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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 (Gass 1984). Exudative retinal detachments (RDs) may rarely be associated with RPE tears (Serels et al. 1991; Laidlaw & Poynter 1998). We report the findings of a patient who developed bilateral exudative RD causing angle- closure glaucoma associated with spontaneous multiple RPE tears. Vitrectomy, endolaser photocoagula- tion and silicone oil tamponade with without scleral window were used to treat this complicated RD. A 68-year-old man complained of blurred vision in his left eye. He had had prophylactic laser iridotomy and persistent pleuritis of unknown origin, but had not had steroid therapy. He also did not have renal dysfunction. His visual acuity was 20 40 OD and 20 200 OS. Ophthalmoscopy of the left eye showed an inferior bullous RD involving the macula without a retinal break, but with large RPE tears (Fig. 1A). An old retinal branch vein occlusion was found in the supe- rior temporal arcade of the right eye. Fluorescein angiography showed hyperfluorescence in the areas of the RPE tears and leakage from the RPE tears in the left eye (Fig. 1B). The axial length was 21 OD and 22 mm OS. Although we expected a spontane- ous resolution of the RD, 1 month later, a total bullous RD developed pushing the lens anteriorly causing angle-closure glaucoma in the left eye (Fig. 1C). At this time, many RPE tears and a RD were found in the right eye (Fig. 1D). The patient underwent lensectomy with preservation of the posterior lens capsule, external drainage of the sub- retinal fluid (SRF) and vitrectomy in the left eye. Multiple RPE tears were noted under the RD. The RPE tears were photocoagulated by endolaser, and silicone oil was injected as a tamponade. A reduction in the RD was achieved, but exudation gradually increased leading to an increase in the intraocular pressure (IOP). The patient underwent a second vit- rectomy with removal of the posterior lens capsule, additional photocoagula- tion and silicone oil tamponade in the left 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

Bilateral exudative retinal detachment due to retinal pigment epithelial tears successfully treated by vitrectomy and scleral window surgery

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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

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