Case Study

Pneumatic Retinopexy for Retinal Detachment After Macular Hole Surgery

In two case studies, the authors repaired RDs after macular hole surgery without vitrectomy.

Amy C. Schefler, MD · Harry W. Flynn, Jr., MD

During the past 15 years, macular hole repair by vitrectomy and membrane peeling has become a widely performed surgery with high rates of successful hole closure and improvement in visual acuity. Complications are rare, but can include cataract, endophthalmitis, elevated intraocular pressure, retinal pigment epithelial alterations, visual field loss, recurrence of macular holes and rhegmatogenous retinal detachments.¹ Iatrogenic retinal breaks after macular hole surgery are thought to occur intraoperatively during removal of the posterior cortical vitreous and are typically repaired by repeat vitrectomy with gas tamponade with or without a scleral buckling procedure.² To our knowledge, there have been no reports of the treatment of retinal detachments occurring after macular hole surgery with pneumatic retinopexy alone. In this report, we describe successful treatment with this approach in two patients.

METHODS

A retrospective review was performed of all patients who had undergone a vitrectomy for macular hole repair. Patients were identified who presented with a retinal detachment within the first two months postoperatively who were treated with pneumatic retinopexy and had at least six months follow-up post-pneumatic retinopexy. Two patients were identified (Table 1). Pneumatic retinopexy was performed with the following technique. The eye was prepped and draped in the usual ophthalmic sterile fashion using povidone-iodine on the lids and conjunctiva. Lidocaine 4% was injected subconjunctivally and a sterile lid speculum was inserted. Under direct visualization, cryotherapy was applied to the site of the retinal break. After a second povidone-iodine preparation, a sterile caliper was used to measure an injection site 4 mm posterior to the surgical limbus.

With the patient positioned on his/her side with the affected eye down, a 27-gauge needle was used to exchange 1 cc of 100% C₃F₈ gas for vitreous cavity fluid. The patient was then instructed to maintain a face-down position 100% of the time for the first night. Positioning was directed toward maximum tamponade of the break after the first night. The patients were seen at one day post-procedure, one week, one month and every three months thereafter.

RESULTS

Case #1

A 61-year-old pseudophakic female presented to the Retina Service at the Bascom Palmer Eye Institute complaining of decreased vision in her right eye (RE). Her RE had been followed closely for several years with vitreomacular traction and an evolving macular hole. She had a history of having undergone surgery for a macular hole in the left eye (LE) several years prior. Visual acuity in the RE was 20/50- and in the LE was 20/20-. OCT demonstrated a full-thickness macular hole in the RE. She underwent a 23-gauge pars plana vitrectomy with internal limiting membrane peeling and 16% C₃F₈ gas injection. Her visual acuity improved to 20/25 after surgery in the RE. On the third postoperative week, she had a visual field loss and was noted to have a retinal detachment caused by a single horseshoe tear at the 6:30 position (Figure 1). Her macula was attached and her macular hole remained closed as demonstrated by spectral domain OCT (Figure 2A).

Figure 1. Retinal drawing demonstrating location of inferior retinal break in Case #1, with associated subretinal fluid.

Figure 2A. SD-OCT of the right eye of Case#1 at the time of presentation of the inferior retinal break three weeks after macular hole repair. The patient's central vision in this eye was 20/30-.

The patient underwent pneumatic retinopexy in the clinic with the technique described above. The patient was instructed to maintain a face-down position 100% of the time for one week. At three years of follow-up, the patient's vision is 20/20 in the RE, the retina remains successfully reattached and stable, and the macular hole is closed (Figures 2B and 2C).

Figure 2B. SD-OCT of the right eye of Case #1 one month after pneumatic retinopexy to repair the inferior retinal detachment. The patient's central vision in this eye was 20/25.

Figure 2C. SD-OCT of the right eye of Case #1 six months after pneumatic retinopexy. The vision was 20/20.

Case #2

A 74-year-old male presented with vision of 20/40+2 in the RE and 20/200 in the LE. The phakic patient had a history of a slowly progressing visual loss in the LE for one year, which was caused by a full-thickness macular hole. A 23-gauge vitrectomy with internal limiting membrane peeling and injection of 16% C₃F₈ gas was performed in the LE. On postoperative week 5, the patient was examined and found to have vision of 20/40-2 with the macular hole fully closed. The patient noted an inferior visual field defect and was noted to have a superior retinal tear at the 11:30 position and a bullous retinal detachment.

Pneumatic retinopexy was performed in the same manner as that described in Case #1. On postprocedure week 8, the patient had a visual acuity of 20/40. After 30 months of follow-up, the patient's vision is 20/40+1 after successful cataract surgery. The retina has remained attached and the macular hole is closed.

DISCUSSION

Retinal detachment is one of the most common serious complications of macular hole surgery and has been reported in 3.5% to 25% of published series.^1,2 More recent experience suggests this rate is probably at the low end of this range.^2,3 Retinal tears occurring during macular hole surgery and resulting in retinal detachment in the early postoperative period are thought to occur due to perpendicular tractional forces occurring during posterior cortical vitreous stripping. Previous series have suggested that the majority of retinal breaks after macular hole repair occur in the inferior retina.² The predilection for inferior tears may occur because this anatomic area is more visible intraoperatively and may undergo a more extensive posterior cortical stripping than the superior retina.² However, some postoperative retinal detachments do occur secondary to superior breaks.

Pneumatic retinopexy, first described in the 1980s by Hilton and Grizzard, is widely used as a minimally invasive office-based technique for retinal detachment repair.⁴ The single operation success rate is highest for patients who are phakic with less extensive retinal detachments (<25%), single retinal breaks rather than multiple, and locations in the superior two-thirds of the fundus rather than the inferior retina.⁵ Although likely in use, this technique has never been described as a primary treatment for retinal detachments after macular hole repair, possibly because the majority of these breaks occur inferiorly. However, pneumatic retinopexy (with or without 10° Trendelenburg positioning) has been described with success for inferior detachments⁶ and its application in these cases regardless of location of the retinal break may be appropriate. In fact, except for the inferior location of the retinal break in Case #1, the clinical characteristics of the retinal detachments in both of the patients in our series made them excellent candidates for pneumatic retinopexy.

Advantages of the use of pneumatic retinopexy in this situation include: patient satisfaction associated with avoidance of a second major operation, faster visual recovery, cost effectiveness, ease of gas injection in a previously vitrectomized eye and possibly lower risk of creating a new iatrogenic retinal break compared to repeat vitrectomy. Furthermore, epiretinal membrane formation, another potential complication after pneumatic retinopexy, would not be expected after a recent epiretinal membrane/internal limiting membrane peeling.

Figure 3. Retinal drawing demonstrating location of superior retinal break in Case #2 with associated subretinal fluid.

It is not known whether these patients’ retinal breaks occurred intraoperatively and were missed during the intra-operative peripheral retinal examination, or if they occurred postoperatively. Regardless of the mechanism, these cases emphasize the importance of repeat peripheral retinal examinations during postoperative visits. In fact, retinal breaks after macular hole surgery have been reported as late as 104 weeks postoperatively.² Furthermore, patients may not complain of symptoms typical for retinal detachment if the subretinal fluid accumulates while the gas bubble is still present. Thus, such a complication may only be detected as a result of a thorough routine postoperative examination. Once a postoperative retinal break is detected, prompt treatment is important for a successful visual outcome.

In summary, these cases illustrate the successful use of pneumatic retinopexy for superior or inferior retinal detachment occurring after macular hole repair. A larger case series will be needed to determine the single operation success rate with this technique. RP

REFERENCES

1. Thompson JT. Macular holes. In: Regillo CD, Brown GC, Flynn HW, Jr., eds. Vitreoretinal Disease: The Essentials. New York, NY; Thieme; 1999:267-282.
2. Tabandeh H, Chaudhry NA, Smiddy WE. Retinal detachment associated with macular hole surgery: characteristics, mechanism, and outcomes. Retina. 1999;19:281-286.
3. Moore JK, Kitchens JW, Smiddy WE, Mavrofrides EC, Gregorio G. Retinal breaks observed during pars plana vitrectomy. Am J Ophthalmol.2007;144:32-36.
4. Hilton GF, Grizzard WS. Pneumatic retinopexy: A two-step outpatient operation without conjunctival incision. Ophthalmology. 1986;93:626-641.
5. Tornambe PE. Pneumatic retinopexy: the evolution of case selection and surgical technique. A twelve-year study of 302 eyes. Trans Am Ophthalmol Soc. 1997;95:551-578.
6. Mansour AM. Pneumatic retinopexy for inferior retinal breaks. Ophthalmology. 2005;112:1771-1776.