SURGICAL EVACUATION OF SUBMACULAR EXUDATES SECONDARY TO A VASOPROLIFERATIVE TUMOR OF THE RETINA Peter N. Youssef, MD, David A. Saperstein, MD
Purpose: To report a case demonstrating excellent visual recovery following surgical removal of subfoveal exudation secondary to a vasoproliferative tumor of the retina (VPTR). Design: Observational case report. Methods: Review of medical records. Results: A 39-year-old man presented with decreased vision secondary to subfoveal exudation from a VPTR. The tumor was successfully treated with cryoretinopexy, but the hard exudates that had formed in under the fovea remained. There was no change in vision for 18 months following the cryoretinopexy. A decision was made to surgically remove the exudates using similar techniques to those presented in the literature for diabetic exudation. Over the next several weeks the patients vision recovered to the 20/25 level and has remained this way for 5 years. Conclusions: Patients with subfoveal exudates secondary to VPTR may benefit from subretinal surgery to remove the exudates. RETINAL CASES & BRIEF REPORTS 1:244 –245, 2007
From the Vitreoretinal Associates, Seattle, Washington.
Family history, neuroimaging, and genetic testing for von Hippel-Lindau disease were negative. The lesion had a height of approximately 6 mm; therefore, cryoretinopexy was used to treat the tumor. While the VTPR rapidly resolved, subfoveal hard exudates remained in the fovea (Figure 1). Eighteen weeks after the cryoretinopexy treatment the patient’s visual acuity and fundus examination remained unchanged, thereby impairing his ability to work. After an in-depth discussion and informed consent the patient underwent pars plana vitrectomy and surgical removal of subfoveal exudates. A surgical method similar to Takagi et al1 was employed. After core vitrectomy and removal of the posterior hyaloid, an angled 33 gauge beveled cannula was placed in the subretinal space infratemporal to the fovea. Buffered balanced salt solution (BSS⫹, Alcon, Inc., Fort Worth, TX) was injected into the subretinal space in an attempt to wash out the exudates. This was partially successful. A retinal pick was then used to free large exudates from the foveal retina and retinal pigment epithelial tissue. The loosened exudates were removed us-
W
e report a case with 5-year follow-up of visual recovery following the surgical removal of subfoveal exudates secondary to a vasoproliferative tumor of the retina (VPTR). A 39-year-old man was referred for the evaluation of a retinal tumor with vision loss in the left eye. Three months before presentation his visual acuity was 20/20 in both eyes. Best-corrected visual acuity at the time of evaluation was 20/20 in the right eye and 20/400 in the left eye. The motility, confrontation visual fields, slit lamp examination of the anterior segment, and the intraocular pressure were normal in both eyes. Dilated funduscopic examination revealed a pre-equatorial retinal mass with a feeder vessel in the superotemporal quadrant of the left eye consistent with a VPTR. Inspection of the macula revealed subfoveal fluid and exudates.
Reprint requests: David A. Saperstein, MD, Vitreoretinal Associates, 1221 Madison St., #1002, Seattle, WA 98104; e-mail: [email protected]
244
245
SURGICAL EVACUATION
Fig. 1. Preoperative fundus photograph of the left eye in December 2000. Note the large accumulation of exudates in the subfoveal space. Visual acuity equals 20/400 in the left eye.
ing a Thomas horizontal subretinal forceps (Synergetics, St. Charles, MO). Further irrigation was used to remove the remaining free-floating exudates. No attempts were made to free the remaining small macular exudates. Laser retinopexy was then applied to the VPTR and an air-fluid exchange was performed before closing. The patient recovered without complications. Over the next several months his visual acuity in this eye steadily improved to 20/25. Amsler grid testing revealed mild distortion just inferior to central fixation in the left eye. Dilated fundus examination at the 9-month follow-up visit showed a 1⫹ nuclear sclerotic cataract, intraretinal residual hard exudates temporal to the fovea, retinal pigment epithelial changes, and mild epiretinal membrane formation (Figure 2).
Fig. 3. Fundus photograph of the left eye 5 years following surgical removal of the subfoveal exudates. Note the remnant retinal pigment epithelial pigment abnormalities and the absence of exudates. Visual acuity equals 20/25 in the left eye.
At the 5-year follow-up examination his vision remained 20/25 in the left eye and the remaining exudates were no longer present (Figure 3). Discussion In the series by Takagi and colleagues, the foveal exudates were under rather than embedded in the neural retina allowing for their removal.1 Their visual outcomes were limited presumably due to retinal damage secondary to diabetic retinopathy. Unlike the patients in the Takagi series, our patient had an otherwise normal macula, lending to his excellent long-term result. Vasoproliferative tumors of the retina often present due to decreased visual acuity secondary to submacular fluid and exudates. Exudative macular involvement has been reported in up to 45% of such cases.2 These changes can result in permanent vision loss.3 Visual recovery depends upon resolution of these exudates before permanent damage to the retina occurs. We have shown that restoration of good visual acuity can be obtained with surgical removal of subfoveal exudates secondary to a VPTR. This technique should be reserved for patients who require rapid visual recovery and those with exudates that are not likely to spontaneously reabsorb. References 1.
2. Fig. 2. Fundus photograph of the left eye 9 months following surgical removal of the exudates. A few small intraretinal exudates remain in the perifoveal area temporal to the fovea. Visual acuity equals 20/25 in the left eye.
3.
Takagi H, Otani A, Kiryu J. New surgical approach for removing massive foveal hard exudates in diabetic macular edema. Ophthalmology 1999;106:249–256. Shields CL, Shields JA, Barrett J. Vasoproliferative tumors of the ocular fundus. Classification and clinical manifestations in 103 patients. Arch Ophthalmol 1995;113:615–623. Heimann H, Bornfeld N, Vij O. Vasoproliferative tumors of the retina. Br J Ophthalmol 2000;84:1162–1169.
Purpose: To report a case demonstrating excellent visual recovery following surgical removal of subfoveal exudation secondary to a vasoproliferative tumor of the retina (VPTR). Design: Observational case report. Methods: Review of medical records. Results: A 39-year-old man presented with decreased vision secondary to subfoveal exudation from a VPTR. The tumor was successfully treated with cryoretinopexy, but the hard exudates that had formed in under the fovea remained. There was no change in vision for 18 months following the cryoretinopexy. A decision was made to surgically remove the exudates using similar techniques to those presented in the literature for diabetic exudation. Over the next several weeks the patients vision recovered to the 20/25 level and has remained this way for 5 years. Conclusions: Patients with subfoveal exudates secondary to VPTR may benefit from subretinal surgery to remove the exudates. RETINAL CASES & BRIEF REPORTS 1:244 –245, 2007
From the Vitreoretinal Associates, Seattle, Washington.
Family history, neuroimaging, and genetic testing for von Hippel-Lindau disease were negative. The lesion had a height of approximately 6 mm; therefore, cryoretinopexy was used to treat the tumor. While the VTPR rapidly resolved, subfoveal hard exudates remained in the fovea (Figure 1). Eighteen weeks after the cryoretinopexy treatment the patient’s visual acuity and fundus examination remained unchanged, thereby impairing his ability to work. After an in-depth discussion and informed consent the patient underwent pars plana vitrectomy and surgical removal of subfoveal exudates. A surgical method similar to Takagi et al1 was employed. After core vitrectomy and removal of the posterior hyaloid, an angled 33 gauge beveled cannula was placed in the subretinal space infratemporal to the fovea. Buffered balanced salt solution (BSS⫹, Alcon, Inc., Fort Worth, TX) was injected into the subretinal space in an attempt to wash out the exudates. This was partially successful. A retinal pick was then used to free large exudates from the foveal retina and retinal pigment epithelial tissue. The loosened exudates were removed us-
W
e report a case with 5-year follow-up of visual recovery following the surgical removal of subfoveal exudates secondary to a vasoproliferative tumor of the retina (VPTR). A 39-year-old man was referred for the evaluation of a retinal tumor with vision loss in the left eye. Three months before presentation his visual acuity was 20/20 in both eyes. Best-corrected visual acuity at the time of evaluation was 20/20 in the right eye and 20/400 in the left eye. The motility, confrontation visual fields, slit lamp examination of the anterior segment, and the intraocular pressure were normal in both eyes. Dilated funduscopic examination revealed a pre-equatorial retinal mass with a feeder vessel in the superotemporal quadrant of the left eye consistent with a VPTR. Inspection of the macula revealed subfoveal fluid and exudates.
Reprint requests: David A. Saperstein, MD, Vitreoretinal Associates, 1221 Madison St., #1002, Seattle, WA 98104; e-mail: [email protected]
244
245
SURGICAL EVACUATION
Fig. 1. Preoperative fundus photograph of the left eye in December 2000. Note the large accumulation of exudates in the subfoveal space. Visual acuity equals 20/400 in the left eye.
ing a Thomas horizontal subretinal forceps (Synergetics, St. Charles, MO). Further irrigation was used to remove the remaining free-floating exudates. No attempts were made to free the remaining small macular exudates. Laser retinopexy was then applied to the VPTR and an air-fluid exchange was performed before closing. The patient recovered without complications. Over the next several months his visual acuity in this eye steadily improved to 20/25. Amsler grid testing revealed mild distortion just inferior to central fixation in the left eye. Dilated fundus examination at the 9-month follow-up visit showed a 1⫹ nuclear sclerotic cataract, intraretinal residual hard exudates temporal to the fovea, retinal pigment epithelial changes, and mild epiretinal membrane formation (Figure 2).
Fig. 3. Fundus photograph of the left eye 5 years following surgical removal of the subfoveal exudates. Note the remnant retinal pigment epithelial pigment abnormalities and the absence of exudates. Visual acuity equals 20/25 in the left eye.
At the 5-year follow-up examination his vision remained 20/25 in the left eye and the remaining exudates were no longer present (Figure 3). Discussion In the series by Takagi and colleagues, the foveal exudates were under rather than embedded in the neural retina allowing for their removal.1 Their visual outcomes were limited presumably due to retinal damage secondary to diabetic retinopathy. Unlike the patients in the Takagi series, our patient had an otherwise normal macula, lending to his excellent long-term result. Vasoproliferative tumors of the retina often present due to decreased visual acuity secondary to submacular fluid and exudates. Exudative macular involvement has been reported in up to 45% of such cases.2 These changes can result in permanent vision loss.3 Visual recovery depends upon resolution of these exudates before permanent damage to the retina occurs. We have shown that restoration of good visual acuity can be obtained with surgical removal of subfoveal exudates secondary to a VPTR. This technique should be reserved for patients who require rapid visual recovery and those with exudates that are not likely to spontaneously reabsorb. References 1.
2. Fig. 2. Fundus photograph of the left eye 9 months following surgical removal of the exudates. A few small intraretinal exudates remain in the perifoveal area temporal to the fovea. Visual acuity equals 20/25 in the left eye.
3.
Takagi H, Otani A, Kiryu J. New surgical approach for removing massive foveal hard exudates in diabetic macular edema. Ophthalmology 1999;106:249–256. Shields CL, Shields JA, Barrett J. Vasoproliferative tumors of the ocular fundus. Classification and clinical manifestations in 103 patients. Arch Ophthalmol 1995;113:615–623. Heimann H, Bornfeld N, Vij O. Vasoproliferative tumors of the retina. Br J Ophthalmol 2000;84:1162–1169.
