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Case Report
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Acta Ophthalmologica 2009
Age (years) 30 40 33 24 32 26
Refraction
OD )4.75 )2.50 )5.50 )9.25 +2.50 0⁄0⁄0
OS )4.75 0⁄0⁄0 )6.00 )11.25 +1.25 0⁄0⁄0
Preoperative LogMAR VA 0.5 0.5 0.4 0.1 0.5 1.8
Final LogMAR VA 0.1 0.1 0 0.3 0.2 1.0
RD duration (days) 60 2 15 20 3 30
RD extension (meridian) 3:00–6:30 5:00–9:00 3:00–7:00 2:30–7:00 3:30–7:30 1:30–8:00
OCT (postoperative) Diffuse SRF ‘Bleb-like’ SRF Diffuse SRF Diffuse SRF Diffuse SRF ‘Bleb-like’ SRF
Flat retina on final OCT Yes Yes Yes Yes Yes Yes
Range of delay during which retinal 6–9 12–20 11–30 6–75 6–63 6–18
flattening on OCT occurred
(months postoperative)*
External drainage of SRF Yes Yes No Yes Yes Yes
Follow-up (months) 17 20 30 75 63 18
OD, 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.
and one hypermetropic (Table 1). The a range of 17–75 months. Mean The mechanism behind these OCT
mean preoperative logMAR visual final postoperative visual acuity was findings is still not completely clear.
acuity was 0.63 ± 0.59 and the mean 0.28 ± 0.37. Postoperative OCT Hypotheses have included retinal
duration of retinal detachment was examination showed two categories of redundancy (Wolfensberger & Gon-
22 ± 21 days. The logMAR equiva- images: four patients with a diffuse vers 2002), reduced choroidal blood
lent of counting fingers visual acuity shallow detachment of the macula flow, which may be induced by the
was determined to be 1.8 according (Table 1; Fig. 1) and two patients encircling buckle (Diddie & Ernest
to the visual standards resolution with a circumscribed foveal detach- 1980, Sugawara et al. 2006), retinal
adopted by the International Council ment with residual subretinal fluid pigment epithelium (RPE) dysfunction
of Ophthalmology. All patients were (Table 1; Fig. 2). Both types of lesions in the macular region (Benson et al.
operated on using a 240 silicone encir- were not visible clinically. The elapsed 2007) and residual viscous fluid, which
cling band and cryotherapy; five out time period between the observation the RPE finds difficult to absorb
of six patients underwent external of persistent retinal fluid on OCT and a (Wolfensberger & Gonvers 2002; Ben-
drainage of subretinal fluid. Postoper- flattened retina varied from 6 to more son et al. 2007).
ative follow-up included a complete than 12 months (Table 1). At the end The findings of the present study
ophthalmic examination and OCT of the follow-up period, all patients confirm a previous more generalized
imaging using a cross-hair protocol showed an attached fovea on OCT. observation that inferior retinal
(Stratus OCT 3; Zeiss Meditec, detachments may take longer to
Dublin, CA, USA) at 6 months and absorb subretinal fluid (Singh et al.
at 11 or more months after surgery.
Discussion 2006). Furthermore, we observed that
Residual subretinal fluid – visible only subretinal fluid may persist in young
on OCT – occurring after buckling patients after successful buckle surgery
Results surgery for macula-off retinal detach- for macula-off retinal detachment for
The primary postoperative retinal ment has been reported to be present many more months than described
reattachment rate was 100%. Mean in 55–68% of cases (Wolfensberger & previously in older patients. This
follow-up was 37 ± 25 months with Gonvers 2002; Benson et al. 2007). persistence of fluid appears to be
(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 buckle
surgery and external fluid drainage. Note the subfoveal hyporeflective band that extends to the edge of the image, representing a diffuse shallow
elevation 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.
97
Acta Ophthalmologica 2009
(A) (B)
Fig. 2. (A) Optical coherence tomography (OCT) image of patient 2, 6 months after buckle surgery and external subretinal fluid drainage for
inferior 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 occurred
between 12 and 20 months after surgery. LogMAR visual acuity remained 0.1.
independent of whether or not exter- 15 days. In this context, it has been surgery in 55% of patients with an
nal drainage of subretinal fluid was suggested that the presence of vitreous age range of 20–73 years. However,
performed. The fact that we observed in the subretinal space for a long per- no particular subgroups of young
a delay of 6 and more months after iod of time may cause a modification patients or patients with inferior reti-
encircling buckle surgery before the of protein concentration and composi- nal detachment were analysed in detail
first patient reattached the retina com- tion leading to a reduced velocity of in this particular study.
pletely on OCT is in stark contrast subretinal fluid resorption by the RPE In summary, our series of patients
with previously published time-frames (Takeuchi et al. 1996). Shallow retinal shows that young individuals with infe-
(Wolfensberger & Gonvers 2002; Wol- detachments can thus persist for sev- rior macula-off retinal detachments
fensberger 2004). In a series of 16 eral months. It has also been pro- may show persisting postoperative sub-
patients operated on with buckle sur- posed that proteinases may play a clinical fluid under the macula for much
gery for macula-off RD with a much role in slower-than-normal subretinal longer periods of time than described
higher mean age (54 ± 4 years) (Wol- fluid resorption, because these previously in older patients. Whether
fensberger & Gonvers 2002), up to enzymes may contribute to RPE cell this persisting fluid has a direct effect
44% of patients showed a flat retina migration into subretinal fluid (Immo- on postoperative visual acuity recovery
on OCT 6 months after surgery. This nen et al. 1996) and this may delay is still a matter of debate.
observation was confirmed in a fur- fluid resorption by impeding RPE and
ther study (Wolfensberger & Gonvers blood–retinal barrier integrity.
2002) with an even higher mean age It could be argued that the References
(65 ± 3 years) in which up to 55% of described OCT findings are caused Abouzeid H & Wolfensberger TJ (2006):
patients had a flat retina on OCT exclusively by the inferior location of Macular recovery after retinal detachment.
6 months after surgery. This suggests often long-standing retinal detachment Acta Ophthalmol Scand 84: 597–605.
a much slower rate of subretinal fluid and that they are not causally linked Benson SE, Schlottmann PG, Bunce C, Xing
resorption among the presented series to the young age of the patients W & Charteris DG (2007): Optical coher-
ence tomography analysis of the macular
of young patients with inferior RDs. (Singh et al. 2006). However, an anal-
after scleral buckle surgery for retinal
Several phenomena may explain this ysis of a subgroup within a previously detachment. Ophthalmology 114: 108–112.
observation. Firstly, young patients published series (Wolfensberger & Diddie KR & Ernest JT (1980): Uveal blood
have been described as having a less Gonvers 2002) shows that 100% of flow after 360 degrees constriction in the
liquefied and more viscous vitreous young patients with superior retinal rabbit. Arch Ophthalmol 98: 729–730.
whose absorption in the subretinal detachments also have postoperative Immonen I, Konttinen YT, Sorsa T, Tommil-
space may take longer. Secondly, infe- subfoveal fluid on OCT at 1 month a P & Siren V (1996): Proteinases in subre-
tinal fluid. Graefes Arch Clin Exp
rior retinal detachments have often postoperatively. This is in contrast to
Ophthalmol 234: 105–109.
been present for a long period of time the findings in older subjects with Lecleire-Collet A, Muraine M, Menard JF &
before being operated on, because superior RD, which showed such sub- Brasseur G (2005): Visual predictive out-
they produce a superior field defect foveal fluid in only two thirds of all come after macula-off retinal detachment
that is often unremarkable or not cases at 1 month after surgery. Look- surgery using optical coherence tomo-
alarming to patients. Therefore, it ing at inferior retinal detachments in graphy. Retina 25: 44–53.
appears that it is not only the localiza- the older age group of the same series Singh R, Gupta V & Gupta A (2006):
tion of the detachment per se that is (Wolfensberger & Gonvers 2002) Delayed foveal reattachment in scleral
buckle surgery for inferior retinal detach-
determinant but the association of showed that up to half of the older
ment. Ann Ophthalmol 38: 225–230.
inferior RDs with a longer duration patients present a completely flat Sugawara R, Nagaoka T, Kitaya N, Fujio N,
of the detachment before the field fovea on OCT at 1 month postopera- Takahashi J, Takahashi A, Yokota H &
defect becomes clinically significant. tively. In a recent series with 98 Yoshida A. (2006): Choroidal blood
In our series, four out of six patients patients, Benson et al. (2007) found flow in the foveal region in eyes with
had an RD duration of more than subclinical fluid on OCT after buckle rhegmatogenous retinal detachment and
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