SCLERAL BUCKLE REMOVAL AS TREATMENT FOR PERSISTENT SUBFOVEAL FLUID AFTER SCLERAL BUCKLE SURGERY FOR RETINAL DETACHMENT John O. Mason III, MD,*† Alinda A. McGowin, BS,† Rachel Vail*
Purpose: To describe the removal of scleral buckle (SB) as a potential treatment option for persistent subfoveal fluid after SB retinal reattachment surgery. Methods: Case report of a single patient. Results: A 56-year-old man with a preoperative best-corrected visual acuity of 20/20 underwent SB surgery for a macula-on retinal detachment. Postoperatively he developed subfoveal fluid with best-corrected visual acuity ranging from 20/30 to 20/40. Nine months after the original retinal reattachment surgery, the patient underwent SB removal as a treatment for persistent subfoveal fluid and incomplete recovery of visual acuity. One week after SB removal, the subfoveal fluid was substantially diminished and best-corrected visual acuity had returned to 20/20. Conclusion: This case suggests that removal of SB after retinal reattachment may be a viable treatment option in patients with persistent subfoveal fluid on optical coherence tomography and incomplete recovery of preoperative visual acuity. RETINAL CASES & BRIEF REPORTS 4:91–93, 2010
From the *Retina Consultants of Alabama, Callahan Eye Foundation Hospital; and †Department of Ophthalmology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.
buckling and/or cryopexy leading to excessive amounts of protein entering the subretinal space, causing delayed fluid resorption resulting from protein difficulty crossing the retinal pigment epithelium.4 Delayed recovery of visual acuity (VA) after successful retinal reattachment has been associated in several studies with persistent foveal detachment, with the VA improving as the foveal detachment resolves.1,3,5 To our knowledge, no successful treatment has been described in the literature for persistent SFF. We describe SB removal as a potential treatment for chronic persistent SFF and decreased VA after SB retinal reattachment.
P
ersistent subfoveal fluid (SFF) is a commonly recognized phenomenon after retinal detachment (RD) repair, particularly in the setting of scleral buckling.1,2 It has been shown by several studies to be present in approximately 50% of patients 4 to 6 weeks postoperatively after scleral buckle (SB) surgery and may take many months to resolve.1,3 The mechanism behind this fluid persistence is inadequately understood thus far, although it has been proposed that the persistence may be the result of a blood–retinal barrier breakdown after
Case Report A 56-year-old man was referred for evaluation after reports of a superior visual field defect and floaters in the left eye. The patient’s history was significant only for a cataract extraction with intraocular lens placement in the left eye, mild arthritis, and generalized anxiety. On examination, best-corrected visual acuity (BCVA) was
Supported by the Research to Prevent Blindness, New York City, NY. Reprint requests: John O. Mason III, MD, Retina Consultants of Alabama, 700 South 18th Street, Suite 707, Birmingham, AL 35233; e-mail: [email protected]
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Fig. 1. Ocular coherence tomography of subfoveal fluid before SB removal (Top), and resolution after SB removal (Bottom).
20/20 in both eyes with intraocular pressures of 14 mmHg in the right eye and 19 mmHg in the left eye. Dilated fundus examination in the left eye revealed an inferior, chronic-appearing, macula-on, rhegmatogenous RD extending to within 3 mm of, but not invading, the inferior arcade with a retinal break and lattice degeneration at 6 o’clock as well as lattice degeneration temporally between 2 and 5 o’clock. Optical coherence tomography confirmed no macular involvement. The retina was successfully reattached 4 days later with a high SB, cryotherapy, laser, and external drainage of subretinal fluid. The high SB consisted of a 7-mm-wide sponge cut to one half thickness placed at the equator and extending to the ora from the inferotemporal to superotemporal quadrant. Two nylon sutures were placed 5 mm apart in both quadrants. The retina was flat on the buckle with no tenting or folding of the retina or posterior troughs of fluid. There were no complications, including vortex veins, which remained unaffected. During the postoperative course, the patient had incomplete recovery of VA in the left eye with BCVAs ranging from 20/30 to 20/40. The retina remained attached with a nicely contoured appearance and without retinal folds on the SB throughout the postoperative course. Seven weeks postoperatively the patient was noted to have SFF confirmed by fluorescein angiography, which was treated with topical prednisolone acetate 1% ophthalmic solution and ketorolac 0.4% ophthalmic solution. Approximately 5 months postoperatively, the patient was noted to have an oval yellow subfoveal cyst in the left eye on fundoscopic examination with optical coherence tomography confirmation of SFF (Figure 1). All drops were discontinued and the SFF was followed for 4 more months with no change, after which time other treatment options were discussed with the patient, including removal of the SB. The patient wanted to proceed with SB removal. Approximately 9 months after the original SB procedure, the SB was removed with no complications. Only 1 week after SB removal, the patient had subjective improvement in vision, the SFF was noted to be substantially diminished, and BCVA had returned to 20/20. On follow-up, the SFF had resolved completely by fundoscopic examination with optical coherence tomography confirmation, and the BCVA in the left eye has remained 20/20 (Figure 1).
Persistent SFF or foveal detachment is a recognized complication of retinal reattachment surgery and seems to be more common with SB than with other methods.1,2 Patients with SB surgeries have also been shown on average to have persistent SFF for longer periods of time than patients treated with vitrectomy.2 The median time to foveal reattachment after surgery with SB in the study by Benson et al3 was cited as 9 months in 1 group and 10 months in another. The resolution of SFF in several other studies occurred within 12 months in the majority of patients.1,2,5 However, most of these studies involved macula-off RD with persistent SFF. Benson et al3 and Theodossiadis et al6 have previously reported on macula-on RD with persistent SFF after surgery, similar to our case. These two studies did not find a definitive etiology for persistent SFF after macula-on RD surgery. All of these studies have also shown in many patients that significant improvements in VA occur only after resolution of SFF has begun. However, after slow, longterm resolution of the SFF, not all patients recover vision. In this case, the half-thickness 7-mm SB was placed in a circumferential fashion as a result of the temporal adjacent areas of lattice degeneration. If a single 6 o’clock retinal break without adjacent lattice degeneration had been found, a small meridional sponge could have been used. After drainage of subretinal fluid was performed, the retina, intraoperatively and postoperatively, was nicely adhered to the SB without any evidence of retinal folds, tenting of the retina, or posterior troughs of fluid. In our particular case, the SFF was followed for 9 months postoperatively with no clinical changes noted and no improvement in BCVA. The patient was extremely disappointed with his BCVA of 20/30 to 20/40, and it was his desire to pursue other options for recovering his preoperative BCVA of 20/20. We cannot be sure that the SFF would not have resolved on its own given additional time and that the patient would not have recovered his original BCVA had the SB been left in place. However, given the rapid 1-week recovery of both the patient’s original 20/20 BCVA and the substantially diminished SFF, and after having noted no SFF changes for 9 months previously, it is reasonable to consider the possibility that removal of the SB in this patient was the cause of his rapid improvement. However, the exact etiology of the rapid improvement in BCVA and fast resolution of SFF after SB removal remains unknown. Any hypothesis we could offer regarding mechanical, vascular, or inflammatory possibilities would be mere conjecture.
93
SCLERAL BUCKLE REMOVAL
This case suggests that in patients with persistent SFF and VA deficits after SB surgery for RD, SB removal may be a potential treatment option to a more rapid and potentially complete recovery of preoperative BCVA. Additional research is needed into this possible treatment for persistent SFF after SB surgery for RD. Key words: retinal detachment, scleral buckle, subfoveal detachment, subfoveal fluid. References 1.
Hagimura N, Iida T, Suto K, Kishi S. Persistent foveal retinal detachment after successful rhegmatogenous retinal detachment surgery. Am J Ophthalmol 2002;133:516 –520.
2.
3.
4. 5.
6.
Wolfensberger TJ. Foveal reattachment after macula-off retinal detachment occurs faster after vitrectomy than after buckle surgery. Ophthalmology 2004;111:1340 –1343. Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG. Optical coherence tomography analysis of the macula after scleral buckle surgery for retinal detachment. Ophthalmology 2007;114:108 –112. Spaide RF, Goldbaum M, Wong DWK, Tang KC, Iida T. Serous detachment of the retina. Retina 2003;23:820 – 846. Wolfensberger TJ, Gonvers M. Optical coherence tomography in the evaluation of incomplete visual acuity recovery after macula-off retinal detachments. Graefes Arch Clin Exp Ophthalmol 2002;240:85– 89. Theodossiadis PG, Georgalas IG, Emefietzoglou J, et al. Optical coherence tomography findings in the macula after treatment of rhegmatogenous retinal detachments with spared macula preoperatively. Retina 2003;23:69 –75.
Purpose: To describe the removal of scleral buckle (SB) as a potential treatment option for persistent subfoveal fluid after SB retinal reattachment surgery. Methods: Case report of a single patient. Results: A 56-year-old man with a preoperative best-corrected visual acuity of 20/20 underwent SB surgery for a macula-on retinal detachment. Postoperatively he developed subfoveal fluid with best-corrected visual acuity ranging from 20/30 to 20/40. Nine months after the original retinal reattachment surgery, the patient underwent SB removal as a treatment for persistent subfoveal fluid and incomplete recovery of visual acuity. One week after SB removal, the subfoveal fluid was substantially diminished and best-corrected visual acuity had returned to 20/20. Conclusion: This case suggests that removal of SB after retinal reattachment may be a viable treatment option in patients with persistent subfoveal fluid on optical coherence tomography and incomplete recovery of preoperative visual acuity. RETINAL CASES & BRIEF REPORTS 4:91–93, 2010
From the *Retina Consultants of Alabama, Callahan Eye Foundation Hospital; and †Department of Ophthalmology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.
buckling and/or cryopexy leading to excessive amounts of protein entering the subretinal space, causing delayed fluid resorption resulting from protein difficulty crossing the retinal pigment epithelium.4 Delayed recovery of visual acuity (VA) after successful retinal reattachment has been associated in several studies with persistent foveal detachment, with the VA improving as the foveal detachment resolves.1,3,5 To our knowledge, no successful treatment has been described in the literature for persistent SFF. We describe SB removal as a potential treatment for chronic persistent SFF and decreased VA after SB retinal reattachment.
P
ersistent subfoveal fluid (SFF) is a commonly recognized phenomenon after retinal detachment (RD) repair, particularly in the setting of scleral buckling.1,2 It has been shown by several studies to be present in approximately 50% of patients 4 to 6 weeks postoperatively after scleral buckle (SB) surgery and may take many months to resolve.1,3 The mechanism behind this fluid persistence is inadequately understood thus far, although it has been proposed that the persistence may be the result of a blood–retinal barrier breakdown after
Case Report A 56-year-old man was referred for evaluation after reports of a superior visual field defect and floaters in the left eye. The patient’s history was significant only for a cataract extraction with intraocular lens placement in the left eye, mild arthritis, and generalized anxiety. On examination, best-corrected visual acuity (BCVA) was
Supported by the Research to Prevent Blindness, New York City, NY. Reprint requests: John O. Mason III, MD, Retina Consultants of Alabama, 700 South 18th Street, Suite 707, Birmingham, AL 35233; e-mail: [email protected]
91
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RETINAL CASES & BRIEF REPORTSℜ
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2010
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VOLUME 4
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NUMBER 1
Discussion
Fig. 1. Ocular coherence tomography of subfoveal fluid before SB removal (Top), and resolution after SB removal (Bottom).
20/20 in both eyes with intraocular pressures of 14 mmHg in the right eye and 19 mmHg in the left eye. Dilated fundus examination in the left eye revealed an inferior, chronic-appearing, macula-on, rhegmatogenous RD extending to within 3 mm of, but not invading, the inferior arcade with a retinal break and lattice degeneration at 6 o’clock as well as lattice degeneration temporally between 2 and 5 o’clock. Optical coherence tomography confirmed no macular involvement. The retina was successfully reattached 4 days later with a high SB, cryotherapy, laser, and external drainage of subretinal fluid. The high SB consisted of a 7-mm-wide sponge cut to one half thickness placed at the equator and extending to the ora from the inferotemporal to superotemporal quadrant. Two nylon sutures were placed 5 mm apart in both quadrants. The retina was flat on the buckle with no tenting or folding of the retina or posterior troughs of fluid. There were no complications, including vortex veins, which remained unaffected. During the postoperative course, the patient had incomplete recovery of VA in the left eye with BCVAs ranging from 20/30 to 20/40. The retina remained attached with a nicely contoured appearance and without retinal folds on the SB throughout the postoperative course. Seven weeks postoperatively the patient was noted to have SFF confirmed by fluorescein angiography, which was treated with topical prednisolone acetate 1% ophthalmic solution and ketorolac 0.4% ophthalmic solution. Approximately 5 months postoperatively, the patient was noted to have an oval yellow subfoveal cyst in the left eye on fundoscopic examination with optical coherence tomography confirmation of SFF (Figure 1). All drops were discontinued and the SFF was followed for 4 more months with no change, after which time other treatment options were discussed with the patient, including removal of the SB. The patient wanted to proceed with SB removal. Approximately 9 months after the original SB procedure, the SB was removed with no complications. Only 1 week after SB removal, the patient had subjective improvement in vision, the SFF was noted to be substantially diminished, and BCVA had returned to 20/20. On follow-up, the SFF had resolved completely by fundoscopic examination with optical coherence tomography confirmation, and the BCVA in the left eye has remained 20/20 (Figure 1).
Persistent SFF or foveal detachment is a recognized complication of retinal reattachment surgery and seems to be more common with SB than with other methods.1,2 Patients with SB surgeries have also been shown on average to have persistent SFF for longer periods of time than patients treated with vitrectomy.2 The median time to foveal reattachment after surgery with SB in the study by Benson et al3 was cited as 9 months in 1 group and 10 months in another. The resolution of SFF in several other studies occurred within 12 months in the majority of patients.1,2,5 However, most of these studies involved macula-off RD with persistent SFF. Benson et al3 and Theodossiadis et al6 have previously reported on macula-on RD with persistent SFF after surgery, similar to our case. These two studies did not find a definitive etiology for persistent SFF after macula-on RD surgery. All of these studies have also shown in many patients that significant improvements in VA occur only after resolution of SFF has begun. However, after slow, longterm resolution of the SFF, not all patients recover vision. In this case, the half-thickness 7-mm SB was placed in a circumferential fashion as a result of the temporal adjacent areas of lattice degeneration. If a single 6 o’clock retinal break without adjacent lattice degeneration had been found, a small meridional sponge could have been used. After drainage of subretinal fluid was performed, the retina, intraoperatively and postoperatively, was nicely adhered to the SB without any evidence of retinal folds, tenting of the retina, or posterior troughs of fluid. In our particular case, the SFF was followed for 9 months postoperatively with no clinical changes noted and no improvement in BCVA. The patient was extremely disappointed with his BCVA of 20/30 to 20/40, and it was his desire to pursue other options for recovering his preoperative BCVA of 20/20. We cannot be sure that the SFF would not have resolved on its own given additional time and that the patient would not have recovered his original BCVA had the SB been left in place. However, given the rapid 1-week recovery of both the patient’s original 20/20 BCVA and the substantially diminished SFF, and after having noted no SFF changes for 9 months previously, it is reasonable to consider the possibility that removal of the SB in this patient was the cause of his rapid improvement. However, the exact etiology of the rapid improvement in BCVA and fast resolution of SFF after SB removal remains unknown. Any hypothesis we could offer regarding mechanical, vascular, or inflammatory possibilities would be mere conjecture.
93
SCLERAL BUCKLE REMOVAL
This case suggests that in patients with persistent SFF and VA deficits after SB surgery for RD, SB removal may be a potential treatment option to a more rapid and potentially complete recovery of preoperative BCVA. Additional research is needed into this possible treatment for persistent SFF after SB surgery for RD. Key words: retinal detachment, scleral buckle, subfoveal detachment, subfoveal fluid. References 1.
Hagimura N, Iida T, Suto K, Kishi S. Persistent foveal retinal detachment after successful rhegmatogenous retinal detachment surgery. Am J Ophthalmol 2002;133:516 –520.
2.
3.
4. 5.
6.
Wolfensberger TJ. Foveal reattachment after macula-off retinal detachment occurs faster after vitrectomy than after buckle surgery. Ophthalmology 2004;111:1340 –1343. Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG. Optical coherence tomography analysis of the macula after scleral buckle surgery for retinal detachment. Ophthalmology 2007;114:108 –112. Spaide RF, Goldbaum M, Wong DWK, Tang KC, Iida T. Serous detachment of the retina. Retina 2003;23:820 – 846. Wolfensberger TJ, Gonvers M. Optical coherence tomography in the evaluation of incomplete visual acuity recovery after macula-off retinal detachments. Graefes Arch Clin Exp Ophthalmol 2002;240:85– 89. Theodossiadis PG, Georgalas IG, Emefietzoglou J, et al. Optical coherence tomography findings in the macula after treatment of rhegmatogenous retinal detachments with spared macula preoperatively. Retina 2003;23:69 –75.
