Rhegmatogenous retinal detachment after successfully regressed aggressive posterior retinopathy of prematurity following laser treatment is a rare occurrence. It has been reported infrequently1 and is usually seen in cases with minimal residual traction. We report a case of regressed aggressive posterior retinopathy of prematurity that developed a rhegmatogenous retinal detachment due to a giant retinal tear at 21 months of age.
A preterm male newborn born at 30 weeks of gestational age with a birth weight of 1,300 g presented at 3 weeks and was referred for retinopathy of prematurity screening in 2013. The first of a set of twins, the newborn was born through normal vaginal delivery. The neonatal period was complicated by respiratory distress, septic shock, and seizures, requiring a stay in the neonatal intensive care unit and oxygen supplementation for 23 days. Screening revealed zone I retinopathy of prematurity with extensive vascular loops and severe plus disease, which was suggestive of aggressive posterior retinopathy of prematurity in both eyes. He underwent uneventful laser photocoagulation in both eyes the following day. There was complete regression of the disease in the following 3 months. Regular follow-up was completed every 3 months and included cycloplegic refraction (1% atropine ointment). At 15 months of age, clinical examination revealed that the disease had fully regressed in both eyes. The central retina was normal with large areas of lasered peripheral retina in the left eye (Figure 1). Refraction under cycloplegia revealed −7.00 diopters (D) of spherical error in both eyes.
Regressed aggressive posterior retinopathy of prematurity treated by laser in the left eye at 15 months of age.
After missing one follow-up visit, the patient was later seen at the age of 21 months when the optometrist referred him due to poor glow in the left eye. The final prescription had changed to −11.00 D of spherical error in the right eye and −5.00 D of spherical error in the left eye. On clinical examination, both eyes showed good pupillary dilatation and clear media. Fundus evaluation of the right eye revealed regressed zone I retinopathy of prematurity treated by laser with minimal sequelae. The left eye revealed a closed funnel retinal detachment with advanced proliferative vitreoretinopathy due to a giant retinal tear present at the posterior edge of laser photocoagulation (Figure 2).
Total retinal detachment in the left eye at 21 months of age with a temporal giant retinal tear and closed funnel retinal configuration.
The poor surgical prognosis in the left eye was explained to the parents. Refractive correction was prescribed for the right eye and regular follow-up every 3 months was advised.
Retinal detachment as a late complication of retinopathy of prematurity is well documented in the literature.2–6 In most of these studies, the retinal detachment occurred late. In a large series by Smith and Tasman,6 the mean age at presentation of retinal detachment after self-regressed retinopathy of prematurity was 35 years (range: 14 to 51 years). Late onset rhegmatogenous retinal detachment after complete disease regression following retinal ablative treatment has also been reported. In the era of cryotherapy, Greven and Tasman7 reported the development of rhegmatogenous retinal detachment in 3 patients with an initial diagnosis of threshold disease that regressed with cryotherapy. Retinal detachment in these eyes developed more than 1 year after the documented disease regression. The retinal breaks that caused detachment were located at the posterior edge of the cryotherapy scar and ranged from slit-like tears to large tears. Vitreous traction was not consistently documented. A larger series (16 eyes of 15 patients) published in 2004 by Park et al.1 reported the development of late onset tractional and rhegmatogenous retinal detachments in treated regressed retinopathy of prematurity cases. They found rhegmatogenous retinal detachment to occur at a later age (mean: 85.8 months after regression) compared with tractional retinal detachment (mean: 20.7 months after regression). They also found rhegmatogenous retinal detachment to occur in cases with minimal cicatricial changes as opposed to tractional retinal detachment. This led them to hypothesize that a change in the vitreoretinal interface rather than reactivation of aborted proliferation caused the rhegmatogenous retinal detachment.1 Most of these cases had variable anatomical and functional success rates with primary buckling and/or pars plana vitrectomy surgery. It is often possible that tractional retinal detachments can be severe enough to cause retinal breaks and rhegmatogenous retinal detachment.
Our case presented with the development of a retinal detachment that was diagnosed at the age of 21 months. This is unusual for retinopathy of prematurity cases treated by laser because they tend to develop rhegmatogenous retinal detachment at a later age.
At times, peripheral vitreoretinal interface changes that represent remnants of fibrovascular tissue developed during the active stage of the disease may be noticed after retinopathy of prematurity regression. Proliferation of such membranes may be aided by localized inflammation and a breakdown of the blood–retinal barrier as a result of the primary ablative treatment. It is known that cryotherapy leads to more inflammation and increased pars plana and ciliary body pigmentation release compared to laser photocoagulation.8 Similar findings noted by Greven and Tasman7 may explain the early development of retinal detachment in cases treated with cryotherapy as opposed to laser photocoagulation.7 This also suggests that cases in which heavy laser burns are applied to extensive areas behave more like cases treated with cryotherapy.
The possible mechanism in our case could be that heavy laser burns applied to extensive areas of the retina caused delayed proliferation of vitreoretinal surface membranes that later contracted. Because the peripheral retina was treated by laser and scarred with possible strong vitreoretinal adhesions, a giant retinal tear occurred at the posterior edge of the laser margin that was complicated by proliferative vitreoretinopathy and an inoperable closed funnel retinal configuration.
To our knowledge, this case documents the earliest development of rhegmatogenous retinal detachment associated with a giant retinal tear after successful regression of aggressive posterior retinopathy of prematurity with laser photocoagulation. It emphasizes the previously reported notion that rhegmatogenous retinal detachment can develop even in eyes with minimal cicatricial sequelae. Such retinal detachments come as a surprise to the surgeon and parents alike. It also suggests the possibility that even regressed retinopathy of prematurity can develop complications at any age and lead to irreversible blindness. It highlights the importance of the early detection and treatment of retinopathy of prematurity and the need for long-term, frequent follow-up that may help in detecting and managing such complications at the earliest point possible.
- Park KH, Hwang JM, Choi MY, Yu YS, Chung H. Retinal detachment of regressed retinopathy of prematurity in children aged 2 to 15 years. Retina. 2004;24:368–375. doi:10.1097/00006982-200406000-00006 [CrossRef]
- Jandeck C, Kellner U, Foerster MH. Late retinal detachment in patients born prematurely: outcome of primary pars plana vitrectomy. Arch Ophthalmol. 2004;122:61–64. doi:10.1001/archopht.122.1.61 [CrossRef]
- Terasaki H, Hirose T. Late-onset retinal detachment associated with regressed retinopathy of prematurity. Jpn J Ophthalmol. 2003;47:492–497. doi:10.1016/S0021-5155(03)00088-1 [CrossRef]
- Tufail A, Singh AJ, Haynes RJ, Dodd CR, McLeod D, Charteris DG. Late onset vitreoretinal complications of regressed retinopathy of prematurity. Br J Ophthalmol. 2004;88:243–246. doi:10.1136/bjo.2003.022962 [CrossRef]
- Kaiser RS, Trese MT, Williams GA, Cox MS Jr, . Adult retinopathy of prematurity: outcomes of rhegmatogenous retinal detachments and retinal tears. Ophthalmology. 2001;108:1647–1653. doi:10.1016/S0161-6420(01)00660-1 [CrossRef]
- Smith BT, Tasman WS. Retinopathy of prematurity: late complications in the baby boomer generation (1946–1964). Trans Am Ophthalmol Soc. 2005;103:225–234
- Greven CM, Tasman W. Rhegmatogenous retinal detachment following cryotherapy in retinopathy of prematurity. Arch Ophthalmol. 1989;107:1017–1018. doi:10.1001/archopht.1989.01070020079034 [CrossRef]
- O'Keefe M, Kirwan C. Diode laser versus cryotherapy in treatment of ROP. Br J Ophthalmol. 2006;90:402–403. doi:10.1136/bjo.2005.086330 [CrossRef]