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Correspondence:
Simon R. J. Taylor, MA, PhD, FRCOphth
UCL Institute of Ophthalmology
11-43 Bath Street
London EC1V 9EL
UK
Tel: + 44 20 7566 2266
Fax: + 44 20 7251 9350
Email: [email protected]
Bilateral exudative retinal
detachment due to retinal
pigment epithelial tears
successfully treated by
vitrectomy and scleral
window surgery
Kazunari Hirota, Akito Hirakata, Mak-oto Inoue and Tomoyuki Hiraoka
Kyorin Eye Center, Kyorin University
School of Medicine, Mitaka, Japan
doi: 10.1111/j.1755-3768.2011.02256.x
Dear Editor,
R etinal pigment epithelial (RPE)tears develop by an excessive
stretching of the RPE layer (Gass1984). Exudative retinal detachments(RDs) may rarely be associated withRPE tears (Serels et al. 1991; Laidlaw& Poynter 1998). We report thefindings of a patient who developedbilateral exudative RD causing angle-closure glaucoma associated withspontaneous multiple RPE tears.Vitrectomy, endolaser photocoagula-tion and silicone oil tamponadewith ⁄without scleral window wereused to treat this complicated RD.
A 68-year-old man complained ofblurred vision in his left eye. He hadhad prophylactic laser iridotomy andpersistent pleuritis of unknown origin,but had not had steroid therapy. Healso did not have renal dysfunction.His visual acuity was 20 ⁄ 40 OD and20 ⁄ 200 OS. Ophthalmoscopy of theleft eye showed an inferior bullousRD involving the macula without aretinal break, but with large RPEtears (Fig. 1A). An old retinal branchvein occlusion was found in the supe-rior temporal arcade of the right eye.Fluorescein angiography showed
hyperfluorescence in the areas of theRPE tears and leakage from the RPEtears in the left eye (Fig. 1B). Theaxial length was 21 OD and 22 mmOS.
Although we expected a spontane-ous resolution of the RD, 1 monthlater, a total bullous RD developedpushing the lens anteriorly causingangle-closure glaucoma in the left eye(Fig. 1C). At this time, many RPEtears and a RD were found in theright eye (Fig. 1D).
The patient underwent lensectomywith preservation of the posterior lens
capsule, external drainage of the sub-retinal fluid (SRF) and vitrectomy inthe left eye. Multiple RPE tears werenoted under the RD. The RPE tearswere photocoagulated by endolaser,and silicone oil was injected as atamponade. A reduction in the RDwas achieved, but exudation graduallyincreased leading to an increase in theintraocular pressure (IOP).
The patient underwent a second vit-rectomy with removal of the posteriorlens capsule, additional photocoagula-tion and silicone oil tamponade in theleft eye. Postoperatively, the IOP was
(A) (B)
(C) (D)
(E) (F)
Fig. 1. Panoramic photograph of the fundus of the left eye of a patient with multiple retinal
pigment epithelial (RPE) tears (arrowheads) at the first visit (A). Fluorescein angiography
showed hyperfluorescence corresponding to the RPE tears and exudative retinal detachment
(RD) (B). One month later, a total RD pushed the lens anteriorly causing angle-closure glau-
coma (C). Simultaneously, multiple RPE tears (arrowheads) and bullous RD developed in the
right eye (D). Postoperative panoramic photographs of the same patient after vitrectomy
(E: left eye, F: right eye). Retina is attached under silicone oil with multiple RPE tears (arrow-
heads) surrounded by laser scars.
Acta Ophthalmologica 2012
e325
reduced to normal levels, and theamount of SRF decreased. However,both the RD and IOP of the right eyehad increased. Lensectomy and vitrec-tomy were performed on the right eye,and two large RPE tears wereobserved. The angle-closure glaucomawas resolved, and the amount of SRFdecreased.
Two months later, the RD in theright eye increased again because ofnew RPE tears and the IOP increasedto 40 mmHg. The patient underwentscleral window surgery with a4 · 5 mm, full thickness scleral flap inthe inferotemporal quadrant. This wasperformed to prevent early SRF accu-mulation following the vitrectomy andto obtain a photocoagulation scar. TheSRF was drained through the scleralwindow during silicone ⁄perfluo-octaneexchange. The new RPE tears were en-dophotocoagulated, and the retina wastamponaded with silicone oil.
The optical coherence tomographicimages showed a complete retinal reat-tachment without a thickening of thechoroid after last surgery in both eyes.Because no recurrence was observedafter 1 year (Fig. 1E,F), the silicone oilwas removed. His best corrected visualacuity (BCVAs) were 20 ⁄ 40 OD and20 ⁄50 OS at his last visit.
There are several pathological condi-tions associated with RPE tears (Gass1984; Serels et al. 1991; Laidlaw & Po-ynter 1998). Our patient had RD withmultiple large RPE tears, but none ofthe findings provided any clues on theaetiology of the RPE tears.
The efficacy of scleral window sur-gery has been reported for patientswith uveal effusion (Gass 1983). Theresults from our patient suggest thatvitrectomy with silicone oil tamponadeand ⁄or scleral window surgery may beused to treat the severe exudative RDcaused by multiple RPE tears.
ReferencesGass JD (1983): Uveal effusion syndrome. A
new hypothesis concerning pathogenesis
and technique of surgical treatment. Retina
3: 159–163.
Gass JDM (1984): Pathogenesis of tears of
the retinal pigment epithelium. Br J Oph-
thalmol 68: 513–519.
Laidlaw DA & Poynter R (1998): Giant pig-
ment epithelial tear and exudative retinal
detachment complicating choroidal effu-
sions. Am J Ophthalmol 126: 448–450.
Serels SR, Liebmann JM, Ritch R, Milch F
& Eisenberg W (1991): Tears of the retinal
pigment epithelium: occurrence in associa-
tion with choroidal effusion. Ophthalmic
Surg 22: 142–144.
Correspondence:
Akito Hirakata, MD
Kyorin Eye Center
Kyorin University School of Medicine
6-20-2 Shinkawa
Mitaka, Tokyo 181-8611
Japan
Tel: + 81 422 47 5511 ext 2606
Fax: + 81 422 46 9309
Email: [email protected]
Delayed closure of
paediatric macular hole in
Coats’ disease
Sui Chien Wong, Melissa D. Neuweltand Michael T. Trese
William Beaumont Hospital, RoyalOak, Michigan, USA
doi: 10.1111/j.1755-3768.2011.02244.x
Editor,
P aediatric full-thickness macularholes (FTMH) are uncommon,
particularly when associated withCoats’ disease (Kumar et al. 2010). Wedescribe an unusual case of a child withunilateral Coats’ disease and delayedmacular hole closure occurring 6 yearsfollowing surgical repair.
An asymptomatic 10-year-old boypresented following a failed school eyeexamination with visual acuities of
20 ⁄150 OD and 20 ⁄ 25 OS. Fundos-copy revealed a right stage 3 FTMHconfirmed on optical coherencetomography (OCT) imaging (Fig. 1),without signs of abnormal vitreoreti-nal traction or exudation. In the nasalretina, 5 clock hours of peripheral tel-angiectasia, subretinal fluid and yellowexudation were evident. Fundus fluo-rescein angiography revealed addi-tional features of peripheral capillarydropout and aneurysmal dilations inthe same area without macularinvolvement, consistent with a diagno-sis of Coats’ disease (Coats 1908). Theleft eye was normal.
Initial management consisted ofcryotherapy using a freeze–refreezetechnique to the areas of peripheraltelangiectasia. Three month post-treat-ment, there was complete resolutionof peripheral subretinal exudationwith formation of chorioretinal scars.Subsequently, two macular hole repairoperations were performed in anattempt to close the macular hole.The first operation, performed4 months following presentation, con-sisted of autologous plasmin enzymeinjection (Wu et al. 2007) 30 min priorto 20-gauge pars plana vitrectomy(PPV) and perfluoropropane (C3F8)12% gas tamponade with post-opera-tive face down positioning for 7 days.Five months later, a second PPV wasperformed with indocyanine green–assisted internal limiting membranepeeling to the vascular arcades andperfluoropropane 12% tamponade.Within 2 weeks following both PPVs,the macular hole was found to beclinically closed, although thissubsequently reopened by 3 monthspost-operatively. Eighteen months fol-
Fig. 1. Optical coherence tomography image demonstrating a full-thickness macular hole with
an associated pseudo-operculum within it.
Acta Ophthalmologica 2012
e326