From the Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Se Joon Woo, MD, Department of Ophthalmology, Seoul National University Bundang Hospital, #300, Gumi-dong, Bundang-gu, Seongnam, Gyeonggi-do 463-707, Korea. E-mail: firstname.lastname@example.org
Macular fold is an uncommon complication after vitrectomy and gas tamponade for retinal detachment. A few case reports described predisposing factors and management of this complication.1–4 Three cases were treated by an additional surgery in which the fold was relieved by iatrogenic retinal detachment to produce successful resolution of the macular fold.1,2,4 A recent report revealed migration of macular fold away from the fovea,5 which supports a conservative approach for the management of this complication. However, that report is limited because a 1-year follow-up might not be enough to uncover the final visual consequences of the fold. In addition, all previous reports on macular folds used time-domain optical coherence tomography, which may be unable to detect outer retinal changes.
To demonstrate a long-term (2-year) change of macular fold, especially in the outer retina, we present a case showing morphologic changes of macular fold following retinal reattachment using spectral-domain optical coherence tomography (SD-OCT). In addition, we reveal unusual findings in the Henle’s fiber layer, which is not easily visualized in the usual setting with SD-OCT.6
A 27-year-old woman was referred to us after being diagnosed as having rhegmatogenous retinal detachment in her right eye. A decrease of best-corrected visual acuity (BCVA) started 1 day before the first visit and her medical history was unremarkable. BCVA was 20/250 in the right eye and 20/20 in the left eye. Fundus examination revealed macula-splitting superior bullous retinal detachment with multiple retinal tears at the 10- and 12-o’clock positions.
Pars plana vitrectomy with intravitreal gas (SF6 0%) tamponade was performed uneventfully. At the first postoperative day, fundus examination revealed the retina to be nearly flat and the vitreous cavity was filled with gas. The patient was recommended to maintain a sitting position during the day and sleep on her left side.
One week later, fundus examination showed a remarkable retinal fold along the border of the previously detached retina involving the macula. The patient was recommended to maintain a prone position to depress the fold with the remaining gas. Follow-up examination 2 weeks postoperatively revealed no change in the macular fold (Fig. 1A). SD-OCT (Spectralis OCT; Heidelberg Engineering, Heidelberg, Germany) demonstrated that the photoreceptor layers in the fovea were crumpled and detached from the retinal pigment epithelium (Fig. 2A). Additional vitrectomy was recommended, but the patient refused.
Figure 1. Serial fundus photographs of the right eye (A) at 2 weeks after retinal reattachment surgery demonstrating macular fold along the border of the previously detached and attached retina. (B) One and (C) 3 months after surgery, the macular fold persisted. (D) Twenty months after surgery, the macular fold resolved spontaneously.
Figure 2. Optical coherence tomography (OCT) (left: Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany in A, B, D, and E; and Stratus OCT, Carl Zeiss Meditec, Inc., Dublin, CA, in C) and infrared image (right) of the macular fold. (A) Two weeks after vitrectomy, a macular fold with subretinal fluid was noted. (B) One month after surgery, the fold did not show significant change. (C) Four months after surgery, the height of the macular fold and the amount of subretinal fluid decreased. Due to a brief mechanical malfunction of the Spectralis OCT, Stratus OCT was performed. (D) Twenty months after surgery, the fold was completely resolved. Infrared image revealed a hyperreflective line (white arrows) on the previously folded retina, which was represented as a central hyperreflectivity in the photoreceptor layer (white arrows). Henle’s fiber layer, of which the upper or lower margin is represented as arrowheads, shows distortion and cross-over. (E) Magnification of the horizontal sectional image demonstrated hyperreflectivity at the outer segment of the photoreceptor and its junction with the inner segment. Two reflective lines of Henle’s fiber layer are also detected in the outer nuclear layer of the central fovea (arrowheads).
At 1 month postoperatively, the BCVA in her right eye was 20/500. Fundus photography and SD-OCT failed to reveal any significant change compared with previous images (Figs. 1B and 2B). At 3 months postoperatively, the macular fold persisted without any changes in BCVA (Figs. 1C and 2C). Twenty months after surgery, she recognized no improvement in her vision (BCVA 20/400). However, fundus photographs and SD-OCT revealed that the macular fold had nearly disappeared and the foveal depression had normalized. A hyperreflective line was found at the location corresponding to the previous macular fold on the level of the photoreceptor inner segment/outer segment (IS/OS) junction layer (Figs. 1D, 2D, and 2E). In addition, the cone outer segment tips layer also showed increased reflectivity (Fig. 2E). The irregular hyperreflective lines from the Henle’s fiber layer were found to be distorted and intermingled in the previously folded retinal area. The distorted Henle’s fiber layer was also present in the outer nuclear layer of the central fovea, where only photoreceptor nuclei are normally observed (Figs. 2D and 2E). No other retinal layers revealed apparent abnormality.
This case demonstrates the long-term changes of macular fold following retinal reattachment (spontaneous resolution) using serial fundus photographs and SD-OCT. Although normal funduscopic appearance of the fovea was obtained without surgical management, changes in photoreceptor layers after resolution of macular fold were detected with SD-OCT. The increase and irregularity in reflectivity of the photoreceptor layer and distorted Henle’s fiber layer on SD-OCT suggest structural damage in the involved photoreceptors and their neural connections, which may be responsible for poor final visual outcome.
A recent case report on SD-OCT of retinal folds not involving the fovea secondary to vitrectomy showed a slightly hyperreflective lesion in the outer retina that occupied a gap in the IS/OS junction.7 The authors speculated the hyperreflective lesion might be related to the remaining folded photoreceptor outer segments. However, our report clearly shows that the hyperreflective lesion is placed over the continuous IS/OS junction layer in the unfolded retina and indicates that the previously reported hyperreflective lesion7 might have been reflective signals from other retinal tissues, including the Henle’s fiber layer. To our knowledge, the current case is the only one in which the resolved retinal fold involved the fovea; thus, it enables the determination of long-term anatomical and visual outcomes of the completely resolved macular fold.
We believe the driving force for flattening macular folds might be the same force exerted on the retina to migrate retinal folds, which was recently reported.5 Likewise, the current case may provide evidence against surgical management of macular folds because they can resolve spontaneously. However, a previous animal experiment revealed that the retina within the folds showed extensive loss of photoreceptor cells8; likewise, hyperreflective changes in the IS/OS junction and outer segment on SD-OCT in our case may represent changes caused by photoreceptor injury. Another interesting finding is the morphologic change in the Henle’s fiber layer, which has never been reported before. The distorted and intermingled layer might be from aberrant regenerations caused by chronic structural damage. However, to explain the pathogenesis of Henle’s fiber layer abnormalities in the resolved macular fold, further studies using SD-OCT are required.
The findings on SD-OCT in this study may suggest a possible benefit of early surgical treatment, which can prevent damage of photoreceptors and their connections in a long-lasting macular fold. Indeed, the final BCVA (20/200) in our case was worse than those of previously reported cases that underwent surgical maneuvers.1,2,4 A prior case report supporting a conservative approach in macular fold5 was a juxtafoveal fold not involving the fovea. Therefore, in cases with retinal folds not involving the macula, spontaneous resolution is possible, which suggests conservative management for treatment. However, considering the poor visual outcome possibly caused by photoreceptor injury and distorted neural connections for a macular fold involving fovea, early surgical treatment may be more appropriate despite the risk of additional vitrectomy and added damage on photoreceptors during macular detachment.1
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