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Abouzeid Et Al-2009-Acta Ophthalmologica

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  Introduction Despite successful surgery for macula-off retinal detachment (RD) and totalretinal reattachment on fundus exami-nation, visual recovery may remainincomplete. This may be caused byseveral pre- and postoperative factorssuch as preoperative visual acuity,duration of the detachment, postoper-ative cystoid macular oedema andepiretinal membrane development(Abouzeid & Wolfensberger 2006). Re-cently, optical coherence tomography(OCT)-based studies have shown afurther possible postoperative factorcharacterized by long-term persistenceof subfoveal fluid after buckle surgery,which may be associated with limitedpostoperative visual acuity recovery(Wolfensberger & Gonvers 2002;Lecleire-Collet et al. 2005). It appearsthat this OCT phenomenon may bemuch less common in patients oper-ated on with vitrectomy (Wolfens-berger & Gonvers 2002). The role of residual vitreous gel and of the surgi-cal technique in the creation andmaintenance of this residual fluidremains unclear to date. In order toinvestigate a specific subgroup of patients with a less liquefied vitreousgel and usually subacute RD, we per-formed an OCT-based study of per-sistent subretinal fluid after bucklesurgery for inferior macula-off RDwith and without external fluid drain-age in young patients. Materials and Methods We studied a group of six youngpatients (five female, one male; meanage 31 ± 6 years) who were operatedon within a 2-year period for a spon-taneous unilateral inferior macula-off retinal detachment caused by one(three patients) or multiple (threepatients) inferior peripheral breaks.All patients were phakic, four patientswere myopic, one was emmetropic C ase Report Submacular fluid after encirclingbuckle surgery for inferiormacula-off retinal detachmentin young patients Hana Abouzeid, 1 Klio Becker, 2 Frank G. Holz 2 andThomas J. Wolfensberger 1 1 Jules-Gonin Eye Hospital, University of Lausanne, Switzerland 2 Department of Ophthalmology, University of Bonn, Germany ABSTRACT. Purpose:  Characterization of persistent diffuse subretinal fluid using opticalcoherence tomography (OCT) after successful encircling buckle surgery forinferior macula-off retinal detachment in young patients. Methods:  Institutional retrospective review of six young patients (mean age31 ± 6 years; five female, one male) with spontaneous inferior rhegmatoge-nous macula-off retinal detachment. All patients were treated with encirclingbuckle surgery and five out of six underwent additional external drainage of subretinal fluid. Mean follow-up was 37 ± 25 months (range 17–75 months)and included complete ophthalmic and OCT examination. Results:  At 6 months, 100% of patients showed persistence of subretinal fluidon OCT. Four patients had diffuse fluid accumulation, whereas two patientsshowed a ‘bleb-like’ accumulation of fluid. This fluid was present independentof whether or not patients had been treated with external fluid drainage. Sub-retinal fluid only started to disappear on OCT between 6 and more than12 months after surgery. Conclusion:  Young patients with inferior macula-off retinal detachments and amarginally liquefied vitreous may show persisting postoperative subclinicalfluid under the macula for longer periods of time than described previously. Key words:  optical coherence tomography – retinal detachment – submacular fluid – surgery of retinal detachment Acta Ophthalmol. 2009: 87: 96–99 ª  2008 The Authors Journal compilation   ª  2008 Acta Ophthalmol  doi: 10.1111/j.1755-3768.2008.01196.x Acta Ophthalmologica 2009 96  and one hypermetropic (Table 1). Themean preoperative logMAR visualacuity was 0.63 ± 0.59 and the meanduration of retinal detachment was22 ± 21 days. The logMAR equiva-lent of counting fingers visual acuitywas determined to be 1.8 accordingto the visual standards resolutionadopted by the International Councilof Ophthalmology. All patients wereoperated on using a 240 silicone encir-cling band and cryotherapy; five outof six patients underwent externaldrainage of subretinal fluid. Postoper-ative follow-up included a completeophthalmic examination and OCTimaging using a cross-hair protocol(Stratus OCT 3; Zeiss Meditec,Dublin, CA, USA) at 6 months andat 11 or more months after surgery. Results The primary postoperative retinalreattachment rate was 100%. Meanfollow-up was 37 ± 25 months witha range of 17–75 months. Meanfinal postoperative visual acuity was0.28 ± 0.37. Postoperative OCTexamination showed two categories of images: four patients with a diffuseshallow detachment of the macula(Table 1; Fig. 1) and two patientswith a circumscribed foveal detach-ment with residual subretinal fluid(Table 1; Fig. 2). Both types of lesionswere not visible clinically. The elapsedtime period between the observationof persistent retinal fluid on OCT and aflattened retina varied from 6 to morethan 12 months (Table 1). At the endof the follow-up period, all patientsshowed an attached fovea on OCT. Discussion Residual subretinal fluid – visible onlyon OCT – occurring after bucklingsurgery for macula-off retinal detach-ment has been reported to be presentin 55–68% of cases (Wolfensberger &Gonvers 2002; Benson et al. 2007).The mechanism behind these OCTfindings is still not completely clear.Hypotheses have included retinalredundancy (Wolfensberger & Gon-vers 2002), reduced choroidal bloodflow, which may be induced by theencircling buckle (Diddie & Ernest1980, Sugawara et al. 2006), retinalpigment epithelium (RPE) dysfunctionin the macular region (Benson et al.2007) and residual viscous fluid, whichthe RPE finds difficult to absorb(Wolfensberger & Gonvers 2002; Ben-son et al. 2007).The findings of the present studyconfirm a previous more generalizedobservation that inferior retinaldetachments may take longer toabsorb subretinal fluid (Singh et al.2006). Furthermore, we observed thatsubretinal fluid may persist in youngpatients after successful buckle surgeryfor macula-off retinal detachment formany more months than describedpreviously in older patients. Thispersistence of fluid appears to be Table 1.  Description of patients.Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6Age (years) 30 40 33 24 32 26RefractionOD  ) 4.75  ) 2.50  ) 5.50  ) 9.25 +2.50 0   ⁄   0   ⁄   0OS  ) 4.75 0   ⁄   0   ⁄   0  ) 6.00  ) 11.25 +1.25 0   ⁄   0   ⁄   0Preoperative LogMAR VA 0.5 0.5 0.4 0.1 0.5 1.8Final LogMAR VA 0.1 0.1 0 0.3 0.2 1.0RD duration (days) 60 2 15 20 3 30RD extension (meridian) 3:00–6:30 5:00–9:00 3:00–7:00 2:30–7:00 3:30–7:30 1:30–8:00OCT (postoperative) Diffuse SRF ‘Bleb-like’ SRF Diffuse SRF Diffuse SRF Diffuse SRF ‘Bleb-like’ SRFFlat retina on final OCT Yes Yes Yes Yes Yes YesRange of delay during which retinalflattening on OCT occurred(months postoperative)*6–9 12–20 11–30 6–75 6–63 6–18External drainage of SRF Yes Yes No Yes Yes YesFollow-up (months) 17 20 30 75 63 18OD, right eye; OS, left eye; VA, visual acuity; SRF, subretinal fluid; OCT, optical coherence tomography; RD, retinal detachment.* Time-span between second-last and last OCT examination. (A) (B) Fig. 1.  (A) Optical coherence tomography (OCT) image of the left eye of patient 1, 1 month after inferior retinal detachment treated with bucklesurgery and external fluid drainage. Note the subfoveal hyporeflective band that extends to the edge of the image, representing a diffuse shallowelevation of the retina. LogMAR visual acuity was 0.5. (B) OCT image 17 months after surgery showing complete reattachment of the fovea,which occurred between 6 and 9 months after surgery. LogMAR visual acuity was 0.1. Acta Ophthalmologica 2009 97  independent of whether or not exter-nal drainage of subretinal fluid wasperformed. The fact that we observeda delay of 6 and more months afterencircling buckle surgery before thefirst patient reattached the retina com-pletely on OCT is in stark contrastwith previously published time-frames(Wolfensberger & Gonvers 2002; Wol-fensberger 2004). In a series of 16patients operated on with buckle sur-gery for macula-off RD with a muchhigher mean age (54 ± 4 years) (Wol-fensberger & Gonvers 2002), up to44% of patients showed a flat retinaon OCT 6 months after surgery. Thisobservation was confirmed in a fur-ther study (Wolfensberger & Gonvers2002) with an even higher mean age(65 ± 3 years) in which up to 55% of patients had a flat retina on OCT6 months after surgery. This suggestsa much slower rate of subretinal fluidresorption among the presented seriesof young patients with inferior RDs.Several phenomena may explain thisobservation. Firstly, young patientshave been described as having a lessliquefied and more viscous vitreouswhose absorption in the subretinalspace may take longer. Secondly, infe-rior retinal detachments have oftenbeen present for a long period of timebefore being operated on, becausethey produce a superior field defectthat is often unremarkable or notalarming to patients. Therefore, itappears that it is not only the localiza-tion of the detachment per se that isdeterminant but the association of inferior RDs with a longer durationof the detachment before the fielddefect becomes clinically significant.In our series, four out of six patientshad an RD duration of more than15 days. In this context, it has beensuggested that the presence of vitreousin the subretinal space for a long per-iod of time may cause a modificationof protein concentration and composi-tion leading to a reduced velocity of subretinal fluid resorption by the RPE(Takeuchi et al. 1996). Shallow retinaldetachments can thus persist for sev-eral months. It has also been pro-posed that proteinases may play arole in slower-than-normal subretinalfluid resorption, because theseenzymes may contribute to RPE cellmigration into subretinal fluid (Immo-nen et al. 1996) and this may delayfluid resorption by impeding RPE andblood–retinal barrier integrity.It could be argued that thedescribed OCT findings are causedexclusively by the inferior location of often long-standing retinal detachmentand that they are not causally linkedto the young age of the patients(Singh et al. 2006). However, an anal-ysis of a subgroup within a previouslypublished series (Wolfensberger &Gonvers 2002) shows that 100% of young patients with superior retinaldetachments also have postoperativesubfoveal fluid on OCT at 1 monthpostoperatively. This is in contrast tothe findings in older subjects withsuperior RD, which showed such sub-foveal fluid in only two thirds of allcases at 1 month after surgery. Look-ing at inferior retinal detachments inthe older age group of the same series(Wolfensberger & Gonvers 2002)showed that up to half of the olderpatients present a completely flatfovea on OCT at 1 month postopera-tively. In a recent series with 98patients, Benson et al. (2007) foundsubclinical fluid on OCT after bucklesurgery in 55% of patients with anage range of 20–73 years. However,no particular subgroups of youngpatients or patients with inferior reti-nal detachment were analysed in detailin this particular study.In summary, our series of patientsshows that young individuals with infe-rior macula-off retinal detachmentsmay show persisting postoperative sub-clinical fluid under the macula for muchlonger periods of time than describedpreviously in older patients. Whetherthis persisting fluid has a direct effecton postoperative visual acuity recoveryis still a matter of debate. References Abouzeid H & Wolfensberger TJ (2006):Macular recovery after retinal detachment.Acta Ophthalmol Scand  84 : 597–605.Benson SE, Schlottmann PG, Bunce C, XingW & Charteris DG (2007): Optical coher-ence tomography analysis of the macularafter scleral buckle surgery for retinaldetachment. Ophthalmology  114 : 108–112.Diddie KR & Ernest JT (1980): Uveal bloodflow after 360 degrees constriction in therabbit. Arch Ophthalmol  98 : 729–730.Immonen I, Konttinen YT, Sorsa T, Tommil-a P & Siren V (1996): Proteinases in subre-tinal fluid. Graefes Arch Clin ExpOphthalmol  234 : 105–109.Lecleire-Collet A, Muraine M, Menard JF &Brasseur G (2005): Visual predictive out-come after macula-off retinal detachmentsurgery using optical coherence tomo-graphy. Retina  25 : 44–53.Singh R, Gupta V & Gupta A (2006):Delayed foveal reattachment in scleralbuckle surgery for inferior retinal detach-ment. Ann Ophthalmol  38 : 225–230.Sugawara R, Nagaoka T, Kitaya N, Fujio N,Takahashi J, Takahashi A, Yokota H &Yoshida A. (2006): Choroidal bloodflow in the foveal region in eyes withrhegmatogenous retinal detachment and (A) (B) Fig. 2.  (A) Optical coherence tomography (OCT) image of patient 2, 6 months after buckle surgery and external subretinal fluid drainage forinferior retinal detachment. Note the voluminous circumscribed subfoveal fluid accumulation corresponding to the ‘bleb-like’ subfoveal hypore-flectivity. LogMAR visual acuity was 0.1. (B) OCT image 20 months after treatment showing complete reattachment of the fovea, which occurredbetween 12 and 20 months after surgery. LogMAR visual acuity remained 0.1. Acta Ophthalmologica 2009 98  scleral buckle procedures. Br J Ophthalmol 90 : 1363–1365.Takeuchi A, Kricorian G & Marmor MF(1996): When vitreous enters the subretinalspace: implications for subretinal fluid pro-tein. Retina  16 : 426–430.Wolfensberger TJ (2004): Foveal reattachmentafter macula-off retinal detachment occursfaster after vitrectomy than after buckle sur-gery. Ophthalmology  111 : 1340–1343.Wolfensberger TJ & Gonvers M (2002):Optical coherence tomography in the eval-uation of incomplete visual acuity recov-ery after macula-off retinal detachments.Graefes Arch Clin Exp Ophthalmol  240 :85–89.Received on July 8th, 2007.Accepted on December 17th, 2007. Correspondence: Thomas J. WolfensbergerJules-Gonin Eye HospitalUniversity of Lausanne15, Av. de FranceCH-1004 LausanneSwitzerlandTel: + 41 21 626 81 11Fax: + 41 21 626 81 44Email: thomas.wolfensberger@ophtal.vd.ch Acta Ophthalmologica 2009 99

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