Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Effect of Subretinal Fluid Drainage Using Perfluorocarbon During Retinal Detachment Repair on Postoperative Metamorphopsia

Amir Sternfeld, MD; Orly Gal-Or, MD; Ivan Budnik, MD, PhD; Elena Gutkovich, MD; Ruth Axer-Siegel, MD; Rita Ehrlich, MD

Abstract

BACKGROUND AND OBJECTIVE:

To determine whether subretinal fluid drainage (SRF) using perfluorocarbon (PFC) during rhegmatogenous retinal detachment (RRD) repair reduces postoperative metamorphopsia.

PATIENTS AND METHODS:

Consecutive patients after RRD were evaluated for best-corrected visual acuity (BCVA), funduscopy, and metamorphopsia using M-CHARTS. Fundus autofluorescence and optical coherence tomography were performed. Clinical and operative data were collected.

RESULTS:

The cohort included 30 patients, of whom 11 (36.7%) underwent intraoperative PFC injection. Rates of macula-off RRD were similar in the two groups (54.5% and 47.4%, P = .705). No association was found between PFC injection and metamorphopsia score. Preoperative macula-off RRD was associated with significantly higher vertical and horizontal metamorphopsia scores than preoperative macula-on. BCVA was significantly worse in the patients with metamorphopsia (logMAR 0.15 vs. logMAR 0.04; P = .042)

CONCLUSION:

Intraoperative SRF drainage with PFC appears to have no beneficial effect on postoperative metamorphopsia. Metamorphopsia is associated with macular status.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:e263–e270.]

Abstract

BACKGROUND AND OBJECTIVE:

To determine whether subretinal fluid drainage (SRF) using perfluorocarbon (PFC) during rhegmatogenous retinal detachment (RRD) repair reduces postoperative metamorphopsia.

PATIENTS AND METHODS:

Consecutive patients after RRD were evaluated for best-corrected visual acuity (BCVA), funduscopy, and metamorphopsia using M-CHARTS. Fundus autofluorescence and optical coherence tomography were performed. Clinical and operative data were collected.

RESULTS:

The cohort included 30 patients, of whom 11 (36.7%) underwent intraoperative PFC injection. Rates of macula-off RRD were similar in the two groups (54.5% and 47.4%, P = .705). No association was found between PFC injection and metamorphopsia score. Preoperative macula-off RRD was associated with significantly higher vertical and horizontal metamorphopsia scores than preoperative macula-on. BCVA was significantly worse in the patients with metamorphopsia (logMAR 0.15 vs. logMAR 0.04; P = .042)

CONCLUSION:

Intraoperative SRF drainage with PFC appears to have no beneficial effect on postoperative metamorphopsia. Metamorphopsia is associated with macular status.

[Ophthalmic Surg Lasers Imaging Retina. 2018;49:e263–e270.]

Introduction

The incidence of rhegmatogenous retinal detachment (RRD) is approximately 20 per 100,000 person-years. About half of all affected patients present with a detached macula.1 The success rates of RRD repair have recently increased, ranging from 76% to 94%, owing to improved surgical techniques.2,3 However, despite the anatomical reattachment, the postoperative quality of vision remains flawed in some cases. One of the major complaints is metamorphopsia, which has a reported prevalence in large-scale studies of 31% to 46%.4–6 The best-established preoperative risk factor for postoperative metamorphopsia is macula-off RRD, documented in up to 86% of cases.1,7,8

It has been suggested that the mechanism underlying postoperative metamorphopsia involves the displacement of the photoreceptors from their anatomical position, resulting in false localization of the perceived image.6,9,10 This hypothesis was supported by fundus autofluorescence (FAF) studies in patients after RRD repair demonstrating the presence of hyperautofluorescent lines parallel to the retinal vessels, a phenomenon termed retinal vessel printing.7,10 The retinal displacement and distortion may be a consequence of a combination of intraocular gas tamponade and the effect of gravity on the residual subretinal fluid (SRF). The intraocular gas moves the retina downward while shifting the residual SRF when the patient sits up immediately after surgery.10,11 If this assumption is correct, maximizing the drainage of SRF during surgery might reduce the occurrence and severity of postoperative metamorphopsia.

Perfluorocarbon (PFC) liquid has a high specific gravity and surface tension. Therefore, its intraocular injection during retinal surgery facilitates the reattachment and immobilization of the posterior retina while pushing the SRF anteriorly and into the retinal cavity through the retinal breaks, thereby potentially decreasing the amount of residual postoperative SRF.12,13 However, intraoperative PFC injection prolongs the surgical time14 and carries a risk of intraocular retention leading to retinal toxicity.15,16 Moreover, its intraoperative use doesn't always result in immediate reattachment of the retina, as some recent studies using intraoperative optical coherence tomography (OCT) demonstrated residual SRF after PFC injection in a significant portion of the patients.17,18 Therefore, it is widely used in complicated RRDs such as severe proliferative vitreoretinopathy, giant retinal tears, and multiple retinal tears, but its use in typical RRD is left to the surgeon's discretion.12

Metamorphopsia has been traditionally assessed using the Amsler grid. In recent years, this method has been replaced by M-CHARTS (Inami & Co., Tokyo, Japan), which allow for quantification of the distortion.19

The purpose of this study was to determine whether SRF drainage using PFC during RRD repair reduces postoperative metamorphopsia.

Patients and Methods

Patients

The study population consisted of consecutive patients older than 18 years who underwent pars plana vitrectomy (PPV) for macula-on and macula-off RRD repair at a tertiary, university-affiliated, medical center and came for a follow-up visit at the outpatient clinics.

Patients treated by a procedure other than PPV or by combined PPV with cataract extraction were excluded, as were patients with other severe vision-impairing eye diseases, especially those involving the macula (eg, age-related macular degeneration, epiretinal membrane (ERM), cystoid macular edema (CME), macular hole), significant cataract, recurrent RRD, best-corrected visual acuity (BCVA) of logarithm of the minimum angle of resolution (logMAR) less than 1, any previous surgery on the posterior segment, or proliferative vitreoretinopathy below grade C.

All RRD repair surgeries were performed with the Stellaris Vitreoretinal Surgical System (Bausch + Lomb, Rochester, NY) and a wide-angle viewing system. Either 25-gauge or 23-gauge instruments were used. The patients were randomly assigned to two surgeons, of whom, one does not routinely use PFC (R.E.) and the other always uses PFC (R.S.) as part of the RRD repair. In all cases, the posterior hyaloid membrane was separated, and the vitreous humor was removed up to the far periphery, with particular attention to vitreous traction on retinal tears and vitreous around the ports and the infusion line. When in use, PFC was injected over the posterior pole to reach the posterior border of the retinal breaks; fluid-air exchange was performed to drain the SRF through the original breaks. In all patients, endolaser therapy or cryotherapy was performed around holes and tears. At the end of surgery, gas or silicone oil tamponade was used. Patients were instructed to remain face-down postoperatively for 1 to 2 hours and thereafter to maintain face-down or appropriate positioning for up to 1 week.

Data Collection

All patients were invited for a follow-up visit specifically for the study. The following data were collected by file review: age, sex, refractive status, preoperative and postoperative BCVA, surgical approach, baseline macular status, hours of retinal detachment, RRD location, tamponade type, intraoperative use of PFC, method of retinopexy, and intraoperative and postoperative complications. During the follow-up visit, BCVA was tested using the Snellen visual acuity chart for distance and the Jaeger eye chart for near, followed by funduscopic examination. Grading was performed by the same vitreoretinal surgeon (R.E.) in all cases. All patients were evaluated for the presence of metamorphopsia using M-CHARTS.

M-CHARTS comprise 19 dotted lines, with dot intervals ranging from 0.2° to 2° of the visual angle. The distortion of the line is reduced until complete resolution as the dotted lines and intervals between the dots become coarser. Patients were first presented with a vertical straight line (0°). If they recognized the line as straight, they received a score of 0; otherwise, they were presented with dotted lines with increasing intervals between the dots until they reported the line to be straight. The visual angle was graded as their metamorphopsia score. Examinations were repeated three times consecutively, and the average score was calculated. The M-CHARTS were then rotated 90°, and horizontal metamorphopsia was assessed in a similar manner. The examiner was masked for the patients' medical record.

All patients were also evaluated by structural spectral domain ocular coherence tomography (SD-OCT) (Heidelberg Engineering, Heidelberg, Germany) and fundus autofluorescence (FAF).

The SD-OCT scans were reviewed by two independent graders (A.S. and R.E.) for integrity of the ellipsoid zone and the external limiting membrane, and the presence of cystoid macular edema, SRF, epiretinal membrane, and retinal folds. Enhanced depth imaging was used to measure subfoveal choroidal thickness. FAF scans were evaluated for retinal vessel printings. The graders were masked for the metamorphopsia scores and the intraoperative use of PFC.

Ethics

The study adhered to the tenets of the Declaration of Helsinki and was approved by the hospital's ethics committee. Informed consent was obtained from all patients.

Statistical Analysis

Statistical analysis was performed using Statistica 10.0 (Statsoft, Tulsa, OK). Continuous variables were tested for normality using the Shapiro-Wilk test. The data were presented as mean ± standard deviation (SD) for normally distributed variables or as median (interquartile range) for non-normally distributed data. Categorical variables were presented as counts and/or proportions. Patient groups were compared for normally distributed data using Student's t-test, for non-normally distributed data using Mann-Whitney U test, and for proportions using Pearson's Chi-squared test or Fisher exact test. Two-tailed P values of less than .05 were considered statistically significant.

Results

A total of 36 patients (36 eyes) were recruited for the study, of whom six were later excluded because of findings of CME or ERM (three each). Eleven of the remaining 30 patients (36.7%) received PFC injections for SRF drainage intraoperatively and 19 did not.

The demographic and baseline clinical characteristics of the PFC and no-PFC groups are detailed in Table 1, and the operative characteristics in Table 2. There were no significant between-group differences in any of the parameters evaluated. Six patients in the PFC group (54.5%) and nine in the no-PFC group (47.4%) had macula-off RRD (P = .705). The extent of RRD was greater in the PFC group, but the difference did not reach statistical significance (5.7 hours ± 2.0 hours vs. 4.4 hours ± 1.7 hours, respectively; P = .066). In two patients (18.2%) in the PFC group, a silicone oil tamponade had been left in place after primary RRD repair. It was extracted more than 6 months prior to the study without recurrence of the RRD.

Demographic and Baseline Characteristics of the PFC and No-PFC Groups

Table 1:

Demographic and Baseline Characteristics of the PFC and No-PFC Groups

Operative Characteristics of the PFC and No-PFC Groups

Table 2:

Operative Characteristics of the PFC and No-PFC Groups

The visual and anatomical outcomes at follow-up are summarized in Table 3. No between-group differences between the PFC and no-PFC groups were found in corrected distance and near visual acuity or in horizontal and vertical metamorphopsia scores. There was no association of the use of PFC with ellipsoid zone or external membrane integrity or with findings of vessel printings on FAF. On questioning prior to M-CHARTS testing, two patients from each group (18.2% of the PFC group, 10.5% of the non-PFC group) had complaints of metamorphopsia. However, testing yielded much higher rates of 54.5% in the PFC group and 47.4% in the no-PFC group, for a total of 15 patients (50%) with postoperative metamorphopsia.

Follow-Up Data of the PFC and No-PFC Groups

Table 3:

Follow-Up Data of the PFC and No-PFC Groups

Subgroup Analyses

Relationship between macular status and metamorphopsia: Patients with macula-off RRD preoperatively had significantly higher postoperative vertical and horizontal metamorphopsia scores than patients with preoperative macula-on RRD (Figure 1). Patients who subjectively complained of metamorphopsia had significantly higher M-CHARTS scores than patients who did not (Figure 2). The use of PFC had no effect on the metamorphopsia score in either the preoperative macula-on or macula-off subgroups (Figure 3).

Association between preoperative macular status and horizontal and vertical metamorphopsia scores.

Figure 1.

Association between preoperative macular status and horizontal and vertical metamorphopsia scores.

Association between subjective complaints of postoperative metamorphopsia and metamorphopsia score evaluated by M-CHART scores.

Figure 2.

Association between subjective complaints of postoperative metamorphopsia and metamorphopsia score evaluated by M-CHART scores.

Association between preoperative macular status and horizontal and vertical metamorphopsia scores.

Figure 3.

Association between preoperative macular status and horizontal and vertical metamorphopsia scores.

Relationship between background factors and metamorphopsia: Table 4 compares the demographics, baseline characteristics, surgical data, and follow-up data of the patients by the presence (M-CHART score > 0) or absence (M-CHART score 0) of metamorphopsia. The patients with metamorphopsia had a significantly worse BCVA than the patients without metamorphopsia (logMAR 0.15 vs. 0.04; P = .042) and a significantly higher rate of macula-off RRD (73.3% vs. 26.7%; P = .027). There were no significant differences between these groups in ellipsoid zone or external limiting membrane integrity, choroidal thickness, or FAF findings.

Demographics, Baseline Characteristics, Surgical, and Follow-Up Data by M-CHARTS Score

Table 4:

Demographics, Baseline Characteristics, Surgical, and Follow-Up Data by M-CHARTS Score

Relationship between lens status and metamorphopsia: The prevalence of postoperative metamorphopsia was higher in phakic patients than pseudophakic patients. This difference, however, was not significant (70% of the phakic patients vs. 40% of the pseudophakic patients, P = .245). In addition, the lens status had no effect on the horizontal or vertical metamorphopsia score (the median horizontal score was 0.60 in the phakic patients vs. 0.65 in the pseudophakic patients, P = .970 and the vertical score 0.60 vs. 0.30, P = .414).

Discussion

Many surgeons adhere to the practice of more meticulous SRF drainage using PFC during RRD repair under the assumption that it leads to better visual outcomes. However, the results of this study did not demonstrate any association of intraoperative SRF drainage using PFC with low metamorphopsia scores. Moreover, no advantage was found for the use of PFC by preoperative macular status.

To the best of our knowledge, this is the first study to address the implications of SRF drainage using PFC during RRD repair on postoperative metamorphopsia. In accordance with our findings, a recent prospective study conducted by Chen et al.14 showed no difference in the postoperative BCVA or anatomical results between patients who underwent complete or partial SRF drainage during RRD repair. The authors, however, did not evaluate metamorphopsia. The present study supports their findings and shows similar results also for metamorphopsia.

The overall prevalence of metamorphopsia according to the M-CHARTS scores was 50%. Similar rates were reported in a large-scale study by Zhou et al.5 (46.58%) using the Amsler grid and in a smaller study of RRD outcomes at one year by Murakama et al.8 (49%) using M-CHARTS. However, Okamoto et al.,6 in a prospective study, reported a lower rate of 38.76% using M-CHARTS. Given that the present study was the only one to exclude patients with epiretinal membrane, cystoid macular edema, and residual subretinal fluid, the actual percentage of patients with metamorphopsia is actually higher than in the other studies. This difference could be attributable to the short follow-up in some of the patients.

Interestingly, in response to a questionnaire administered prior to the M-CHARTS evaluation, only four patients in our cohort (13.3% of the whole cohort, 26.7% of patients with positive results on the M-CHART) complained of distorted vision. Considerably higher rates were reported by Amemiya et al.4 and Wright et al.,20 who noted that on questioning of patients after scleral buckling4,20 and vitrectomy,20 33% and 22%, respectively, reported metamorphopsia. However, considering our finding of an association between subjective complaints of metamorphopsia and higher scores on the M-CHARTS, it is possible that the postoperative metamorphopsia today is less severe than decades ago owing to improvements in surgical techniques. Moreover, by excluding patients with residual SRF, ERM, and CME on OCT, we may have limited the cohort to patients with less severe metamorphopsia and hence, fewer subjective complaints. The low number of patients with subjective complaints in our study might also be attributable, especially in those with macula-off RDD, to our postoperative instruction to maintain a face-down position for 1 to 2 hours after surgery. Further studies using OCT are needed to assess this issue in addition to the discrepancy between the subjective complaints and the objective findings related to metamorphopsia.

In agreement with previous studies, we found an association between macular status and metamorphopsia. In the large cross-sectional study of Zhou et al.,5 metamorphopsia was diagnosed in 56.7% of the 254 patients with macula-off RRD at 6 months to 81 months after treatment with vitrectomy or scleral buckling. In other analyses of patients with macula-off RDD, reported rates of metamorphopsia were 70% by M-CHARTS at 12 months postoperatively in 30 patients,8 67% by Amsler grid at 2 months after scleral buckling in 46 patients,21 and 64% by M-CHARTS at 12 months after vitrectomy with PFC in 22 patients.22 Our 73.33% rate of metamorphopsia in patients with macula-off RDD is in line with these values.

Several recent studies used OCT to detect abnormal microstructures related to postoperative metamorphopsia. However, the present study yielded no association of the integrity of the ellipsoid zone or external limiting membrane with either metamorphopsia or the use of PFC. Murakami et al.8 likewise noted no difference in metamorphopsia scores between patients with and without an intact ellipsoid zone and external limiting membrane, although they reported a significant association of metamorphopsia with disruption of the interdigitation zone. Okuda et al.22 found that neither ellipsoid zone nor interdigitation zone integrity was a predictor of the metamorphopsia score, whereas in the large cross-sectional study of Zhou et al.5 disruption of the external limiting membrane junction proved to be an independent predictor of metamorphopsia. Others also observed that in patients after epiretinal membrane surgery, preoperative ellipsoid zone integrity was associated with postoperative metamorphopsia as well as BCVA.23,24

The presence of retinal vessel printings on FAF in our patients was unrelated to the postoperative metamorphopsia scores or the use of PFC. Only four of our patients (13.3%) had positive FAF findings. Accordingly, Dell'omo et al.7 observed retinal vessel printings in 12.1% of eyes with RRD at 24 days postoperatively. Although Shiragami et al.11 reported a higher rate of 62.8%, the FAF findings were not correlated with PFC use. None of these earlier studies evaluated a possible linkage between these lines and metamorphopsia. It is interesting that the highest overall metamorphopsia scores in our cohort were found in two of the four patients with vessel printings on FAF. Although the number of patients is too small for statistical analysis, this finding could hypothetically be attributed to greater dislocation of the retina postoperatively and the relatively short follow-up period.

The limitations of this study are the small sample size and variety of follow-up periods. Nevertheless, the findings definitively show that intraoperative use of PFC does not lead to a decreased risk of metamorphopsia. In addition, there was a great discrepancy between the objective and subjective findings regarding metamorphopsia using M-CHARTS. It seems that the major risk factor for metamorphopsia is macula-off RRD, which is not reduced by the use of PFC. As several recent studies have shown,17,18 the use of intraoperative OCT might provide valuable information on the extent of SRF at completion of surgery after using PFC, and means of preventing postoperative metamorphopsia.

References

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Demographic and Baseline Characteristics of the PFC and No-PFC Groups

CharacteristicsPFC GroupNo-PFC GroupP Value

Number of Patients (Eyes)1119

Age (Years), Mean ± SD59.4 ± 11.062.6 ± 9.8.409*

Sex (M/F), n9/211/8.180

CDVA at Diagnosis (logMAR), Median (IQR)0.10 (0.10–0.15)0.10 (0.00–0.30).683

Lens Status, n (%)
  Phakia3 (27.2%)8 (42.1%).417
  Pseudophakia8 (72.8%)11 (57.9%)

Macula Status, n (%)
  On5 (45.5%)10 (52.6%).705
  Off6 (54.5%)9 (47.4%)

RRD Extent (Hours), Mean ± SD5.7 ± 2.04.4 ± 1.7.066*

RRD Location, n (%)
  Upper4 (36.4%)12 (63.2%).339
  Lower4 (36.4%)3 (15.8%)
  Nasal0 (0%)1 (5.3%)
  Temporal2 (18.2%)3 (15.8%)
  Total1 (9.1%)0 (0%)

Operative Characteristics of the PFC and No-PFC Groups

PFC GroupNo-PFC GroupP Value

Number of Patients (Eyes)1119

Retinopexy, n (%)
  Laser Therapy4 (36.4%)7 (36.8%).141*
  Cryotherapy2 (18.2%)9 (47.4%)
  Both5 (45.5%)3 (15.8%)

Tamponade, n
  Gas9 (81.8%)19 (100%).126
  Silicone2 (18.2%)0 (0%)

Follow-Up Data of the PFC and No-PFC Groups

CharacteristicsPFC GroupNo-PFC GroupP Value

Number of Patients (Eyes)1119

Time to Follow-Up Visit (Days), Mean ± SD777 ± 613256 ± 175.002*

CDVA at Follow-Up (Snellen) (logMAR), Median (IQR)0.10 (0.10–0.15)0.10 (0.00–0.30).683

CNVA at Follow-Up (Jaeger), (logMAR) Median (IQR)1 (1–1)1 (1–1).897

Metamorphopsia Score, Median (IQR)
  Horizontal0.0 (0.0–0.5)0.0 (0.0–0.5).763
  Vertical0.0 (0.0–0.5)0.0 (0.0–0.3)1.000

Disrupted Ellipsoid Zone, n (%)
  No9 (81.8%)15 (78.9%)1.000
  Yes2 (18.2%)4 (21.1%)

Disrupted ELM, n (%)
  No8 (72.8%)15 (78.9%).646
  Yes3 (27.2%)3 (15.8%)

Retinal Vessels Printings, n (%)
  No9 (81.8%)17 (89.5%).611
  Yes2 (18.2%)2 (10.5%)

Choroidal Thickness (μm), mean ± SD253 ± 87202 ± 52.056*

Demographics, Baseline Characteristics, Surgical, and Follow-Up Data by M-CHARTS Score

CharacteristicsMetamorphopsia (Score > 0)No Metamorphopsia (Score = 0)P Value

Number of Patients (Eyes)1515

Age (Years), Mean ± SD60.5 ± 11.262.4 ± 9.4.614*

Time to Follow-Up Visit (Days), Mean ± SD420 ± 522475 ± 411.751*

CDVA at Follow-Up (logMAR), Median (IQR)0.15 (0.10–0.40)0.04 (0.00–0.15).042

Macula Status, n
  On411.027
  Off114

Tamponade, n
  Gas14141.000
  Silicone11

Disrupted EZ, n
  No1113.651
  Yes42

Disrupted ELM, n
  No11121.000
  Yes33

Retinal Vessel Printings, n
  No1214.598
  Yes31

Choroidal Thickness (μm), Mean ± SD212 ± 79222 ± 63.919*
Authors

From the Department of Ophthalmology, Rabin Medical Center – Beilinson Hospital, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (AS, OGO, RAS, RE); the Department of Ophthalmology, Galilee Medical Center, Nahariya, Israel (EG); and the Department of Pathophysiology, Sechenov First Moscow State Medical University, Moscow, Russia (EB).

The authors report no relevant financial disclosures.

Address correspondence to Amir Sternfeld, MD, Department of Ophthalmology, Rabin Medical Center – Beilinson Hospital, Petach Tikva 4941492, Israel; email: shtery@gmail.com.

Received: February 02, 2018
Accepted: May 03, 2018

10.3928/23258160-20181203-17

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