Evolution of Outer Retinal Folds Occurring after Vitrectomy for Retinal Detachment Repair

Morphologic Features of Regulated vs. Dysregulated Rhegmatogenous Retinal Detachment Using Swept-Source Optical Coherence Tomography

OBJECTIVE

To describe varying morphological features of patients with RRD based on the extent of regulation of the subretinal space by the retinal pigment epithelium (RPE) pump using swept-source optical coherence tomography (SS-OCT).

DESIGN

Prospective clinical cohort study.

METHODS

 Setting: St. Michael's Hospital, Toronto, Canada, from August 2020-August 2023.

PARTICIPANTS

120 consecutive eyes with primary RRD. Cohorts: Subclinical, non-progressive, localized RRD defined as regulated vs. acute, progressive, and extensive defined as dysregulated, assessed with SS-OCT.

MAIN OUTCOME

Morphological features of regulated vs. dysregulated RRDs with SS-OCT.

RESULTS

19.2% (23/120) of RRDs were classified as regulated and 80.8% (97/120) were dysregulated. The mean age of patients with regulated RRDs was 37.1 years (±13.7 SD) vs. 62.6 years (±11.6SD) for patients with dysregulated RRDs (P < .001). The presence of outer retinal corrugations (ORCs) on OCT was observed in 4.3% (1/23) of regulated vs. 81.4% (79/97) of dysregulated RRDs (P < .001). CME was found in 41.6% (5/12) of regulated RRDs compared to 87.3% (83/95) of dysregulated RRDs (P < .001). ORC presence was an independent predictor of having a dysregulated RRD (P = .02, β = 6.6, 95% CI [1.3-33.2]) when controlling for age, sex, baseline VA, lens status, and RD extent. Among patients with regulated RRDs, 25.0% (3/12) were in Stage 2, 0% (0/16) in Stage 3A, 8.3% (1/12) in Stage 3B, 0% (0/16) in Stage 4, and 66.7% (8/12) in Stage 5. In patients with dysregulated RRDs, 14.7% (14/95) were in Stage 2, 15.7% (15/95) were in Stage 3A, 37.9% (36/95) in Stage 3B, 22.1% (21/95) in Stage 4, and 9.5% (9/95) in Stage 5 (P < .001).

CONCLUSIONS

There are significant morphologic differences between regulated and dysregulated RRDs using SS-OCT. ORCs are present in almost all dysregulated cases but in a minority of regulated cases and they are an independent predictor of RPE-photoreceptor regulation status. Demographic and clinical features differentiate regulated and dysregulated RRD and understanding these differences has significant implications for optimal management and postoperative outcomes.

Changes in Metamorphopsia in Patients Undergoing Treatment for Vitreoretinal Disorders

PURPOSE

To quantify and compare the severity of metamorphopsia in patients undergoing vitrectomy for vitreoretinal disorders.

METHODS

Data were collected evaluated from 319 patients with vitreoretinal disorders, including epiretinal membrane (ERM), macular hole (MH), cystoid macular edema with branch retinal vein occlusion (BRVO-CME), CME with central retinal vein occlusion (CRVO), diabetic macular edema (DME), macula-off rhegmatogenous retinal detachment (M-off RD), and macula-on RD (M-on RD). Metamorphopsia was recorded with the M-CHARTS preoperatively and at 3 and 6 months postoperatively.

RESULTS

Preoperative and 6-month postoperative metamorphopsia scores were 0.69 ± 0.50 and 0.50 ± 0.52, respectively. Before surgery, 94% of patients presented with metamorphopsia (score ≥0.2). Preoperative metamorphopsia scores were significantly correlated with postoperative metamorphopsia scores (r = 0.378, p < 0.0001). Preoperative metamorphopsia score was significantly higher for ERM (0.89) than for DME (0.51). Vitrectomy significantly improved metamorphopsia in ERM and MH but not in the other disorders. In contrast, treatment improved visual acuity for all disorders except CRVO-CME and M-on RD.

CONCLUSION

This quantitative study indicated that metamorphopsia is present in most patients undergoing surgery for vitreoretinal diseases and is most severe in ERM. In these patients, vitrectomy improved visual acuity but not metamorphopsia.

Multiple Types Late-Onset Postoperative Retinal Folds following Vitrectomy for Retinal Detachment Repair with Silicone Oil: Morphologic Variability and Optical Coherence Tomography Angiography Features - A Case Report

Introduction

Retinal folds (RFs) may develop following rhegmatogenous retinal detachment (RRD) repair, though it consists an uncommon complication.

Case Presentation

Herein, we present a case of late-onset postoperative outer RFs with aggravating characteristics following vitrectomy with silicone oil (SO) tamponade for RRD repair; early clinical findings, complications, anatomical and functional status during a 12-month follow-up period are described. Retinal imaging by acquiring optical coherence tomography scans and angiograms indicates detailed morphological and angiographic characteristics of the evolution of RFs over time. Our case provides insight into a combination of various types of RFs along with retinal disorganization with appearance in the late postoperative period after RRD repair with SO tamponade.

Conclusion

Our aim was to raise awareness of the pathological processes that may be associated with the development and evolution of RFs after successful RRD repair, indicating that it is critical to accurately diagnose the type of RFs and closely monitor their progression in an attempt to provide prognostication for future visual outcomes.

LONG-TERM CHANGES IN VISUAL FUNCTION AND EN FACE OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN FOVEA-OFF RETINAL DETACHMENT: A 2-Year Prospective Study

PURPOSE

To investigate the long-term changes in visual function and outer retinal abnormalities on en face optical coherence tomography after fovea-off rhegmatogenous retinal detachment and to assess associations between functional outcomes and outer retinal abnormalities.

METHODS

Prospective, observational study. The following data were collected at 1, 3, 6, 12, and 24 months after retinal reattachment: Best-corrected visual acuity, metamorphopsia (M-CHARTS), aniseikonia (New Aniseikonia Test), altered ellipsoid zone reflectivity, outer retinal folds, macular detachment demarcation, and subfoveal fluid.

RESULTS

Thirty-eight patients were included. Best-corrected visual acuity improved significantly from 1 to 12 months and from 12 to 24 months (P < 0.001; P = 0.022). Vertical and horizontal metamorphopsia improved significantly from 1 to 12 months (P < 0.001; P = 0.002), and at 24 months, scores of ≥0.2° were present in 54% and 42% of patients, respectively. The degree of aniseikonia did not change. Best-corrected visual acuity and aniseikonia scores were positively associated with outer retinal fold (r 0.4, P = 0.009; r 0.4, P = 0.048). A gradual normalization of outer retinal reflectivity took place during 24 months.

CONCLUSION

Visual acuity improved significantly during the second year after reattachment surgery for fovea-off rhegmatogenous retinal detachment, in parallel with normalization of outer retinal abnormalities on en face optical coherence tomography. Metamorphopsia did not improve after 12 months, and aniseikonia remained unchanged.

Outer Retinal Corrugations in Rhegmatogenous Retinal Detachment: The Retinal Pigment Epithelium-Photoreceptor Dysregulation Theory

PURPOSE

Outer retinal folds occur when outer retinal corrugations (ORCs) persist after retinal reattachment with worse functional outcomes. We investigate the pathophysiology of ORCs in vivo.

DESIGN

Prospective cohort study.

METHODS

Patients with rhegmatogenous retinal detachment (RRD) presenting to St. Michael's Hospital, Toronto, Ontario, Canada, between August 2020 and February 2022 were assessed with swept-source optical coherence tomography (SS-OCT) and ultra-widefield SS-OCT for ORCs. Clinical characteristics of eyes with/without ORCs were compared. Mathematical models were used to deduce mechanical properties leading to ORCs.

RESULTS

Sixty-six patients were included. More than half (60.6%, 40/66) were fovea-off and 48.4% (32/66) had ORCs at presentation. All eyes (32/32) with ORCs had retinal pigment epithelium (RPE)-photoreceptor dysregulation for at least 2 days, defined as loss of RPE control with acute, progressive, and extensive RRDs. In all (34/34) eyes without ORCs the RPE was in relative control of the subretinal space with nonprogressive subclinical or small localized or resolving RRDs, or with RPE-photoreceptor dysregulation for fewer than 2 days. Mathematical models indicate that a modulus of elasticity of the outer retina relative to the inner retina of 0.05 to 0.5 leads to ORCs.

CONCLUSIONS

ORCs develop with (1) acute exposure of subretinal space to liquified vitreous, (2) for >2 days, that (3) overwhelms RPE capacity, leading to progressive and extensive RRD. Mathematical models suggest that a reduction in the modulus of elasticity of the outer retina occurs such that intrinsic compressive forces, likely related to progressive outer retinal hydration and lateral expansion, lead to ORCs. Understanding the pathophysiology of ORCs has implications for management.

Clinical and imaging characteristics of outer retinal folds in eyes with retinitis

Purpose

To describe clinical and imaging characteristics of the outer retinal folds (ORF) in cases of retinitis, retinochoroiditis, and chorioretinitis.

Methods

Retrospective review of retinitis cases with presence of ORFs either at presentation or during follow up.

Results

ORFs were seen adjacent to retinitis lesions in 16 eyes of 14 cases (retinitis post-febrile illness n = 10, toxoplasma retinochoroiditis n = 2, fungal chorioretinitis n = 2) either at presentation (n = 2) or during follow up (n = 14). Optical coherence tomography (OCT) appearance was outer retinal vertical stout lesions involving ellipsoid, external limiting membrane, and outer nuclear layer. All the cases had a presence of past or concurrent subretinal fluid and/or subretinal hyperreflective material when ORF was seen. ORF resolved with variable outer retinal atrophy over a mean period of 2.86 months.

Conclusion

ORF is observed in cases of retinitis with subretinal fluid either at presentation or during resolution. It is not specific to any etiological disease. Differentiation of this sign from vertical outer retinal stripes in viral retinitis on OCT is important to avoid misinterpretation.

[Macular folds after surgical repair of retinal detachment]

The incidence of retinal folds following surgical repair of retinal detachment is underestimated. The extent of retinal folds is variable and can include the complete retina with all layers and an apposition of the photoreceptor outer segments or only partially affect the outer or inner retinal layers. While complete folds can be relatively easily detected by clinical examination, discrete partial folds are sometimes difficult to assess biomicroscopically. In these cases, high-resolution optical coherence tomography (OCT) plays an important role as a tool for differential diagnosis. If macular translocation occurs during the formation of folds, mostly in associated with inferior retinal folds, patients often complain of binocular double vision. A significant reduction of visual acuity and metamorphopsia occur in cases where the folding involves the fovea. In general, retinal folds tend to resolve spontaneously over a prolonged period of follow-up of several months; however, in cases of foveal involvement and corresponding symptoms, a surgical revision can be indicated, although the surgical procedure is not standardized.

Enlightening new underpinnings in hydration retinal folds

PURPOSE

To describe and value a peculiar alteration typically found in rhegmatogenous retinal detachment raising news foundations of its role in the photoreceptors and visual prognosis.

DESIGN

Case description and rationale formulation.

SUBJECTS

An isolated case.

INTERVENTION

We report a case of a 52-year-old male patient complaining of sudden visual acuity (VA) loss in the left eye. Fundoscopic findings revealed rhegmatogenous retinal detachment, macula off, and an isolated horseshoe tear in the infero-temporal periphery. Spectral-domain optical coherence tomography (SD-OCT) evinced prominent hydration retinal folds.

MAIN OUTCOME MEASURES

Restructuring of the retinal layers, visual acuity and complaints.

RESULTS

The patient underwent scleral buckling surgery with complete re-attachment of the retina and significant improvement of the hydration retinal folds. In addition, there was resolution of visual symptoms, with a final VA of 20/30.

CONCLUSIONS

We speculate that the increase in arc length of the outer retina generates a centripetal force towards the fovea. Its association with the higher density of photoreceptors in this region, generates resistance in the water inflow, preventing swelling and cellular damage of the central photoreceptors.

Autofluorescence Imaging in the Long-Term Follow-Up of Scleral Buckling Surgery for Retinal Detachment

Purpose

To analyse fundus autofluorescence (AF) changes in retinal reattachment following primary scleral buckling (SB) surgery for rhegmatogenous retinal detachment (RRD).

Methods

Prospective noninterventional chart review study. AF images were reviewed for peripheral and central changes and compared to clinical and OCT findings.

Results

A total of 73 eyes from 69 patients were included, four presenting with bilateral RRD. Mean age was 55 ± 12 years, male/female ratio 40/29, fovea-on/-off RRD 43/30, and mean follow-up time 376 ± 270 days, with a mean of 5 ± 3 postoperative visits. Preoperatively, RRD was seen as a hypofluorescent area with a hyperfluorescent leading edge. Immediately postoperatively, three types of cryopexy could be differentiated, gradually transforming to scleral hyperfluorescence. Buckle tightening produced alternating hyper-/hypofluorescent streaks, and demarcation lines showed a persistent rugged hyperfluorescent signal. Choroidal detachment led to transient hypofluorescence, whereas vortex vein compression induced persistent hypofluorescence. Peripheral retinal folds were hyperfluorescent and the drainage site was hypofluorescent. AF was highly sensitive in detecting even small amounts of hyperfluorescent persistent subretinal fluid (SRF) that showed a slow resolution during follow-up. A granular “salt-and-pepper-” like pattern in the central macula was seen in 80% of eyes with fovea-off RRD and alternating streaks in 10%. Findings from OCT imaging correlated well with AF regarding SRF, macular oedema, retinal pigment epithelial detachment, and presence of a subretinal scar, but only moderately in epiretinal membrane formation and choroidal folds.

Conclusions

AF is a useful, noninvasive, adjuvant tool in the long-term follow-up after SB surgery.

A Splicing Mutation in Slc4a5 Results in Retinal Detachment and Retinal Pigment Epithelium Dysfunction

Fluid and solute transporters of the retinal pigment epithelium (RPE) are core components of the outer blood-retinal barrier. Characterizing these transporters and their role in retinal homeostasis may provide insights into ocular function and disease. Here, we describe RPE defects in tvrm77 mice, which exhibit hypopigmented patches in the central retina. Mapping and nucleotide sequencing of tvrm77 mice revealed a disrupted 5' splice donor sequence in Slc4a5, a sodium bicarbonate cotransporter gene. Slc4a5 expression was reduced 19.7-fold in tvrm77 RPE relative to controls, and alternative splice variants were detected. SLC4A5 was localized to the Golgi apparatus of cultured human RPE cells and in apical and basal membranes. Fundus imaging, optical coherence tomography, microscopy, and electroretinography (ERG) of tvrm77 mice revealed retinal detachment, hypopigmented patches corresponding to neovascular lesions, and retinal folds. Detachment worsened and outer nuclear layer thickness decreased with age. ERG a- and b-wave response amplitudes were initially normal but declined in older mice. The direct current ERG fast oscillation and light peak were reduced in amplitude at all ages, whereas other RPE-associated responses were unaffected. These results link a new Slc4a5 mutation to subretinal fluid accumulation and altered light-evoked RPE electrophysiological responses, suggesting that SLC4A5 functions at the outer blood-retinal barrier.

Outer Retinal Folds Following Pars Plana Vitrectomy vs Pneumatic Retinopexy for Retinal Detachment Repair: Post Hoc Analysis from PIVOT

PURPOSE

To assess the incidence of post-operative outer retinal folds (ORFs) in pars plana vitrectomy (PPV) vs pneumatic retinopexy (PnR) following rhegmatogenous retinal detachment (RRD) repair and to determine the association of ORFs with functional outcomes at 1 year.

DESIGN

Randomized controlled trial PARTICIPANTS: Patients with primary macula-off RRD meeting PIVOT trial criteria randomly assigned to PPV vs PnR.

METHODS

Post-hoc analysis of the PIVOT trial. Incidence and quantitative morphological features of ORFs were assessed with en face and cross-sectional OCT at 1 month post-operatively by two masked graders. ETDRS letter score and quantitative metamorphopsia were measured at 1 year.

MAIN OUTCOME MEASURES

Proportion of patients with ORFs following PPV vs PnR at 1 month post-operatively. Secondary outcomes include the association of ORFs with visual acuity (ETDRS letter score) and metamorphopsia (M-CHARTS) at 12 months post-operatively.

RESULTS

Eighty-eight of the 176 participants enrolled in PIVOT were macula-off RRD. 94.3% (83/88) of these macula-off eyes had month 1 post-operative OCT scans that were gradable, 93.2% (41/44) in the PPV group and 95.5% (42/44) in the PnR group. The incidence of ORFs formation was 34.1% (14/41) in the PPV group and 14.3% (6/42) in the PnR group (p=0.034). ETDRS letter score at 1 year was 65.7±6.6 letters in patients with ORFs versus 75.1±1.4 letters in those without ORFs (difference=9.4 letters, 95% CI=7.5-11.3, p=0.047). Among patients in the PPV group only, mean ETDRS letter score at 1 year in patients with ORFs was 62.8 ± 24.7 letters compared to 75.4 ± 9.2 letters in patients without ORF formation (difference=12.6 letters, 95% CI=0.05-24.59, p=0.04). Horizontal and vertical metamorphopsia scores were similar in patients with vs without ORFs: horizontal: 0.35 ± 0.12 versus 0.29 ± 0.07 (difference=0.06, 95% CI=0.01-0.11, p=0.69) and vertical: 0.25±0.07 versus 0.29±0.07 (difference=0.04, 95%CI=0-0.08, p=0.60) respectively. There was a negative correlation between the closest distance of the ORFs from the fovea and the vertical metamorphopsia score (r=-0.507, p=0.045).

CONCLUSIONS

There is a greater risk of developing ORFs following PPV compared to PnR for RRD. ORFs at 1 month are associated with significantly worse ETDRS visual acuity letter score at 1 year.

Real-Time In Vivo Assessment of Retinal Reattachment in Humans Using Swept-Source Optical Coherence Tomography

PURPOSE

To assess the in vivo physiology of retinal reattachment in humans using swept-source optical coherence tomography (SS-OCT) in real time.

DESIGN

Prospective case series.

METHODS

Fifteen consecutive patients with fovea-involving rhegmatogenous retinal detachment were undergoing pneumatic retinopexy. SS-OCT was performed at presentation and frequent intervals immediately after pneumatic retinopexy. The primary outcome was longitudinal assessment of early postoperative SS-OCT to establish stages of reattachment.

RESULTS

Most patients (93.3%, 14/15) achieved successful reattachment at the median follow-up duration of 13 weeks (interquartile range 7.5-18.0). Reattachment occurred in 5 specific stages: 1) redistribution of fluid and approach of the neurosensory retina toward the retinal pigment epithelium occurred in 100% (15/15); 2) reduction in cystoid macular edema and improvement of outer retinal corrugations was achieved in 100% (15/15); 3) initial contact of the neurosensory retina to the retinal pigment epithelium occurred completely in 66.7% (10/15); 4) deturgescence of the inner and outer segments of the photoreceptors occurred in 66.7% (10/15); and 5) recovery of photoreceptor integrity occurred in 3 specific substages: 5A) external limiting membrane recovery (10/15, 66.6%); 5B) ellipsoid zone recovery (9/15, 60%); and 5C) interdigitation zone/foveal bulge recovery (3/15, 20%). Twenty percent (3/15) had delayed progression through stage 2, characterized by formation of outer retinal folds. Similarly, 33.3% (5/15) developed residual subfoveal fluid blebs (delayed progression to stage 3).

CONCLUSIONS

This study characterizes the in vivo physiology of retinal reattachment in humans using high-resolution SS-OCT that occurs in 5 specific stages. Delayed progression through certain stages was characterized by postoperative anatomic abnormalities. Am J Ophthalmol 2021;221:•••-•••. © 2021 Elsevier Inc. All rights reserved.

EN FACE IMAGING OF OUTER RETINAL PATHOLOGY AFTER RETINAL DETACHMENT

PURPOSE

To explore the potentials of multicolor (MC) confocal scanning laser ophthalmoscopy (cSLO) to detect structural retinal pathology after macula-off rhegmatogenous retinal detachment (RRD) and to describe their appearances.

METHODS

Thirty MC cSLO images of 30 eyes after RRD repair were prospectively studied for the presence of RRD-related pathology. All MC cSLO findings were verified using swept source optical coherence tomography. Positive percent agreements were calculated using swept source optical coherence tomography as reference.

RESULTS

Eight RRD-related structural pathologies were identified and characterized: ellipsoid zone (EZ) disruption, foveal EZ rosette, outer retinal fold, retinal detachment line, subretinal fluid blebs, subretinal fluid layer, retinal striae, and intraretinal cysts. Multicolor cSLO positive percent agreements were as follows: EZ disruption: 79%, foveal EZ rosette: 73%, outer retinal fold: 67%, retinal detachment line: 84%, subretinal fluid blebs: 0.70%, subretinal fluid layer: 50%, intraretinal cysts: 60%, and retinal striae: 100%.

CONCLUSION

En face MC cSLO imaging detected and delineated RRD-related structural pathology in high agreement with cross-sectional swept source optical coherence tomography and can supplement optical coherence tomography in the documentation and monitoring of outer retinal remodeling processes after macula-off RRD. Foveal EZ rosette is a new finding of the foveal EZ.

A possible strategic role of air during pars plana vitrectomy for macula-involving rhegmatogenous retinal detachment

AIM

To evaluate the advantages and safety of vitrectomy under air for treating macula-involving rhegmatogenous retinal detachment (RRD).

METHODS

Consecutive patients with macula-involving RRD who underwent vitrectomy under air were recruited. Demographic and clinical data were: age, gender, eye, lens status, best corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR), axial length, intraocular pressure (IOP). RRD parameters were: RRD extent, retinal breaks number. Surgical data were: cataract surgery, tamponade used. Postoperative parameters were: BCVA, IOP at first, third, sixth month, recurrent RD, incidence of retinal folds, subretinal fluid (SRF) persistence, macular displacement.

RESULTS

Seventy-one eyes (71 patients) were recruited. Cataract surgery was performed in 32 of 45 phakic patients. The tamponade used was: sulfur hexafluoride 18% (41), silicon oil (SO) (26), high-density SO (4). BCVA improved significantly from baseline (1.2 ± 0.4 logMAR) to the last control (0.8 ± 0.7 logMAR) (P = 0.03285). Recurrent RD incidence was 14.1%. Postoperative complications were: retinal folds (2), SRF persistence (3), macular displacement (2).

CONCLUSION

Vitrectomy under air is a safe alternative technique for treating macula-involving RRD. Vitrectomy under air allows surgeon to remove accurately the vitreous from the peripheral retina and facilitates the removal of SRF reducing the complications related to its postoperative persistence.

Comparative analysis of metamorphopsia and aniseikonia after vitrectomy for epiretinal membrane, macular hole, or rhegmatogenous retinal detachment

This study investigated postoperative changes in metamorphopsia and aniseikonia in eyes that underwent vitrectomy for epiretinal membrane (ERM), macular hole (MH), or rhegmatogenous retinal detachment (RRD). In total, 166 eyes were included from 166 patients with ERM, MH, or RRD who underwent primary vitrectomy. Metamorphopsia and aniseikonia were quantified by M-CHARTS and the New Aniseikonia Test (NAT). Best-corrected visual acuity (BCVA), M-CHARTS, NAT assessments, and OCT examination were performed at 1, 3, and 6 months postoperatively. Of the 166 eyes, 65 had ERM, 21 had MH, 42 had macula-off RRD, and 38 had macula-on RRD. BCVA improved significantly between 1 and 6 months postoperatively in eyes with ERM, MH, and macula-off RRD (P = 0.0057, P = 0.0065, and P = 0.0021, respectively). M-CHARTS scores at 1 month postoperatively significantly decreased in eyes with ERM (P = 0.0034) and tended to decrease in eyes with MH (P = 0.068). NAT scores did not change between baseline and 1 month postoperatively in eyes with ERM or MH. Between 1 and 6 months postoperatively, M-CHARTS and NAT scores significantly decreased in eyes with macula-off RRD (P = 0.0064 and P = 0.0009, respectively), but not in eyes with ERM, MH, or macula-on RRD. At 6 months postoperatively, significant metamorphopsia was evident in 33.3% of eyes with ERM, 29.2% of eyes with MH, and 35.7% of eyes with macula-off RRD; 61.5% of eyes with ERM showed macropsia and 52.3% of eyes with macula-off RRD showed micropsia. In eyes with ERM, more central retinal thickness (CRT) correlated with postoperative BCVA, and deep retinal folds on enface OCT image correlated with postoperative metamorphopsia. In eyes with macula-off RRD, less CRT correlated with postoperative BCVA, and tended to correlate with postoperative micropsia. Macular morphologies could contribute to differences in postoperative visual acuity, metamorphopsia, and aniseikonia.

Macular optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment

The primary aim of this study was to summarize and illustrate the main structural cross-sectional optical coherence tomography findings encountered after vitreoretinal surgery for rhegmatogenous retinal detachment. This was a non-systematic review of literature on structural cross-sectional optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment. Adequate illustrations of the main findings described were found after a retrospective analysis of imaging and charts of patients operated at the department where this study was performed. The main structural cross-sectional optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment included persistent subretinal fluid, subretinal blebs, retinal folds, subretinal perfluorocarbon liquids, macular alterations related to silicone oil, epiretinal membranes, proliferative vitreoretinopathy, cystoid macular edema, macular holes, and recurrent retinal detachment. In conclusion, optical coherence tomography was a useful tool after vitreoretinal surgery for rhegmatogenous retinal detachment. Some optical coherence tomography findings may not be evident on fundus examination, and optical coherence tomography can reveal essential details for the clinical management and the visual prognosis. Other findings, despite being visible on funduscopic examination, may be better assessed with the aid of optical coherence tomography. All these elements contribute to support the importance of tomographic assessment in the follow-up of eyes treated for vitreoretinal conditions.

Interpretation of OCT and OCTA images from a histological approach: Clinical and experimental implications

Optical coherence tomography (OCT) and OCT angiography (OCTA) have been a technological breakthrough in the diagnosis, treatment, and follow-up of many retinal diseases, thanks to its resolution and its ability to inform of the retinal state in seconds, which gives relevant information about retinal degeneration. In this review, we present an immunohistochemical description of the human and mice retina and we correlate it with the OCT bands in health and pathological conditions. Here, we propose an interpretation of the four outer hyperreflective OCT bands with a correspondence to retinal histology: the first and innermost band as the external limiting membrane (ELM), the second band as the cone ellipsoid zone (EZ), the third band as the outer segment tips phagocytosed by the pigment epithelium (PhaZ), and the fourth band as the mitochondria in the basal portion of the RPE (RPEmitZ). The integrity of these bands would reflect the health of photoreceptors and retinal pigment epithelium. Moreover, we describe how the vascular plexuses vary in different regions of the healthy human and mice retina, using OCTA and immunohistochemistry. In humans, four, three, two or one plexuses can be observed depending on the distance from the fovea. Also, specific structures such as vascular loops in the intermediate capillary plexus, or spider-like structures of interconnected capillaries in the deep capillary plexus are found. In mice, three vascular plexuses occupy the whole retina, except in the most peripheral retina where only two plexuses are found. These morphological issues should be considered when assessing a pathology, as some retinal diseases are associated with structural changes in blood vessels. Therefore, the analysis of OCT bands and OCTA vascular plexuses may be complementary for the diagnosis and prognosis of retinal degenerative processes, useful to assess therapeutic approaches, and it is usually correlated to visual acuity.

Quantitative assessment of outer retinal folds on enface optical coherence tomography after vitrectomy for rhegmatogenous retinal detachment

We aimed to investigate the possible causes of metamorphopsia for rhegmatogenous retinal detachment (RRD) based on findings of enface optical coherence tomography (OCT). The study was a retrospective, consecutive case series of 33 eyes with macula-off RRD. Metamorphopsia was measured by M-CHARTS and enface OCT images covering a macular area of 6 × 6 mm square obtained at 1, 3, and 6 months postoperatively. Within the outer retinal slabs of enface OCT, multiple lines that looked like folds were delineated in all eyes at month 1, and we succeeded in extracting images of folds by subtracting retinal vessels. We calculated their density by an image-processing technique. The mean M-CHARTS scores were 0.62 ± 0.47 at month 1 and 0.30 ± 0.29 at month 6 (P < 0.001). The fold density was 8.3 ± 4.2 at month 1 and 6.1 ± 3.1 at month 6 (P = 0.0044). The M-CHARTS scores at 6 months were significantly associated with the fold density at 1 month (r = 0.515, P = 0.002). In conclusion, enface OCT visualized the outer retinal folds in eyes that had undergone successful RRD surgery, and a larger number of folds was related to the remaining metamorphopsia.

Inner, outer, and full-thickness retinal folds after rhegmatogenous retinal detachment repair: A review

Partial-thickness folds of the inner retina and outer retina, as well as full-thickness retinal folds, may occur after the repair of rhegmatogenous retinal detachment. Although these can look similar on clinical examination, imaging with optical coherence tomography facilitates differentiation. With optical coherence tomography analysis, inner retinal folds exhibit corrugations of the inner retina while outer retinal folds display hyperreflective lesions located just above the retinal pigment epithelium that may extend into the outer nuclear layer. In the case of a classic full-thickness retinal fold, all layers of the neurosensory retina may separate together from the retinal pigment epithelium with retinal reduplication and base-to-base photoreceptor orientation. We review the pathogenesis, risk factors, prevention, and management options of retinal folds. As the terminology for retinal folds is diverse, we highlight optical coherence tomography-based descriptions for retinal folds that have been used in the literature. Factors predicting visual recovery, mechanisms of spontaneous fold regression, and the effect of internal limiting membrane peeling on the incidence of folds are potential areas of future study.

TREATMENT OF MACULAR FOLDS COMPLICATING RETINAL DETACHMENT SURGERY USING AIR FOR RETINAL UNFOLDING

PURPOSE

We discuss a modified surgical procedure for the treatment of macular folds complicating retinal reattachment surgery.

METHODS

To facilitate the completion of the macular redetachment and the subsequent unrolling of the fold, we propose the subretinal injection, in addition to the conventional balanced salt solution, of filtered air as an original approach. In the presence of a subretinal air bubble, the action of gravity on the perfluorocarbon liquid in the vitreous cavity combined with an active globe manipulation proved to be very effective for flattening the central retina. Short-term tamponade with gas was successful at stabilizing the result.

RESULTS

This technique has been used to treat symptomatic macular fold after surgery for rhegmatogenous retinal detachment in 3 consecutive eyes since 2014. Flattening of the macula with progressive visual recovery was achieved in all cases by the end of follow-up.

CONCLUSION

Direct injection of air into the macular fold may represent an effective strategy to enhance the surgical management of such a vision-threatening complication. Air also minimizes the risks related to the forceful injection of fluid under the macula. An overview of recently reported surgical techniques is included, along with a brief discussion.

Potential role of Müller cells in the pathogenesis of macropsia associated with epiretinal membrane: a hypothesis revisited

Pathophysiological explanations for metamorphopsia associated with retinal pathologies generally focus on photoreceptor organization disruption. However, the retinal microarchitecture is complicated, and we hypothesize that other retinal cells may also be involved. Metamorphopsia has been widely studied in eyes with epiretinal membranes and we revisit the idea that Müller cell displacement causes retinal macropsia. A PubMed query and related article search for the macula ultrastructure under normal and pathological conditions revealed an enormous amount of information, particularly ultrahigh definition optical coherence tomography and other retinal imaging modality studies. Findings of these imaging studies support our hypothesis that Müller cells, and not cone photoreceptors, are primarily responsible for macropsia in eyes with epiretinal membranes. More specifically, we conclude that displacement of Müller cell endfeet, and not photoreceptor cones, is a more likely the explanation for retinal macropsia associated with epiretinal membranes.

Optical coherence tomography evaluation of patients with macula-off retinal detachment after different postoperative posturing: a randomized pilot study

PURPOSE

To assess the presence of outer and inner retinal folds (RFs) and drop-out of the ellipsoid zone (EZ) occurring after surgical repair of macula-off rhegmatogenous retinal detachment (RRD) with different postoperative posture and preoperative use of adjuvant perfluorocarbon liquid (PFCO).

METHODS

In this prospective study, 56 eyes of 56 consecutive patients affected by RRD were subjected to 23- or 25-gauge pars plana vitrectomy (PPV). The patients were randomized in four groups (14 prone 5 hr without PFCO, 14 supine 5 hr without PFCO, 14 prone 5 hr with PFCO and 14 supine 5 hr with PFCO) and followed up with spectral domain optical coherence tomography (SD-OCT).

RESULTS

Spectral domain optical coherence tomography (SD-OCT) was recorded before surgery, at days 30 and 90 to detect the presence of outer RFs, inner RFs and drop-out of EZ and to follow their variation over time. No statistical significance was found in our groups for outer RFs, inner RFs, drop-out of EZ formation and evolution. The postoperative best-corrected visual acuity (BCVA) improved in all groups (mean preoperative BCVA 1.47 logMar ± 0.19, mean postoperative BCVA 0.27 logMar ± 0.11, p < 0.01), without statistical variations between the four groups in BCVA after surgery.

CONCLUSION

The use of adjuvant and variation in postoperative position did not change the risk of presenting outer RFs, inner RFs and drop-out of EZ after RRD.

Fundus Autofluorescence Patterns of Submacular Fluid Resolution Following Repair of Macula-Involving Rhegmatogenous Retinal Detachments

BACKGROUND AND OBJECTIVE

Submacular fluid (SMF) can persist for months to years following rhegmatogenous retinal detachment (RD) repair. The authors' objective was to describe fundus autofluorescence (FAF) and optical coherence tomography (OCT) findings associated with the absorption of persistent submacular fluid (SMF) following RD repair.

PATIENTS AND METHODS

Retrospective review of clinical data and FAF and OCT imaging from sequential postoperative visits in a cohort of patients with persistent SMF following RD repair.

RESULTS

In 11 of 13 eyes with persistent SMF, patches of decreased FAF signal corresponded to SMF on OCT. In eight eyes, there was a hypo- to hyperautofluorescence transition at the time of SMF resolution. These areas of increased FAF signal correlated with inner segment/outer segment (IS/OS) junction loss on OCT.

CONCLUSION

FAF imaging can be informative when following SMF after RD repair; a hypo- to hyper-FAF signal transition correlates with SMF resolution and photoreceptor loss. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1020-1029.].

OUTER RETINAL FOLDS FOLLOWING PARS PLANA VITRECTOMY WITH MEMBRANE PEEL

PURPOSE

To report a case of outer retinal folds following pars plana vitrectomy with epiretinal membrane peel.

METHODS

Retrospective case report. Spectral-domain and en face optical coherence tomography findings are described.

RESULTS

A 54-year-old man presented with distorted vision 1 month following pars plana vitrectomy with epiretinal membrane peel and subsequent cataract extraction. Optical coherence tomography of the affected eye revealed ripple-type and taco-type outer retinal folds. En face optical coherence tomography illustrated a curvilinear characteristic pattern of the folds that spontaneously resolved with follow-up.

CONCLUSION

The authors report a case of outer retinal folds developing in a patient following pars plana vitrectomy with membrane peel. En face optical coherence tomography findings of outer retinal folds may enhance diagnosis.

Multiple subretinal fluid blebs after successful retinal detachment surgery: incidence, risk factors, and presumed pathophysiology

PURPOSE

To investigate the incidence and the clinical factors associated with the occurrence of multiple subretinal fluid (SRF) blebs after successful rhegmatogenous retinal detachment (RD) repair.

DESIGN

Retrospective, observational case series.

METHODS

We retrospectively investigated the medical records of 185 eyes of 184 patients who had undergone successful RD surgery, either vitrectomy or scleral buckling. Each patient had undergone spectral-domain optical coherence tomography (SDOCT) combined with infrared reflectance (IR) imaging every 3 months postoperatively. We carefully examined postoperative SDOCT and fundus IR images, in an effort to identify any SRF blebs present.

RESULTS

Multiple (≥3) SRF blebs were observed in 40 of 185 cases (21.6%). SRF blebs were first detected 1.7 ± 1.8 months postoperatively. In 22 cases that could be fully followed up, SRF blebs were completely absorbed 13.1 ± 6.1 months postoperatively. Multiple logistic regression analysis showed that only young age (<30 years) was significantly associated with the occurrence of multiple SRF blebs (odds ratio, 5.1; 95% confidence interval, 1.5-17.6; P = .010). Serial measurements of SRF bleb size using SDOCT showed that SRF bleb height was greatest at postoperative 2.9 ± 0.9 months, while SRF bleb width tended to decrease gradually over time. The SRF blebs typically spared large retinal vessels.

CONCLUSIONS

Multiple SRF blebs are commonly found after successful RD surgery, especially in young patients. The serial morphologic features evaluated in this study indicate that multiple SRF blebs may result from the active reattachment of retinal pigment epithelium and photoreceptors during the resolution of RD.

Update on retinal detachment surgery

PURPOSE OF REVIEW

Update on controversies in the surgical management of rhegmatogenous retinal detachment.

RECENT FINDINGS

There are multiple new reports regarding the development and management of retinal detachment. Current use of oral fluoroquinolones may be associated with onset of retinal detachment, although the clinical relevance of this correlation is uncertain at this time and the finding has not been replicated in subsequent studies. Pars plana vitrectomy (PPV) continues to demonstrate efficacy as a primary treatment for retinal detachment, especially in pseudophakic patients. In many patients with macula-on retinal detachment, scheduling surgery after a short time delay is not necessarily deleterious and may actually be beneficial. Novel surgical tools, including bioerodible scleral buckling materials and artificial vitreous substitutes, are being investigated.

SUMMARY

Retinal detachment remains an important cause of visual loss. Although current surgical techniques demonstrate high rates of anatomic and visual success, further advances will probably benefit patients with retinal detachment.