A delay in absorption of subretinal fluid after surgical repair for rhegmatogenous retinal detachment beyond 6 weeks was recognized in 39 of 575 consecutive cases undergoing scleral buckling procedures. The most common preoperative condition that was identified in these eyes was large clumps of cells on the undersurface of the detached retina. These cream-colored aggregates appeared similar to mutton-fat keratic precipitates and are referred to as subretinal precipitates. Most likely caused by aggregates of macrophages, they were present in 12 percent of the overall series of cases; subretinal precipitates also were recognized and documented before operation in nearly half of the eyes with delayed fluid absorption, a relationship that is highly significant in statistical analysis (P less than 0.001). On recognizing them before operation, the clinician can expect that approximately a fourth of the eyes will have fluid persisting beyond 6 weeks from the time of surgical repair until complete absorption. A second relatively common condition associated with delayed absorption of fluid that could be recognized in advance of surgical treatment was a long-standing peripheral (usually inferior) retinal detachment, which typically spared the macula, was associated with demarcation lines, and was caused by round atrophic holes with or without lattice degeneration. The presence of demarcation lines (reflecting relatively long-standing retinal detachment) was also positively correlated with delayed fluid absorption (P less than 0.02). Other conditions associated with delayed absorption of fluid included detachments of long-standing duration by history (especially when associated with previous unsuccessful efforts to repair the retina), vitreoretinal traction, and conditions whereby the choriocapillaris-retinal pigment epithelial complex and been significantly disturbed. Such conditions included hemorrhage into the subretinal space as a complication of surgical relase of subretinal fluid, previous retinal surgery, and possibly heavy treatment with cryopexy, especially when associated with exudative detachment. An analysis of subretinal fluide from 39 eyes showed a positive relationship between protein concentration and duration of the detachment but no relationship to a variety of other factors, including the presence of subretinal precipitates. Commonly identified cellular structures in the subretinal space consisted of pigmentladen macrophages. When studied by electron microscopy, some of these were thought to have originated from the retinal pigment epithelium.
This paper reports a young patient with a traumatic rhegmatogenous retinal detachment and massive vitreous gel incarceration into the subretinal space, who was successfully treated with 23-gauge transconjunctival vitrectomy.
An 11-year-old boy was referred to the authors’ clinic with traumatic retinal detachment in the right eye, 2 weeks after ocular contusion in a baseball accident. At the time of the injury, emergency fundus examination by his local doctor had revealed vitreous hemorrhage in the inferior quadrant of the right eye. Visual acuity was 1.5. He had continued to play baseball as usual for 2 weeks after the injury. At his first visit to the authors’ clinic, fundus examination showed a highly bullous retinal detachment involving the inferior two quadrants, associated with multiple irregular retinal breaks. There was an oval hole in the inferior quadrant which was 10-disc diameter × 5-disc diameter in size and was surrounded by edematous and hemorrhagic retina. The macula remained attached. Absolute rest for 4 hours in the supine position with binocular occlusion did not diminish the height of the retinal detachment. A 23-gauge three-port pars plana vitrectomy combined with 360° circumferential buckling was performed under general anesthesia. The lens was retained. Incarceration of massive vitreous gel, including vitreous hemorrhage into the subretinal space through the largest break, was observed during vitrectomy. Reattachment of the retina was achieved by fluid–air exchange and internal tamponade using SF6 gas. At follow-up at 9 months, the retina remained attached and visual acuity in the right eye was 1.2.
retinal detachment; trauma; contusion; vitrectomy
The role of vitreous traction on retinal detachment “settling” with bilateral patching has been studied computationally. Vitreous traction, induced by eye movements and suppressed with bilateral patching, creates a subretinal vacuum that promotes increased retinal detachment.
When a patient suffers a retinal detachment and surgery is delayed, it is known clinically that bilaterally patching the patient may allow the retina to partially reattach or “settle.” Although this procedure has been performed since the 1860s, there is still debate as to how such a maneuver facilitates the reattachment of the retina.
Finite element calculations using commercially available analysis software are used to elucidate the influence of reduction in eye movement caused by bilateral patching on the flow of subretinal fluid in a physical model of retinal detachment.
It was found that by coupling fluid mechanics with structural mechanics, a physically consistent explanation of increased retinal detachment with eye movements can be found in the case of traction on the retinal hole. Large eye movements increase vitreous traction and detachment forces on the edge of the retinal hole, creating a subretinal vacuum and facilitating increased subretinal fluid. Alternative models, in which intraocular fluid flow is redirected into the subretinal space, are not consistent with these simulations.
The results of these simulations explain the physical principles behind bilateral patching and provide insight that can be used clinically. In particular, as is known clinically, bilateral patching may facilitate a decrease in the height of a retinal detachment. The results described here provide a description of a physical mechanism underlying this technique. The findings of this study may aid in deciding whether to bilaterally patch patients and in counseling patients on pre- and postoperative care.
To assess microstructural changes in the retina that may explain incomplete visual recovery after anatomically successful repair of rhegmatogenous retinal detachments (RD) using ultrahigh-resolution optical coherence tomography (UHR OCT).
Retrospective observational case series.
Seventeen patients with decreased visual acuity after RD repair. Twelve patients had macula-involving and 5 had macula-sparing RDs.
The UHR OCT prototype capable of ~3 μm axial resolution was developed for clinical use. The UHR OCT images through the center of the fovea in 17 patients with visual complaints after RD surgery were obtained. Patients were either postoperative patients from the New England Eye Center or tertiary referrals. Baseline visual acuity, preoperative lens status, location of retinal detachment, macular involvement, and postoperative visual acuity were recorded.
Main Outcome Measures
The UHR OCT images after RD repair.
The UHR OCT images were obtained 1 to 84 months (median, 5 months) postoperatively. The mean preoperative logarithm of the minimum angle of resolution (logMAR) visual acuity was 1.37 (Snellen equivalent, 20/390). The mean postoperative logMAR visual acuity was 0.48 (Snellen equivalent, 20/60). Anatomical abnormalities that were detected included distortion of the photoreceptor inner/outer segments (IS/OS) junction in 14 of 17 patients (82%), epiretinal membranes in 10 of 17 patients (59%), residual subretinal fluid in 3 of 17 patients (18%), and cystoid macular edema in 2 of 17 patients (12%). Of the 5 patients with preoperative macula-on detachments, 4 had distortion of the outer retina after RD repair.
The higher resolution of UHR OCT facilitates imaging of the IS/OS junction. Therefore, UHR OCT is able to confirm prior histopathologic findings that damage to photoreceptor outer segments may occur as a consequence of retinal detachment. This may explain poor postoperative visual acuity in eyes with anatomically successful repair.
To report the rare occurrence of peripheral retinal sea-fan neovascularization in a patient with chronic rhegmatogenous retinal detachment and describe the surgical management.
A 29-year-old female patient was referred to our department by her ophthalmologist for investigation and treatment of peripheral retinal neovascularization in her right eye(RE). Visual acuity(VA) at presentation was 20/200 RE and 20/20 LE. Fundoscopy of the RE revealed a chronic inferotemporal retinal detachment and peripheral neovascularization with a sea fan configuration. Fundoscopy of the LE was without any findings. Fluorescein angiography confirmed the sea fan neovascularization in the RE with leakage of the newly formed vessels and peripheral ischemia while the LE did not demonstrate any neovascularization angiographically. Family history was negative for retinitis pigmentosa and haemoglobinopathies. Patient underwent full blood count and haemoglobin electrophoresis to exclude thrombocytosis and sickle cell anaemia, and serum angiotensin-converting enzyme (SACE) measurement to exclude sarcoidosis. Examination with scleral indentation of the RE revealed 2 peripheral small retinal holes close to the ora serrata . The patient underwent a scleral buckling procedure with a small segmental buckle limited to the area of the holes and cryotherapy. Ccryotherapy was not applied to the area with neovascularization and no subretinal fluid drainage was performed. The detached retina was successfully re-attached surgically and the subretinal fluid was gradually absorbed within three months from the time of surgery. Complete regression of neovascularization was evident 2 months postoperatively and VA improved to 20/30. Three years later the clinical and functional findings remain unchanged.
Our case illustrates the rare but possible association of chronic retinal detachment with peripheral retinal sea-fan neovascularization; although the incidence is rare it may pose diagnostic and treatment dilemmas. In such cases and in the presence of retinal breaks, cryotherapy and a segmental buckle limited to the retinal holes and not on the neovascularization seems to suffice for the regression of the new vessels.
Chronic retinal detachment; Sea-fan neovascularization; Scleral buckling
The following is a brief summary of the results in our ten groups of cases. The positive features of laser scotometry are emphasized. The normal response is well defined: there are no uncertain blind spot margins. The peripheral field is probably extended beyond 60 degrees nasally and superiorly. The size and shape of the small central scotomas associated with macular holes are easily defined and correlated directly with the visible edge of the hole. This result is distinct from the intact subjective response with cystoid maculopathy and surface wrinkling retinopathy. Plotting the margins of peripheral abnormalities such as retinal detachments, retinoschisis, and lattice degeneration is easily done. Schisis is distinguished by an absolute scotoma. This scotometry is facilitated by a larger "normal" field with the laser instrument. Lattice degeneration causes a field defect. A branch retinal artery occlusion shows a slightly jagged border, difficult to detect by standard methods. A cotton-wool spot does not show a total nerve-fiber-bundle defect. Small absolute scotomas are correlated with degenerative changes within nevi. Degenerative changes over small melanomas--ie, the orange spots--also produce absolute field defects. "Bear track" lesions have a normal field, whereas dense black isolated lesions are associated with absolute scotomas. In macular degeneration the bright laser test object is usually visible to the patient within detachments of neuroepithelium, detachments of the pigment epithelium, and over recent subretinal neovascularization. Response is absent over sharply-defined zones of pigment atrophy and over late subretinal fibrovascular mounds. In contrast to the degenerative cases, a selection of hereditary cases showed no direct correlation between the zone of pigment atrophy and the zone of absolute scotoma. The scotoma was much larger than the atrophic region, extending to the edge of the cream-colored subretinal spots. The laser target method sharply defines the absolute scotoma associated with papilledema. It also detects a slit-like nerve-fiber-bundle defect, suggesting progressive damage. Small, but possibly not the earliest, scotomas associated with glaucoma can be detected with laser scotometry. In some cases they are detected when the Goldmann perimetric field is normal. Late residual visual fields are easily defined, since fixation can be directly monitored. The vertical border of hemianopic defects can be defined within one degree of accuracy.
Extramacular branch retinal vein occlusion (BRVO) occasionally causes serous macular detachment. We studied the movement of extravasated fluid from BRVO lesions to the submacular space.
We examined nine eyes from nine patients with serous retinal detachment caused by extramacular BRVO. In addition to a comprehensive ophthalmic examination, optical coherence tomography was performed in all nine eyes. Six of the patients also underwent fluorescein angiography.
Visual acuity ranged from 0.03 to 0.9 (median 0.5). All nine eyes showed localized macular detachment and retinal edema which extended from the extramacular BRVO to the macula. Fluorescein angiography revealed dye leakage in the extramacular area but no macular leakage in the six eyes examined. Optical coherence tomography revealed serous retinal detachment in the macula and intraretinal swelling, with low reflectivity in the outer retina extending from the distant BRVO toward the detached macula in all nine eyes. Six eyes were treated with laser photocoagulation, covering the entire area of BRVO, and the other three eyes were treated with intravitreal bevacizumab. Serous retinal detachment and retinal swelling resolved within 3 months of treatment in all nine eyes.
Distant retinal vascular leakage appears to diffuse through the outer retina to the macula, then permeate into the subretinal space.
branch retinal vein occlusion; optical coherence tomography; serous macular detachment; fluorescein angiography; outer retina
Purpose. To describe the findings of fundus autofluorescence (FAF) and optical coherence tomography (OCT) in patients with branch retinal vein occlusion (BRVO). Methods. In this institutional, retrospective, observational case series, FAF was evaluated in 65 eyes with BRVO in 64 consecutive patients and compared with visual acuity, OCT findings, and other clinical observations. Results. Five types of autofluorescence appeared during the course of BRVO: (1) petaloid-shaped hyperautofluorescence in the area of macular edema and (2) hyperautofluorescence coincident with yellow subretinal deposits. (3) Diffuse hyperautofluorescence appeared within the area of serous retinal detachment (SRD) and OCT showed precipitates on the undersurface of the retina in 5/5 of these eyes (100%). (4) The area of vein occlusion showed diffuse hyperautofluorescence after resolution of the retinal bleeding. (5) Hard exudates exhibited hyper- or hypoautofluorescence. OCT indicated that most of the hard exudates with hyperautofluorescence were located on the retinal pigment epithelium. Conclusions. Hyperautofluorescence associated with subretinal fluid or hard exudate appeared in the subretinal space. This type of hyperautofluorescence may be attributed to blood cell or macrophages. FAF and OCT are noninvasive modalities that provide additional information regarding macular edema due to BRVO.
A group of patients with retinal breaks without detachment were analyzed. They were divided into a treatment and a nontreatment group. The treatment group consisted of cases that the authors felt to be at high risk for the development of retinal detachment. Most of these were cases of horseshoe tears following the onset of an acute posterior vitreous detachment. Although a number of modalities were used in the treatment, a transconjunctival cryotherapy approach with topical anesthetic drops is currently used and was the most frequently employed. It is of note that while no case in this series developed a detachment because of inadequate treatment of the original tear a certain number did develop new tears and detachments. This would speak for a frequent follow-up, especially within the first three months following treatment, to anticipate such an occurrence. In the untreated group there were essentially two types of patients. One was the asymptomatic patient in which a retinal tear was found on routine examination and the other was the symptomatic patient with a round hole with pulled out operculum. New tears and or detachments also occurred in the asymptomatic group (4 of 72 eyes) but none of the round holes with pulled out opercula detached. Complications of treatment were related to the anesthesia and included vasovagal reactions and retrobulbar hemorrhage. One case seen in consultation had evidence of scleral perforation from a bridle suture and illustrates the inherent danger in any ophthalmic ocular procedure. The question of macular pucker (pre-retinal fibrosis) as a high risk of treatment is not shown by this study and in fact was more common in the untreated group than the treated group; however the vision of patients with macular pucker in the treated group was generally less than that of those untreated. Recurrent vitreous hemorrhage from bridging or avulsed vessels represented a significant problem following treatment and led to the only case of total visual loss in this study. The prophylactic treatment of acute horseshoe tears with continuing vitreous traction significantly reduces the incidence of subsequent retinal detachment. Whatever method of treatment is chosen by the surgeon, he must follow the principles laid down many years ago by Jules Gonin and completely close the tear. However, it is important to recognize that a new tear or detachment may occur in some cases and seems related to the continuing evolution of the posterior vitreous detachment or residual vitreo-retinal adherence rather than a cause of the treatment itself.
In a consecutive series of 470 cases of rhegmatogenous retinal detachment 25 (5%) were found to have shifting subretinal fluid (SRF) at the preoperative examination. The study showed that the association between SRF and rhegmatogenous retinal detachment is unusual but not rare. Shifting SRF was most often associated with aphakic and longstanding retinal detachment, and found in cases in which the retinal holes were small.
The purpose of this study was to characterize the peripheral retinal findings in highly myopic young children without other known risk factors for retinal detachment.
A retrospective review of all cases of children ≤10 years of age with high myopia (>6.00 diopters) who were evaluated for presumed risk of retinal detachment by either an examination under anesthesia or office examination by a single retina specialist from January 2001 through December 2008. Patients with regressed retinopathy of pre-maturity, retinal detachment in the fellow eye, or known Stickler syndrome were excluded.
Fifty-four eyes of 30 patients with high myopia were examined. Twenty-six eyes of 14 patients were examined under anesthesia because of the examiner’s inability to adequately visualize the peripheral retina during an office examination. Mean age at examination was 6 ± 3 (range, 1–10) years. Mean spherical equivalent refractive error was −13.88 ± 3.79 (range, −6.00 to −25.00) diopters. Peripheral retinal findings were identified in 33% of eyes, the most common being lattice degeneration (20%), white without pressure (11%), and retinal holes with subretinal fluid (4%).
Approximately one third of highly myopic children in our study showed peripheral retinal findings. If the peripheral retina is not adequately visualized during an office evaluation, examination under anesthesia should be considered.
high myopia; fundus features; peripheral retina; lattice degeneration; retinal detachment; retinal holes; white without pressure; examination under anesthesia; pediatric
Earlier studies have revealed a decreased level of cGMP in vitreous fluid obtained from patients with a retinal detachment. To further investigate this phenomenon, we developed an experimental retinal detachment model in pigs.
Experimental unilateral retinal detachments were induced in pig eyes by subretinal injection of 0.25% sodium hyaluronate. Fourteen days later the vitreous and retinas were analyzed for cGMP expression. Following enucleation, the retinas were incubated in the presence of a nonselective phosphodiesterase inhibitor (IBMX), and the particulate guanylyl cyclase stimulator atrial natriuretic peptide (ANP) or the soluble guanylyl cyclase stimulator sodium nitroprusside (SNP). cGMP was visualized in retinal wholemounts by immunochemistry combined with a computer based stereology system. cGMP levels in vitreous were determined by ELISA.
The mean vitreous cGMP level in pig eyes with a retinal detachment (1.45 pmol/ml) was significantly lower compared to the mean level of cGMP in healthy pig eyes (4.61 pmol/ml; p=0.028 was considered significant). In the inner retina, ANP as well as SNP induced cGMP immunoreactivity in both detached and healthy retinas. After incubation with ANP, cGMP could also be detected in the outer nuclear layer of the detached retina, whereas this was not the case in the normal retina.
Experimental retinal detachment in the pig eye leads to a decrease of cGMP levels in vitreous similar to that observed in clinical studies. This model may be helpful to analyze the mechanisms involved in cGMP dynamics following retinal detachment.
The pathogenesis of development and progression of neurosensory retinal detachment (NSD) in diabetic macular edema (DME) is not yet fully understood. The purpose of this study is to describe the spectral domain optical coherence tomography (SD-OCT) morphological characteristics of NSD associated with DME in the form of outer retinal communications and to assess the correlation between the size of communications and various factors.
Materials and Methods:
This was an observational retrospective nonconsecutive case series in a tertiary care eye institute. We imaged NSD and outer retinal communications in 17 eyes of 16 patients having NSD associated with DME using SD-OCT. We measured manually the size of the outer openings of these communications and studied its correlation with various factors. Statistical analysis (correlation test) was performed using the Statistical Package for Social Sciences (SPSS) software (version 14.0). The main outcome measures were correlation of the size of communications with dimensions of NSD, presence of subretinal hyper-reflective dots, and best-corrected visual acuity (BCVA).
The communications were seen as focal defects of the outer layers of elevated retina. With increasing size of communication, there was increase in height of NSD (r = 0.701, P = 0.002), horizontal diameter of NSD (r = 0.695, P = 0.002), and the number of hyper-reflective dots in the subretinal space (r = 0.729, P = 0.002). The minimum angle of resolution (logMAR) BCVA increased with the increasing size of communications (r = 0.827, P < 0.0001).
Outer retinal communications between intra and subretinal space were noted in eyes having NSD associated with DME. The size of communications correlated positively with the size of NSD and subretinal detachment space hyper-reflective dots, and inversely with BCVA.
Diabetic macular edema; neurosensory detachment; outer retinal communications; spectral domain optical coherence tomography; subretinal detachment space hyper-reflective dots
Finding all retinal breaks is a critical step in rhegmatogenous retinal detachment (RRD) surgery in order to prevent persistent/recurrent retinal detachment (RD). We describe a technique of trans-scleral dye injection into the subretinal fluid under the detached retina in the context of recurrent/persistent RD in vitrectomized eyes, in order to determine the location of clinically unidentified (occult) retinal breaks causing RD.
Retrospective consecutive single-surgeon case-series analysis of patients presenting with a repeat RRD after having been treated with pars plana vitrectomy (PPV) as the method of primary RRD repair. Trans-scleral injection of subretinal vision blue (TSVB) was used to help identify retinal breaks during repeat vitrectomy. Outcome measures: successful detection of a break; location of breaks; persistent retinal attachment; final visual acuity (VA); complications.
There were 395 cases of RRD during the 3-year period reviewed. TSVB was used for eight instances in seven eyes. All eight instances were repeat RRD. TSVB facilitated occult break detection in 7/8 instances of use. Breaks were at or adjacent to the previous cryo site in three instances. Persistent retinal attachment was achieved in 5/7 cases. Final VA increased in 5/7 cases. There was no evidence of complications as a result of TSVB injection.
TSVB coupled with indentation to vent a plume of dye through an occult break during vitreous surgery is a relatively simple technique that may facilitate the identification of occult retinal breaks and help achieve anatomical success and functional success.
retinal detachment; retinal re-detachment; occult retinal breaks; sub-retinal dye injection; vision blue; chromophore-assisted break detection
The purpose of this paper is to report an unusual case of accumulation of residual subretinal fluid after surgery for acute rhegmatogenous retinal detachment, sparing the fovea. A 28-year-old male presented with a four-day history of acute visual loss in his right eye secondary to bulbous rhegmatogenous retinal detachment, sparing the fovea. The patient underwent an uneventful pars plana vitrectomy and scleral buckling procedure. At four weeks postoperatively (after complete gas resorption), the visual acuity was 20/40. However, the patient complained of blurred vision. A dilated fundus examination showed a fat retina and the presence of multiple yellowish subretinal deposits resembling vitelliform lesions in the macula. Some lesions were encroaching on the fovea, and were connected via a tract to a previous horseshoe tear with evidence of a thin layer of subretinal fluid. The patient symptoms persisted for one year postoperatively. However, the retina remained fat with evidence of retinal pigment epithelium mottling and faint scars corresponding to previous lesions. Persistent subretinal fluid with thick subretinal precipitate can occur even after successful surgery for acute retinal detachment sparing the fovea and cause visual dysfunction.
rhegmatogenous retinal detachment; subretinal fluid composition; persistent subretinal fluid; visual dysfunction
To evaluate the ability of X-linked inhibitor of apoptosis (XIAP) gene therapy to provide neuroprotection to cells of the outer nuclear layer (ONL) of the retina after retinal detachment.
Subretinal injections of a recombinant adenoassociated virus (rAAV) encoding either XIAP or green fluorescent protein (GFP; injection control) were performed in the left eye of Brown Norway rats. Two weeks later, retinal detachments were created at the site of viral injection by delivering sodium hyaluronate into the subretinal space. Retinal tissue was harvested at 24 hours after retinal detachment and was analyzed for caspase 3 and 9 activity. Histologic analysis was conducted on samples taken at 3 days and 2 months after detachment to confirm the presence of XIAP or GFP expression and to assess levels of apoptosis and changes in retinal thickness.
Caspase assays performed 24 hours after detachment confirmed an expected increase in caspase 3 and 9 activity in the detached regions of GFP-treated retinas, whereas XIAP-treated detached retinas behaved comparably to attached controls. TUNEL analysis of 3-day tissue samples showed fewer apoptotic cells in XIAP-treated detachments than in GFP-treated detachments. At 2 months after the detachment, histology and immunohistochemistry confirmed the preservation of the ONL at sites of XIAP overexpression, whereas the GFP-treated detached retinas had significantly deteriorated.
The results suggest that XIAP confers structural neuroprotection of photoreceptors for at least 2 months after retinal detachment.
To define optical coherence tomographic (OCT) criteria for the diagnosis of a lamellar macular hole, and to increase understanding of lamellar hole pathogenesis by examining fine anatomic features using ultrahigh-resolution optical coherence tomography (UHR OCT).
Retrospective observational case series.
Nineteen eyes of 18 patients with lamellar holes were imaged with UHR OCT between 2002 and 2004.
A UHR OCT system was developed for use in the ophthalmology clinic. All 6 UHR OCT images for each eye imaged were examined. Lamellar holes were diagnosed based on a characteristic OCT appearance. Criteria for the OCT diagnosis of a lamellar hole were as follows: (1) irregular foveal contour; (2) break in the inner fovea; (3) intraretinal split; and (4) intact foveal photoreceptors. From 1205 eyes of 664 patients imaged with UHR OCT, and retrospectively reviewed, 19 eyes of 18 patients were diagnosed with a lamellar hole based on these criteria. All 19 eyes were also imaged with standard resolution OCT. Their charts were retrospectively reviewed.
Main Outcome Measures
Standard and ultrahigh-resolution OCT images.
On chart review, clinical diagnosis of a lamellar hole was made in only 7 of 19 eyes (37%). Twelve of 19 eyes (63%) had an epiretinal membrane (ERM) on clinical examination. Ten of 19 eyes (53%) had a posterior vitreous detachment. On UHR OCT, 17 of 19 eyes (89%) had ERMs. Eleven ERMs had an unusual thick appearance on UHR OCT. Due to poor visual acuity, 4 eyes underwent vitrectomy. Only 1 of 4 surgeries (25%) was visually and anatomically successful. Another eye improved visually, but a lamellar hole persisted. One eye progressed to a full-thickness macular hole preoperatively, which reopened after surgery. One eye developed a full-thickness hole postoperatively.
The diagnosis of a lamellar hole can be made based on OCT criteria, which could be applied to both standard and ultrahigh-resolution OCT. The increased resolution of UHR OCT sheds light on the pathogenesis of the lamellar hole. Epiretinal membranes were visualized on UHR OCT in the majority of eyes. Many ERMs had an unusual thick appearance on UHR OCT, which may represent either trapped vitreous or posterior hyaloid, and may help stabilize retinal anatomy. Conversely, ERM contraction may play a role in lamellar hole formation. Vitrectomy surgery was anatomically and visually successful in only 1 of 4 patients, suggesting caution when performing vitrectomy on lamellar holes.
Seventy-seven patients developed retinal breaks following an episode of ocular contusion, and 65 (84.4%) of these developed rhegmatogenous retinal detachment. Surgical treatment successfully restored or maintained retinal apposition in 74 (96.1%) of the eyes. Thirty-six (46.8%) eyes recovered visual acuity of 6/9 or better. Of the retinal breaks recognised dialysis at the ora serrata was observed in 49 eyes, of which 28 were situated at the lower temporal quadrant. Seventeen eyes had irregular breaks arising within necrotic retina at the site of scleral impact. Twenty-four (31.2%) patients had retinal break or retinal detachment diagnosed within 24 hours of injury and 49 (63.6%) within six weeks. Immediate retinal detachment was a feature of necrotic retinal breaks, while inferior oral dialyses led to a slow accumulation of subretinal fluid. Delayed diagnosis of retinal detachment was due either to opaque media or to failure to examine the retina after injury. Visual prognosis was good when retinal break or detachment were diagnosed within six weeks of injury. However, those patients who escaped initial retinal examination and were lost to follow-up had a less favourable visual outcome.
Diplopia following retinal detachment usually responds to simple measures. Fifteen out of 311 cases developed diplopia lasting more than three months after conventional retinal detachment surgery. Binocular single vision was restored in 12 of the 15 cases (80%). The mean follow-up was four years. Diplopia was eliminated stepwise. If prisms were ineffective, our first surgical procedure was removal of the scleral buckle. If the retina was flat, we were prepared to remove the buckle early. When diplopia persisted after buckle removal, we proceeded to strabismus surgery. Our most consistent results followed strabismus surgery on the untreated eye. Prisms alone restored binocular single vision in six patients (40%), one of whom preferred to adopt a compensatory head posture. Removal of the scleral buckle restored binocular single vision in three patients (20%), with the help of a prism in one case and a compensatory head posture in another. Binocular single vision was restored after buckle removal and strabismus surgery in three further patients (20%), one requiring a prism in addition. Binocular single vision was not restored in three patients (20%).
Blood–retinal barrier breakdown secondary to retinal detachment and retinal detachment repair is a factor in the pathogenesis of proliferative vitreoretinopathy (PVR). We wished to investigate whether an estimated 700 to 1000 ng/ml subretinal dexamethasone concentration at the time of surgery would decrease the blood–retinal barrier breakdown postoperatively.
Prospective, placebo-controlled, double blind clinical trial. In 34 patients with rhegmatogenous retinal detachment scheduled for conventional scleral buckling retinal detachment surgery, a subconjunctival injection of 0.5 ml dexamethasone diphosphate (10 mg) or 0.5 ml placebo was given 5–6 hours before surgery. Differences in laser flare photometry (KOWA) measurements taken 1, 3 and 6 weeks after randomisation between dexamethasone and placebo were analysed using mixed model ANOVA, while correcting for the preoperative flare measurement.
Six patients did not complete the study, one because of recurrent detachment within 1 week, and five because they missed their postoperative laser flare visits. The use of dexamethasone resulted in a statistically significant decrease in laser flare measurements at the 1-week postoperative visit.
The use of a preoperative subconjunctival injection of dexamethasone decreased 1-week postoperative blood–retina barrier breakdown in patients undergoing conventional scleral buckling retinal detachment surgery. This steroid priming could be useful as a part of a peri-operative regime that would aim at decreasing the incidence of PVR.
Preoperative; Subconjuctival injection; Dexamethasone; PVR; Blood–retina barrier; Breakdown
To characterize the development of retinal detachment after open globe trauma.
892 patients comprising 893 open globe injuries, of which 255 were ultimately diagnosed with retinal detachment, with the remaining eyes serving as controls.
Retrospective chart review of open globe injuries presenting to the Massachusetts Eye and Ear Infirmary between 1999 and 2011. Kaplan-Meier analysis was used to estimate time to detachment and multivariable logistic regression was used to define clinical factors associated with retinal detachment after open globe injury.
Main Outcome Measures
Demographic and clinical characteristics at the time of presentation after open globe injury, date of retinal detachment diagnosis, and last date of follow-up.
Primary repair of the open globe was typically undertaken within hours of presentation. 255 eyes were ultimately diagnosed with retinal detachment after open globe trauma, yielding an incidence of 29% (95% confidence interval: 26%-32%). For eyes that developed retinal detachment, 27% (69/255) detached within 24 hours of primary open globe repair, 47% (119/255) detached within one week, 72% (183/255) within one month. Multivariable regression analysis revealed presence of vitreous hemorrhage (odds ratio: 7.29, p<0.001), higher zone of injury (odds ratio: 2.51 per integer increase in zone number, odds ratio: 1.00-6.30, p<0.001), and poorer Logarithm of the Minimum Angle of Resolution visual acuity at the time of presentation after open globe injury (odds ratio: 2.41 per integer increase in Logarithm of the Minimum Angle of Resolution visual acuity, odds ratio: 1.00-81.30, p<0.001) to be associated with retinal detachment. A screening tool, named herein the Retinal Detachment after Open Globe Injury (RD-OGI) score, was created.
Retinal detachment is common after open globe trauma, though often not appearing until days to weeks after the initial traumatic event. Several clinical variables at the time of initial presentation can predict the future risk of detachment.
Aim: To study the etiology of rhegmatogenous retinal detachment and visual outcome after retinal detachment surgery.
Materials and Methods: Retrospective study conducted at the tertiary eye care hospital over a period of one year. Thirty eyes of 30 patients were included after fulfilling the inclusion criteria. Complete ocular examination details of each patient such as visual acuity for distant vision (checked with Snellen’s acuity chart),slit lamp examination, fundus examination (done with +90D lens) and binocular indirect ophthalmoscopy. In addition the following were noted: extent of the detachment present, position and number of breaks, status of the macula, presence of PVR, mobility of retina and presence of any peripheral retinal degenerations, and fundus photographs of the patient (before and after surgery).
Results: Risk factors for retinal detachment included myopia in 7 eyes (23.3%), prior cataract surgery in 10 eyes (33.3%), peripheral retinal degeneration in 3 eyes (10%) and traction with new vessels in 1 eye (3.3%). Eighteen eyes (60%) presented with macula off while 12 eyes (40%) presented with macula partly or completely attached. Visual acuity at presentation was <3/60 in 16 eyes. Following surgery, retina was attached in 28 eyes (93.3%) and remained detached in 2 eyes (6.7%). Visual acuity after surgery was <3/60 in 12 eyes.Visual acuity improved in 13 eyes (43.3%), remained the same in 16 eyes (53.3%) and worsened in 1 eye (3.3%).
Conclusion: Myopia and prior cataract surgery are important risk factors for Rhegmatogenous Retinal Detachment. Majority of patients in this setting presented late with Rhegmatogenous Retinal Detachment and this was responsible for relatively poor visual outcomes despite good anatomical results after surgery. Proper screening of eyes at risk and education of patients is important for preventing visual loss due to retinal detachment.
Buckling; Cryopexy; Proliferative vitreoretinopath; y Retinal detachment
Spontaneous closure of an idiopathic full-thickness macular hole has been reported to occasionally occur. However, the cells involved in plugging the macular hole have not been determined conclusively. We aimed to report the early structural changes that occur during a spontaneous closure of an idiopathic full-thickness macular hole determined by spectral-domain optical coherence tomography.
A 71-year-old Japanese man with an idiopathic full-thickness macular hole and subclinical posterior vitreous detachment in the left eye was followed. Three weeks after the identification of the macular hole, optical coherence tomography showed tissue that protruded from the interior wall of the macular hole at the level of the external limiting membrane toward the center of the macular hole. Five months after the first examination, he returned with improvements of his visual symptoms, and the macular hole was closed by a thin retinal tissue which included the restored external limiting membrane that bridged across the macular hole. However, the inner segment/outer segment junction line was not intact and the fovea was detached. Two months later, optical coherence tomography showed an almost normal foveal configuration with an essentially restored inner segment/outer segment junction line and foveal reattachment.
Our results suggest that Müller cells proliferate and/or extend at the level of the end of the external limiting membrane to form a tissue bridge across the macular hole associated with the external limiting membrane restoration first of all. This leads to the adhesion of other retinal layers and resolution of the foveal detachment.
Idiopathic full thickness macular hole; Spontaneous resolution of macular hole; Optical coherence tomography; Müller cell; External limiting membrane
Macular hole related retinal detachment is a common entity with poor surgical prognosis in highly myopic eyes. We describe the first case of spontaneous closure of a macular hole with complete retinal reattachment in a highly myopic eye with posterior staphyloma.
A 64-year-old Chinese woman with high myopia was diagnosed as having a macular hole-related retinal detachment with vitreo-retinal traction in her right eye by optical coherence tomography. Thirty-three months later, the macular hole closed, with formation of a lamellar hole and decreased retinal detachment. Twelve months later, retinal reattachment was found to have occurred, accompanied by the development of macular retinoschisis. Fifty-four months after initial examination, the retina remained attached with a lamellar hole and retinoschisis in the macular area. The vitreo-retinal traction persisted during the follow-up period.
As evidenced by the current case, in highly myopic eyes, the vitreoretinal traction force, which contributes to a macular hole and retinal detachment, could be partially released by the development of a lamellar hole or foveal schisis. This reduction of traction might contribute to retinal reattachment.
Myopia; Macular hole; Retinal detachment; Optical coherence tomography
Optical coherence tomography (OCT) has revolutionized the field of ophthalmology since its introduction 20 years ago. Originally intended primarily for retina specialists to image the macula, it has found its role in other subspecialties that include glaucoma, cornea, and ocular oncology. In ocular oncology, OCT provides axial resolution to approximately 7 microns with cross-sectional images of the retina, delivering valuable information on the effects of intraocular tumors on the retinal architecture. Some effects include retinal edema, subretinal fluid, retinal atrophy, photoreceptor loss, outer retinal thinning, and retinal pigment epithelial detachment. With more advanced technology, OCT now provides imaging deeper into the choroid using a technique called enhanced depth imaging. This allows characterization of the thickness and reflective quality of small (<3 mm thick) choroidal lesions including choroidal nevus and melanoma. Future improvements in image resolution and depth will allow better understanding of the mechanisms of visual loss, tumor growth, and tumor management.