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BMJ Case Rep. 2010; 2010: bcr11.2009.2488.
Published online 2010 May 11. doi:  10.1136/bcr.11.2009.2488
PMCID: PMC3047528
Unusual presentation of more common disease/injury

Saved by the buckle: primary buckle vitrectomy for macular hole detachment due to rapid progression of premacular fibrosis in acute retinal necrosis

Abstract

This report describes the rapid progress of a case of unilateral acute retinal necrosis (ARN) that led to formation of a macular hole rhegmatogenous retinal detachment with advanced proliferative vitreo-retinopathy (PVR) changes over the space of 2 weeks. This necessitated primary vitrectomy with circumferential scleral buckle placement, which facilitated reattachment of the retina.

Background

I wish to inform my colleagues how rapidly fibrosis secondary to uveitis can progress in acute retinal necrosis (ARN) and lead to severe proliferative vitreo-retinopathy (PVR)-like changes. This frustrates the removal of cortical vitreous and necessitates placement of a circumferential scleral buckle during the primary vitrectomy.

Case presentation

A 38-year-old healthy Indian woman presented with features consistent with unilateral left ARN. She gave history of chicken pox in childhood. A 1 week course of intravenous aciclovir followed by oral aciclovir and oral steroids resulted in improvement of clinical signs and maintenance of 6/9 vision with normal looking macula. Prophylactic barricade laser photocoagulation was applied surrounding the areas of retinal necrosis. Six weeks after presentation she complained of 2 days of blurred vision and metamorphopsia. Dense premacular fibrosis was noted with a macula hole confirmed on ocular coherence tomography (fig 1), Vision was 6/36. There was no peripheral detachment. She was listed for elective surgery. On review 6 days later, there was total retinal detachment (RD) with stiff looking folds (fig 2).

Figure 1
Fundus photograph of the patient’s left eye showing fibrosis overlying the posterior pole with a macular hole.
Figure 2
Taken 5 days later, this photograph shows a rhegmatogenous retinal detachment with stiff looking retinal folds.

Investigations

  • HIV screening: negative
  • Herpes simplex virus 1 and 2 screening: IgM negative; IgG positive
  • Cytomegalovirus screening: IgM negative; IgG positive.

Treatment

Primary 20G pars planar vitrectomy/heavy liquid/intravitreal triamcinolone staining was performed the following day and revealed a macular hole detachment. The fibrosis and internal limiting membrane overlying the macula were peeled. The cortical vitreous was adherent to the retina and PVR membranes were immature. Primary encircling scleral buckle (276 band) was placed at the equator in anticipation of aggressive anterior PVR vitreous contraction with laser applied to the buckle and 1300 Cs silicone oil injection. The patient adopted a face down position for 2 weeks.

Outcome and follow-up

The posterior retina remained flat with a closed macular hole (fig 3). Eight months later, top-up laser, membrane peeling and combined lensectomy with oil removal were performed. There were severe anterior PVR changes flat on the buckle. She has been rendered aphakic and awaits a stable retina at 6 months postoperation for secondary intraocular lens implantation. Her vision at last review, 3 months after oil removal, was 6/18 (pinhole and +10D lens).

Figure 3
Fundus photograph showing the macular hole has closed and the posterior retina is flat under silicone oil.

Discussion

RD occurs in half of ARN eyes1—35.3% of prophylactically lasered eyes still develop RD2; 96.3% of RDs occur 3 weeks after presentation.2 Visual acuity after surgical repair only improves in a third of patients.2

Pre-retinal fibrosis and severe anterior PVR changes characterise rhegmatogenous RD (RRD) in ARN.3 Vitrectomy, silicone oil tamponade and mid periphery laser4 are recommended treatment for viral related detachments due to the presence of multiple breaks.

Scleral buckling may be omitted in cytomegalovirus related detachments in which there is very minimal PVR, unlike in this case.4 Other studies considered use of vitrectomy and scleral buckle without silicone oil,5 highlighting the importance of prophylaxis for anterior PVR in these cases with use of a buckle. Early vitrectomy with intravitreal aciclovir is a new option under study.6 There was no published study describing a macular hole detachment in ARN.

Learning points

  • Posterior fibrosis in ARN may lead to a macular hole.
  • Macular hole in ARN may rapidly lead to rhegmatogenous RD (RRD) within days.
  • PVR changes in ARN-RRD progress rapidly.
  • Prophylactic scleral buckle during primary vitrectomy is recommended when anterior cortical vitreous is adherent in ARN-RRD and for missed breaks.

Acknowledgments

Professor Dr Muhaya Hj Mohamad; my clinic staff and colleagues

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Sternberg P, Jr, Han DP, Yeo JH, et al. Photocoagulation to prevent retinal detachment in acute retinal necrosis. Ophthalmology 1988; 95: 1389–93. [PubMed]
2. Lau Chun H, Missotten T, Salzmann J, et al. Acute retinal necrosis: features, management, and outcomes. Ophthalmology 2007; 114: 756–762.e1. [PubMed]
3. Hamid A, Masoud S, Mohsen A, et al. Surgical management of retinal detachment secondary to acute retinal necrosis: clinical features, surgical techniques, and long-term results. Jpn J Ophthalmol 2003; 47: 484–91. [PubMed]
4. García RF, Flores-Aguilar M, Quiceno JI, et al. Results of rhegmatogenous retinal detachment repair in cytomegalovirus retinitis with and without scleral buckling. Ophthalmology 1995; 102: 236–45. [PubMed]
5. Canzano JC, Morse LS, Wendel RT. Surgical repair of cytomegalovirus-related retinal detachment without silicone oil in patients with AIDS. Retina 1999; 19: 274–80. [PubMed]
6. Hillenkamp J, Nölle B, Bruns C, et al. Acute retinal necrosis: clinical features, early vitrectomy, and outcomes. Ophthalmology 2009; 116: 1971–5.e2. [PubMed]

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