce!ure too#ercome traction an! a#oi!
complication of scleral uc6lin".
VI/EC/OM0clean up hyaloid corte" o! vitreous avoid vitreoretinal traction
# associated vitreous mobility 'li1ue!action 2 PV#.
$cleral/c3le
ela"ation vitreal
traction
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IT)R-TUR) R)?I);
VI/EC/OM0 POCE#3E
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'#D'&'O#
#isease%
(ia:etic 7etinopathy
P<7
Macular in)ol)ement
Trauma
Malinancy case
Condition%
iant tears
<itreous hemorrhae
Multiple :rea@
?>uatorial tear
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IT)R-TUR) R)?I);
<itrectomy Complication
Intra operati#e
Iatro"enic rea6
Iatro"enic to lens
'ost operati#eIncrease IO'
+silicone$uc6lin",
Cataract form
2yphema +hea#y
8ui! to -C,
CM)
'?R
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iant retinal tears circumferentialretinal rea6s of @= !e"rees or more
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The "eneral principles of mana"ement> Unfol! the posterior 8ap of the tear 9latten it a"ainst the eye all (eal the tear ith a A rm a!hesion.
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DI(CU((ION
-namnesis (u!!en lur #ision
No re!!ish eye 'hotopsia 9loaters
Curtain1li6e #ision
#eein flash liht
,photopsia. and =lyin
matter, floaters. are 50
of 77( early symptoms%
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DI(CU((ION
9un!us )xamination>K Retinal !etachment +un!ulation
ulae,K 9o#eal in#ol#ementK iant retinal tearK attice !e"eneration
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DI(CU((ION
2istory of earin" spectacles +F, 1@D hi"hmiopia lattice !e"eneration
Lattice *egeneration.
-normal con!ition of retina cause! y thinnin"of inner limittin" memrane ith athropic process
of neurosensory$ hich is lea! retinal rea6formation mi"ration of #itreous 8ui! suretinal the sensory retinaKR') separation
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Mana"ement for this patient is (clerauc6le F 'ars 'lana ?itrectomy F)n!olaser F InJection (ilicone OilIntra#itreal
iant retinal tear
4H
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Reason .
Retinal !etachment shallo oo! i!entiAcation of retinal tear
Post operati)e o/tcome.
Complication not foun!
Retinal 8at +F, ?isual acuity impro#ement at follo up
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'ro"nosis > Luo a! #itam > onam
Luo a! fun"sional > !uia a! onam
9ollo Up > etter #isual acBuity$
attache! retina$ no complication
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Its ha#e een reporte! a case of Rhe"mato"enretinal !etachment ith "iant retinal tear mana"e!y (clera uc6le F 'ars 'lana ?itrectomy F)n!olaser F InJection silicone oil intra#itreal.
RRD cause! y lattice !e"eneration history ofhi"h miopia.
'ro"nosis !uia a! onam for this patient etter#isual acBuity$ attache! retina$ no complication
O#L"$'O#
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H !O"
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R--T
'ro"nosis > !uia a! onam
(etelah tin!a6an operasi !i!apat6anretina yan" attach dan perai6an taJam
pen"lihatan pa!a follow up$ serta ti!a6!i!apat6an 6ompli6asi tin!a6an e!ah.
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-()R TI((U) )99)CT
'hotocoa"ulation e*ects. Thermal e*ects$ those most commonly
encountere! ith retinal photocoa"ulation #isile or infrare! li"ht is asore! y tissue
pi"ment asorption of laser ener"y results in a= to = C temperature rise 111 protein!enaturation is seen clinically as tissue hitenin"
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-()R TI((U) )99)CT
Thermal e*ects.
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(EM'TOM( 8oaters 1 its of !eris in Ael! of
#ision that loo6 li6e spots$ hairs orstrin"s
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IT)R-TUR) R)?I);
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IT)R-TUR) R)?I);
Vitrectomy 4 &cleral Buc5le
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De"enerasi lattice merupa6an6elainan !ari permu6aan#itreoretinal$ !apat !itemu6an 01=% !ari populasi umum !anilateral pa!a &3 sampai
Jumlah6asus!e"enerasi lattice.De"enerasi lattice serin" munculpa!a pasien !en"an miopia$ tapiti!a6 hanya teratas pa!a pasien
?ITR)CTOME CUTT)R <-U(2 -ND
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?ITR)CTOME CUTT)R <-U(2 -NDOM<
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Retinal breaks
a - Large U-tear with‘ subclinical RD ’
- treatb - Large symptomatic U-tear
- treat
c - Operculated tear bridgedby blood vessel
- treatd - Asymptomatic operculated
tear- do not treat
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Retinal breaks not reuiring treatment
e - Asymptomatic dialysissurrounded by pigment
! - "reaks in both layers o! retinoschisis
g - #mall asymptomatic holesnear ora serrata
h - #mall inner layer holes inretinoschisis
$ypical lattice degeneration
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$ypical lattice degeneration• %resent in about &' o! general population• %resent in about ()' o! eyes with RD
• #pindle-shaped islands o! retinal thinning• *etwork o! white lines within islands• +ariable associated R%, changes• #mall round holes within lesions are common
• Overlying vitreous liue!action• ,aggerated attachments
around margin o! lesion
Retina +itreous
. li ti ! l tti d ti
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.omplications o! lattice degeneration
/ndications !or prophylais
• *o complications - in most cases• RD associated with atropic holes0 particularly in young myopes• RD associated with tractional tears in eyes with acute %+D
• RD in !ellow eye• ,tensive lattice in high myopia
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C-((I9IC-TION O9 '?R
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C-((I9IC-TION O9 '?R
The term Pproliferati#e #itreoretinopathyP as coine! in@:3 y the Retina (ociety Terminolo"y Committee.
In @:@$ the classiAcation as amen!e! y the (ilicone(tu!y roup efore ein" most recently mo!iAe! in @@ toits current classiAcation.
Currently$ '?R is !i#i!e! into "ra!es -$ <$ an! C. ra!e - is limite! to the presence of #itreous cells or ha4e. ra!e < is !eAne! y the presence of rolle! or irre"ular
e!"es of a tear or inner retinal surface rin6lin"$ !enotin"suclinical contraction.
ra!e C is reco"ni4e! y the presence of preretinal orsuretinal memranes. ra!e C is further !elineate! asein" anterior to the eBuator +"ra!e Ca, or posterior to theeBuator +"ra!e Cp, an! y the numer of cloc6 hoursin#ol#e! + to ,.
i! i i i
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%roli!erative vitreoretinopathy
• +itreous ha1e and
tobacco dust
2rade A 3minimal4
• Rigid retinal !olds
• +itreous condensationsand strands
2rade . 3severe4
• Retinal wrinkling and
sti!!ness• Rolled edges o! tears
2rade " 3moderate4
%R/*./%L,# O5 R,$/*AL D,$A.67,*$ #UR2,R8
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%R/*./%L,# O5 R,$/*AL D,$A.67,*$ #UR2,R8
9: #cleral buckling
;: %neumatic retinopey
• .on!iguration o! buckles• %reliminary steps• Locali1ation o! breaks• /nsertion o! local eplant• ,ncircling procedure• Drainage o! subretinal !luid
<: +itrectomy
• 2iant tears• %roli!erative vitreoretinopathy 3%+R4• Diabetic tractional RD
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+itrectomy !or Retinal Detachment
Release o! circum!erentialtraction
Release o! antero-posterior traction ,ndophotocoagulation
+itrectomy !or %+R
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+itrectomy !or %+R
• Dissection o! star !olds and peeling o! membranes• /n=ection o! epanding gas or silicone oil
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'ntraoc/lar gases
(ulfur hexa8uori!e +(90,per8uoropropane +C39:, are the "ases
most freBuently use!.(uccess also has een reporte! ithsterile room air.
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%reliminary steps
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%reliminary steps
%eritomy /nsertion o! suint hook underrectus muscle
/nsertion o! bridle suture /nspection o! sclera !or thinningor anomalous vorte veins
,ncircling procedure
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,ncircling procedure
#trap !ed under !our recti ,nds secured with >at1ke sleeve
#trap slid posteriorly and securedin each uadrant
#trap tightened to produce reuiredamount o! internal indentation