Two patients with perfluorocarbon liquid (PFCL) trapped under the fovea after vitreoretinal surgery for repair of rhegmatogenous retinal detachment were reported. PFCL was used to flatten the retina intraoperatively. Postoperatively, a bubble of PFCL was trapped under the fovea and was removed surgically in both patients. Three-dimensional and orthogonal optical coherence tomography (OCT) features in both cases are reported. Three-dimensional OCT features in our two cases were retinal pigment epithelium (RPE) pigment disorganization, disruption of both external limiting membrane backreflection line and reflectivity of the photoreceptor inner and outer segment junction, and hyperreflectivity at the base of the PFCL bubble corresponding to the zone of interface of PFCL and damaged RPE. Trapped subfoveal PFCL should be removed surgically as soon as possible to prevent structural retinal damage. Spectral domain OCT is a useful tool to demonstrate subclinical structural damage of the neurosensory retina and RPE.
Three-Dimensional OCT Features of Perfluorocarbon Liquid Trapped Under the Fovea
From the Ophthalmology Department and Ophthalmic Research Center (MS, RN, NS), Labbafinejad Medical Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran; Negah Eye Center (MS), Tehran, Iran; and Associated Retina Consultants, Phoenix, Arizona, and the Department of Ophthalmology (GAP), Tulane University Medical Center, New Orleans, Louisiana.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Gholam A. Peyman, Associated Retina Consultants, 7600 North 15th Street, Phoenix, AZ 58020.
Accepted: August 21, 2009
Posted Online: March 09, 2010
Subretinal migration of perflurocarbon liquids (PFCL) has been reported to occur with a frequency of 0.9%. Migration of PFCL into the subretinal space may be more common when there are small fish-egg bubbles, and when there is unrelieved traction at the retinal breaks. Retention of PFCL under the fovea is a well-recognized complication of vitreoretinal surgery with unknown long-term consequences.1 Spectral-domain (SD) optical coherence tomography (OCT) features of this complication have not been previously reported to the best of our knowledge. In addition to reduced image acquisition time, SD-OCT provides simultaneous multiple perspective views to define the locations of the PFCL bubble as well as precise retinal structural pathologies induced by PFCL. Herein, we report the visual outcome, anatomical outcome, and SD-OCT features in two patients who had retained subfoveal PFCL.
A 64-year-old man was referred because of rhegmatogenous retinal detachment and proliferative vitreoretinopathy grade C (PVR C) in his right eye. He underwent standard three-port pars plana vitrectomy with implantation of silicone oil. PFCL (DK- line Bausch & Lomb, Waterford, Ireland) was used to flatten the retina intraoperatively. Trapped subretinal PFCL was noticed in the macular area after surgery. Best-corrected visual acuity (BCVA) was 20/400. Three months later, the PFCL was removed with a small surgical retinotomy. The retina became flattened, but vision did not improve. SD-OCT was performed (TOPCON 3D OCT-1000 TOPCON Corp. 2006, Paramus, NJ) (Fig. 1).
Figure 1. Three- Dimensional and Orthogonal Cross-Sectional Images from the 3-Dimensional Data Set Acquired by the 256×256 Raster Scan Protocol with Fourier Domain Optical Coherence Tomography (OCT). (A) Fundus Photograph of the Silicone-Filled Right Eye of Patient 1. Overt Subfoveal Perfluorocarbon Liquid (PFCL) Bubble is Visible; as is Clearly Visible, Retinal Pigment Epithemlium (RPE) is Damaged. (B) Corresponding SD-OCT Image of PFCL Trapped Under the Macula. The PFCL Bubble is Hyporeflective and the Overlying Retina has Almost Normal Architecture. The Image Shows Disruption of the External Limiting Membrane (ELM) Backreflection Line. Reflectivity of the Photoreceptor Inner and Outer Segment Junction (IS/OS) is also Disrupted in the Region of the PFCL Bubble. The Hyperreflective Band (arrowhead) is Corresponding to Choriocapillaris Because of RPE Loss. An Alternate Explanation for This Hyperreflective Band May Be an Optical Phenomenon, at the Interface Between Two Media with Different Refractive Indices (PFCL and Choroid). Similarly, Another Unlikely Possibility for the Absence of ELM in OCT May Be not a Real Histologic Disruption but Rather Its Compression into the Thin and Stretched Retina Above the PFCL Bubble. (C) En Face Sectional Volume Image Through the Vitreous Subretinal PFCL Bubble Is Visible. Magnified View of Precipitated PFCL Backreflection Forms a Circle. (D) Fundus Photograph of the Patient After Surgical Removal of Subfoveal PFCL Bubble. (E) Corresponding SD-OCT Image of the Same Patient After PFCL Removal.
A 21-year-old man was referred to the retina service because of penetrating trauma and retinal detachment in his right eye. The scleral laceration had been repaired. There was dense vitreous hemorrhage. Standard pars plana vitrectomy was performed and the cataractous lens removed. PFCL was used during the operation to stabilize the mobile retina and was removed after endolaser photocoagulation of the retinal break. Silicone oil was injected at the end of the procedure. The migration of subretinal PFCL under fovea was noticed the day after the surgery. BCVA was 20/400. A YAG laser retinotomy was performed successfully; however, the PFCL bubble was not drained despite positioning. Two months after primary vitrectomy, a small surgical retinotomy was performed, and subretinal PFCL and the silicone oil were removed. The macula flattened but vision did not improve. Figure 2 shows the preoperative SD-OCT image; unfortunately, this patient was lost to follow-up and postoperative OCT photos are not available.
Figure 2. (A) Fundus Photograph of Silicone-Filled Right Eye of Patient 2 with a Trapped Perfluorocarbon Liquid (PFCL) Bubble Under Macula and Retinal Pigment Epithelium (RPE) Damage. Arrowhead Shows the Site of Previous YAG Laser Retinotomy. (B) Corresponding Spectral-Domain Optical Coherence Tomography (SD-OCT) Image of Trapped PFCL Under Macula. The PFCL Bubble Is Hyporeflective and a Full-Thickness Hole Is Visible in the Overlying Neurosensory Retina After YAG Laser Retinotomy. In This Case, the Inner Layers of Retina Around Trapped PFCL Bubble Disclosed Cystic Changes (asterisk). (C) Corresponding SD-OCT Image Showing a Hole in the Neurosensory Retina Corresponding to YAG Laser Retinotomy Site.
The effects and prognosis of longstanding subfoveal PFCL retention are unknown. Available reports describe the consequences of retention of less than a few months’ duration as most authors perform or recommend early removal of subfoveal PFCL to improve vision and prevent foveal toxicity.2,3 The toxicity profile of subretinal PFCL, however, has not been well established. In animal models, short-term exposure to subretinal PFCL has resulted in damage to the overlying retina in some studies4 but not in others.5 Clinical reports on short-term subfoveal PFCL retention have been additionally varied in their conclusions; some indicate severe and early retinal pigment epithelium (RPE) damage and poor outcome;3 others demonstrate relative short-term stability of the subfoveal PFCL bubble and visual acuity. Visual improvement after subfoveal PFCL removal has also been inconsistent.2,3
Entrapment of PFCL in the subretinal space is a complication that may be encountered in vitreoretinal surgeries.6 Regarding management, if PFCL is trapped under the retina out of the macular area, sometimes conservative management is recommended. In the submacular area, removal of subretinal PFCL is mandatory to prevent complications.7 In such cases; one of the suggested methods for treatment is YAG laser retinotomy of the overlying retina. We used this procedure in one of the cases; however, despite proper positioning, the PFCL bubble was not drained and had to be drained surgically using 25-gauge vitrectomy instrumentation through active suction in both cases.
SD-OCT features of trapped submacular PFCL bubbles have not been reported yet. In a previously published report, Le Tien et al. reported good functional results after surgical displacement of retained subfoveal PFCL in three cases.8 They reported Stratus OCT features of subfoveal PFCL in one of their patients; however, use of this time-domain machine has its limitations including lower image resolution. In this report, we examined the SD-OCT images from two cases with PFCL trapped under the fovea. These images provided interesting information about the microstructural morphology of the RPE, sensory retina, and the border between the PFCL bubble and the RPE-choriocapillaris complex. A trapped subretinal PFCL bubble may induce severe RPE and neurosensory retinal damage, which in both of our patients was evident clinically by RPE pigment derangement and also by SD-OCT. SD-OCT disclosed a hyperreflective band in the border between the PFCL bubble and the RPE–choriocapillaris complex and disruption of both the external limiting membrane (ELM) backreflection line and also reflectivity of the photoreceptor inner and outer segment (IS/OS) junction. One explanation for the presence of the hyprerreflective band between the PFCL bubble and the RPE–choriocapillaris complex can be RPE loss due to PFCL toxicity as was shown by fundus photography and resulted in increased reflectivity of the choriocapillaris. An alternate explanation for this hyperreflective band may be an optical phenomenon at the interface between two media with different refractive indices (PFCL and choroid). Similarly, another less likely possibility for the absence of ELM in the OCT may not be a real histologic disruption but rather its compression into the thin and stretched retina above the PFCL bubble. With the use of SD-OCT, more precise morphologic changes of the RPE and sensory retina can be detected, allowing the identification of early subclinical structural changes and early removal of PFCL to prevent permanent structural damage and visual loss in such cases.
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