This report describes a case of macular pucker after triple freeze–thaw cryotherapy for retinoblastoma. Seven months after cryotherapy, the macular pucker resolved spontaneously.
From the Pediatric Retina & Ocular Oncology Department, Aravind Eye Hospital, Coimbatore, Tamilnadu, India.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Parag K. Shah, DNB, Retina & Vitreous Department, Aravind Eye Hospital, Avinashi Road, Coimbatore, Tamilnadu, 641014 India.
Received: August 24, 2008
Accepted: November 26, 2008
Posted Online: May 21, 2010
Retinoblastoma is the most common intraocular malignancy of childhood.1 Triple freeze–thaw cryotherapy has been available for treatment for several years.2 Complications reported after cryotherapy are vitreous hemorrhage, transient subretinal fluid (ablatio fugax), atrophic retinal holes, and rhegmatogenous retinal detachment.2 This report describes a case of macular pucker that occurred after triple freeze–thaw cryotherapy for retinoblastoma and resolved spontaneously after 7 months.
A 7-month-old male infant was brought to the hospital because the parents had seen a white reflex in the right eye since 3 months of age. Examination under anesthesia showed total exudative retinal detachment touching the lens, with a large subretinal calcified tumor seen on B-scan, suggestive of group E endophytic retinoblastoma.3 The left eye showed a tumor with basal diameters of 4.1 × 4.3 mm and 3.3 mm in height, suggestive of group B retinoblastoma (Fig. A).3 Treatment was planned to include six cycles of chemotherapy with intervening local therapy in the left eye. The patient was evaluated by the authors only after completion of all six cycles. Examination under anesthesia showed settled detachment with subretinal exudates and a large calcified tumor over the macula with surrounding retinal folds in the right eye. The tumor in the left eye showed a partially regressed mass with a fish flesh appearance along with calcification. The right eye was enucleated, and the tumor in the left eye was treated with triple freeze–thaw cryotherapy (Fig. B). Macular pucker was noticed in the left eye 6 weeks after treatment (Fig. C) and was closely observed. At 3 months of follow-up, the same results were seen. Seven months after cryotherapy, the macular pucker had completely disappeared (Fig. D).
Figure. (A) Retinal Camera Photograph of the Left Eye Showing Tumor in the Inferonasal Quadrant. (B) Retinal Camera Photograph Taken Immediately After Cryotherapy Showing Tumor Surrounded by Retinal Edema with Superficial Hemorrhage. (C) Six Weeks After Treatment, Macular Pucker Is Seen (arrow), and a Good Cryotherapy Scar Is Present. (D) The Macular Pucker Has Completely Disappeared 7 Months After Cryotherapy.
Vitreoretinal complications, such as rhegmatogenous and tractional retinal detachments, traction bands, preretinal and subretinal fibrosis, and pseudovitreous seedings, have been reported4 during the treatment of retinoblastoma. Although macular pucker had been seen earlier, the current case is unique in that it spontaneously resolved after 7 months.
Macular pucker is a known complication of cryotherapy of retinal breaks5 because of the inflammatory reaction it causes. Aggressive treatment of retinoblastoma posterior to the equator with triple freeze–thaw cryotherapy increases the chance of macular epiretinal membrane formation. However, once macular pucker develops in these eyes, only observation is recommended. The macular pucker may resolve spontaneously over time, as seen in the current case.
- Shields JA, Shields CL. Retinoblastoma: introduction, genetics and clinical features, and classification. In: Shields JA, Shields CL. Intraocular Tumors: An Atlas and Textbook. Philadelphia: Lippincott, Williams & Wilkins, 2008:294–317.
- Shields JA, Parsons H, Shields CL, Giblin ME. The role of cryotherapy in the management of retinoblastoma. Am J Ophthalmol. 1989;108:260–264.
- Murphree LA, Chantada G. Staging and grouping of retinoblastoma. In: Singh AD, Damato BE, Peer J, Murphree LA, Perry JD, eds. Clinical Ophthalmic Oncology. Philadelphia: Elsevier; 2007:422–427.
- Tawansy KA, Samuel MA, Shammas M, Murphree LA. Vitreoretinal complications of retinoblastoma treatment. Retina. 2006;26: S47–S52. doi:10.1097/01.iae.0000225350.83931.f6 [CrossRef]
- Combs JL, Welch RB. Retinal breaks without detachment: natural history, management and long term follow up. Trans Am Ophthal Soc. 1982;80:64–97.