DISAPPEARANCE OF DRUSEN AFTER RHEGMATOGENOUS RETINAL DETACHMENT Ron Margolis, MD,*† Michael D. Ober, MD,*†‡ K. Bailey Freund, MD*†
Purpose: To describe the disappearance of drusen after rhegmatogenous retinal detachment. Methods: Descriptive case report. Results: A 72-year-old man with confluent subfoveal drusen developed a rhegmatogenous retinal detachment and subsequently improved in vision with disappearance of the subfoveal drusen less than 1 month after repair. Conclusion: Rhegmatogenous retinal detachment can result in the disappearance of drusen. RETINAL CASES & BRIEF REPORTS 4:254–256, 2010
with improvement in vision after laser photocoagulation2–5 or concurrent macular hole repair6 has also been described previously. We report the disappearance of drusen associated with visual improvement after a macula-involving rhegmatogenous retinal detachment and subsequent surgical repair.
From the *The LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear and Throat Hospital, New York, New York; †The Vitreous-Retina-Macula Consultants of New York, New York, New York; and ‡Retina Consultants of Michigan, Southfield, Michigan.
S
oft drusen are deposits of extracellular material lying between the retinal pigment epithelium (RPE) and the inner collagenous zone of Bruch membrane.1 Soft drusen have indistinct borders that readily become confluent and are specific for agerelated macular degeneration. They frequently harbor collections of serous fluid, which accumulates when the lipoid material creates a hydrophobic barrier interfering with retinal pigment epithelial function.2 Subfoveal confluent drusen are associated with visual loss even without choroidal neovascularization secondary to the accompanying serous fluid, the drusen themselves, and/or overlying RPE atrophy. Confluent drusen are known to occasionally disappear spontaneously, but this is usually associated with RPE atrophy and visual impairment. Drusen reduction
Case Report A 72-year-old man with multiple soft drusen within the macula of the right eye associated with a shallow detachment of the RPE and a baseline vision of 20/60 (Figure 1) presented with recently decreased vision to 20/100 and metamorphopsia. Fundus examination revealed a rhegmatogenous retinal detachment with involvement of the superior macula, including the fovea, and sparing of the inferior macula (Figure 2). Detachment was successfully treated with cryopexy and pneumatic retinopexy. Visual acuity improved to 20/25, and a significant reduction in the number, size, and thickness of drusen was observed 1 month after treatment, which persisted during the 6 years of follow-up (Figure 3).
Discussion The rapid regression and temporal association of the drusen disappearance to the retinal detachment in our patient suggest a causal relationship. It is possible that the large volumes of subretinal fluid ‘‘washed out’’ the lipophilic material by overwhelming its low solubility with the solvent. Mechanical stimulation of RPE cells from surgery is another plausible explanation. Of note,
Supported by The Macula Foundation, Inc., and The LuEsther T. Mertz Retinal Research Center, New York, NY. Dr. Margolis is funded by the Heed Foundation Fellowship, Cleveland, OH. The authors have no financial interest in any aspect of this study. Reprint requests: K. Bailey Freund, MD, Vitreous-RetinaMacula Consultants of New York, 460 Park Avenue, 5th Floor, New York, NY 10022; e-mail: [email protected]
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C O L O R Fig. 1. Color fundus photograph of the right eye showing confluent soft drusen centrally.
visual acuity after macula-off retinal detachment exceeded visual acuity before the detachment. This improvement suggests that drusen disappearance resulted in anatomic restoration of the RPE-Bruch membrane complex, leading to an improvement in visual function. Drusen are known to disappear spontaneously on occasion.2 The hyalinized amorphous contents in older patients may become coarsely granular and reduce in overall volume, but this is often associated with degenerative changes to the overlying RPE cells. Atrophy of the outer retina, RPE, and/or choriocapillaris often develops concurrently with spontaneous drusen disappearance, which may be the result of an
C O L O R Fig. 2. Color fundus photograph 2 years later showing a superior rhegmatogenous retinal detachment with subretinal fluid extending into the superior portion of the macula (dotted line). The inferior aspect of the macula was not affected.
C O L O R Fig. 3. Color fundus photograph 1 year (A) and 6 years (B) after retinal detachment repair showing a reduction in the number, size, and thickness of drusen in the part of the macula that was detached. Drusen in the unaffected macula are unchanged from baseline.
accumulation of metabolic abnormalities in the RPE. Consequently, drusen disappearance does not necessarily indicate a return of normal function. Drusen have also been shown to disappear after laser photocoagulation, possibly through stimulation of phagocytic cells from the choroid or macrophages, creation of a mechanical barrier to further drusen deposition, or stimulation of RPE proliferation, which subsequently resorb and phagocytize drusen.2–5 Autologous platelet concentrate and nonspecific mechanical factors have been proposed to play a role in drusen disappearance after macular hole surgery.6 To our knowledge, this is the first report of a significant change in drusen morphology associated with retinal detachment. Key words: drusen disappearance, retinal detachment, age-related macular degeneration.
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References 1. Sarks JP, Sarks SH, Killingsworth MC. Evolution of soft drusen in age-related macular degeneration. Eye 1994;8:269–283. 2. Abdelsalam A, Del Priore L, Zarbin MA. Drusen in age-related macular degeneration: pathogenesis, natural course, and laser photocoagulation-induced regression. Surv Ophthalmol 1999; 44:l–29. 3. Wetzig PC. Treatment of drusen-related aging macular degeneration by photocoagulation. Trans Am Ophthalmol Soc 1988;86:276–290.
4. Ho AC, Maguire MG, Yoken J, et al. Laser-induced drusen reduction improves visual function at one year. Ophthalmology 1999;106:1367–1373. 5. Complications of Age-Related Macular Degeneration Prevention Trial Research Group. Laser treatment in patients with bilateral large drusen: the complications of age-related macular degeneration prevention trial. Ophthalmology 2006;113: 1974–1986. 6. Holz FG, Staudt S. Disappearance of soft drusen following macular hole surgery. Retina 2001;21:184–186.
Purpose: To describe the disappearance of drusen after rhegmatogenous retinal detachment. Methods: Descriptive case report. Results: A 72-year-old man with confluent subfoveal drusen developed a rhegmatogenous retinal detachment and subsequently improved in vision with disappearance of the subfoveal drusen less than 1 month after repair. Conclusion: Rhegmatogenous retinal detachment can result in the disappearance of drusen. RETINAL CASES & BRIEF REPORTS 4:254–256, 2010
with improvement in vision after laser photocoagulation2–5 or concurrent macular hole repair6 has also been described previously. We report the disappearance of drusen associated with visual improvement after a macula-involving rhegmatogenous retinal detachment and subsequent surgical repair.
From the *The LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear and Throat Hospital, New York, New York; †The Vitreous-Retina-Macula Consultants of New York, New York, New York; and ‡Retina Consultants of Michigan, Southfield, Michigan.
S
oft drusen are deposits of extracellular material lying between the retinal pigment epithelium (RPE) and the inner collagenous zone of Bruch membrane.1 Soft drusen have indistinct borders that readily become confluent and are specific for agerelated macular degeneration. They frequently harbor collections of serous fluid, which accumulates when the lipoid material creates a hydrophobic barrier interfering with retinal pigment epithelial function.2 Subfoveal confluent drusen are associated with visual loss even without choroidal neovascularization secondary to the accompanying serous fluid, the drusen themselves, and/or overlying RPE atrophy. Confluent drusen are known to occasionally disappear spontaneously, but this is usually associated with RPE atrophy and visual impairment. Drusen reduction
Case Report A 72-year-old man with multiple soft drusen within the macula of the right eye associated with a shallow detachment of the RPE and a baseline vision of 20/60 (Figure 1) presented with recently decreased vision to 20/100 and metamorphopsia. Fundus examination revealed a rhegmatogenous retinal detachment with involvement of the superior macula, including the fovea, and sparing of the inferior macula (Figure 2). Detachment was successfully treated with cryopexy and pneumatic retinopexy. Visual acuity improved to 20/25, and a significant reduction in the number, size, and thickness of drusen was observed 1 month after treatment, which persisted during the 6 years of follow-up (Figure 3).
Discussion The rapid regression and temporal association of the drusen disappearance to the retinal detachment in our patient suggest a causal relationship. It is possible that the large volumes of subretinal fluid ‘‘washed out’’ the lipophilic material by overwhelming its low solubility with the solvent. Mechanical stimulation of RPE cells from surgery is another plausible explanation. Of note,
Supported by The Macula Foundation, Inc., and The LuEsther T. Mertz Retinal Research Center, New York, NY. Dr. Margolis is funded by the Heed Foundation Fellowship, Cleveland, OH. The authors have no financial interest in any aspect of this study. Reprint requests: K. Bailey Freund, MD, Vitreous-RetinaMacula Consultants of New York, 460 Park Avenue, 5th Floor, New York, NY 10022; e-mail: [email protected]
254
DRUSEN DISAPPEARANCE AFTER RRD
255
C O L O R Fig. 1. Color fundus photograph of the right eye showing confluent soft drusen centrally.
visual acuity after macula-off retinal detachment exceeded visual acuity before the detachment. This improvement suggests that drusen disappearance resulted in anatomic restoration of the RPE-Bruch membrane complex, leading to an improvement in visual function. Drusen are known to disappear spontaneously on occasion.2 The hyalinized amorphous contents in older patients may become coarsely granular and reduce in overall volume, but this is often associated with degenerative changes to the overlying RPE cells. Atrophy of the outer retina, RPE, and/or choriocapillaris often develops concurrently with spontaneous drusen disappearance, which may be the result of an
C O L O R Fig. 2. Color fundus photograph 2 years later showing a superior rhegmatogenous retinal detachment with subretinal fluid extending into the superior portion of the macula (dotted line). The inferior aspect of the macula was not affected.
C O L O R Fig. 3. Color fundus photograph 1 year (A) and 6 years (B) after retinal detachment repair showing a reduction in the number, size, and thickness of drusen in the part of the macula that was detached. Drusen in the unaffected macula are unchanged from baseline.
accumulation of metabolic abnormalities in the RPE. Consequently, drusen disappearance does not necessarily indicate a return of normal function. Drusen have also been shown to disappear after laser photocoagulation, possibly through stimulation of phagocytic cells from the choroid or macrophages, creation of a mechanical barrier to further drusen deposition, or stimulation of RPE proliferation, which subsequently resorb and phagocytize drusen.2–5 Autologous platelet concentrate and nonspecific mechanical factors have been proposed to play a role in drusen disappearance after macular hole surgery.6 To our knowledge, this is the first report of a significant change in drusen morphology associated with retinal detachment. Key words: drusen disappearance, retinal detachment, age-related macular degeneration.
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References 1. Sarks JP, Sarks SH, Killingsworth MC. Evolution of soft drusen in age-related macular degeneration. Eye 1994;8:269–283. 2. Abdelsalam A, Del Priore L, Zarbin MA. Drusen in age-related macular degeneration: pathogenesis, natural course, and laser photocoagulation-induced regression. Surv Ophthalmol 1999; 44:l–29. 3. Wetzig PC. Treatment of drusen-related aging macular degeneration by photocoagulation. Trans Am Ophthalmol Soc 1988;86:276–290.
4. Ho AC, Maguire MG, Yoken J, et al. Laser-induced drusen reduction improves visual function at one year. Ophthalmology 1999;106:1367–1373. 5. Complications of Age-Related Macular Degeneration Prevention Trial Research Group. Laser treatment in patients with bilateral large drusen: the complications of age-related macular degeneration prevention trial. Ophthalmology 2006;113: 1974–1986. 6. Holz FG, Staudt S. Disappearance of soft drusen following macular hole surgery. Retina 2001;21:184–186.
