Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Augmented Posterior Hyaloid Adhesion Associated With Retinal Detachment After Macular Hole Repair

Danielle M. Lo, MD; Michael R. Chua, MD; Ryan D. Larochelle, BA; Kenneth J. Wald, MD

Abstract

BACKGROUND AND OBJECTIVE:

There remains a low but intractable risk of rhegmatogenous retinal detachment (RRD) after surgical repair of macular holes (MHs). The purpose of this study is to identify potential causes for RRDs after MH surgery.

PATIENTS AND METHODS:

The authors retrospectively examined a single surgeon series of stage 3 MH repair surgeries during a 5-year period. Clinical data, including preoperative, intraoperative, and postoperative evaluations, were reviewed to determine potential causes of RRD.

RESULTS:

Of the 332 eyes that received MH surgery, 12 (3.6%) developed postoperative RRD. Seven RRD cases exhibited no evident precursor pathology; however, augmented posterior hyaloid adhesions (APHAs) were found intraoperatively and postoperatively.

CONCLUSIONS:

In MH surgery, APHA increases risk for RRD. During PPV, the vitreous typically separates to the peripheral vitreous base. Some eyes have APHAs near the equator that cannot be elevated, consistent with strong adhesion. The authors believe the high postoperative RRD rate is due to continued hyaloid elevation after surgery.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:635–638.]

Abstract

BACKGROUND AND OBJECTIVE:

There remains a low but intractable risk of rhegmatogenous retinal detachment (RRD) after surgical repair of macular holes (MHs). The purpose of this study is to identify potential causes for RRDs after MH surgery.

PATIENTS AND METHODS:

The authors retrospectively examined a single surgeon series of stage 3 MH repair surgeries during a 5-year period. Clinical data, including preoperative, intraoperative, and postoperative evaluations, were reviewed to determine potential causes of RRD.

RESULTS:

Of the 332 eyes that received MH surgery, 12 (3.6%) developed postoperative RRD. Seven RRD cases exhibited no evident precursor pathology; however, augmented posterior hyaloid adhesions (APHAs) were found intraoperatively and postoperatively.

CONCLUSIONS:

In MH surgery, APHA increases risk for RRD. During PPV, the vitreous typically separates to the peripheral vitreous base. Some eyes have APHAs near the equator that cannot be elevated, consistent with strong adhesion. The authors believe the high postoperative RRD rate is due to continued hyaloid elevation after surgery.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:635–638.]

Introduction

One of the serious complications of macular hole (MH) surgery is retinal detachment (RD). It is likely related to the surgical creation of a vitreous separation.1 Despite advances in vitreoretinal surgery to improve closure rate and visual acuity (VA) for idiopathic MH, there remains a low but intractable rate of rhegmatogenous RD (RRD) in the postoperative period. Rates of RD after MH surgery vary widely and should be analyzed in the context of differing eras, case selection (stage 3 vs. 4), and follow-up protocols. The only prospective analysis of MH surgery found in the literature was completed by Banker et al., who demonstrated an 11% RD rate at 1-year follow-up in a prospective trial of 187 patients.2 Several retrospective studies with similar surgical methods for MH repair have reported varying rates of postoperative RD. Park reported 14% in 98 patients, Adkuman reported 8% in 73 patients, and Tabandeh reported 1.8% in 438 cases.3–5 Vaziri conducted a retrospective analysis of 23,465 MH surgeries from 2007 to 2013 in the MarketScan database using International Classification of Disease and Current Procedural Terminology codes and determined a postoperative RD rate of 3.9% to 5.7%.6 Krishnan reported a postoperative RD rate of zero in 72 patients who received MH repair via PPV, inner limiting membrane peel, gas injection, combined with phacoemulsification and insertion of a posterior chamber intraocular lens implant. The mean follow-up for patients in this cohort was 24 months.7

The purpose of this retrospective, observational clinical study is to identify potential causes for RRDs after MH surgery.

Patients and Methods

A retrospective chart review was performed of 332 patients who received surgical repair of stage 3 MHs during a 5-year period (2012–2017) by a single surgeon. All patients underwent uniform surgical approach with 25-gauge pars plana vitrectomy, elevation of the posterior hyaloid face with attempted vitreous removal out to the vitreous base, internal limiting membrane peeling with indocyanine green (ICG), and use of 20% SF6 gas. Preoperative and intraoperative scleral indentation and laser treatment to any detected precursor pathology or retinal breaks was performed in all eyes. The charts and operative records of those patients with postoperative RRD were analyzed for potential causes.

Results

Twelve (3.6%) of the 332 eyes that received MH surgery were found to have RRD postoperatively (Table 1). Of these patients, seven (58.3%) were female and five (41.7%) were male. Mean age at presentation of MH was 63.3 years (standard deviation [SD] ± 8.73 years; range: 48 years to 80 years). During MH surgery, four of these eyes (33.3%) were found to have lattice degeneration and were treated with intraoperative endolaser photocoagulation. Seven eyes did not exhibit any evident precursor pathology; however, they were found and noted to have augmented posterior hyaloid adhesions (APHAs) intraoperatively and postoperatively (Figure 1).

Demographics and Clinical Characteristics of Patients With Postoperative RRD AfterSurgical Repair of Stage 3 MHs

Table 1:

Demographics and Clinical Characteristics of Patients With Postoperative RRD AfterSurgical Repair of Stage 3 MHs

Ultra-widefield image depicting augmented posterior hyaloid adhesion (arrows) temporally in an eye that later developed rhegmatogenous retinal detachment after macular hole surgery.

Figure 1.

Ultra-widefield image depicting augmented posterior hyaloid adhesion (arrows) temporally in an eye that later developed rhegmatogenous retinal detachment after macular hole surgery.

Mean time to RRD was 55.2 days (SD ± 62.5 days; range 11 days to 196 days) (Table 2). Ten retinal tears were located inferiorly (83.3%), whereas two were located superiorly (16.7%). Mean improvement of VA was 1.40 lines (SD ± 2.12). Postoperatively, 10 of the MHs (83.3%) were successfully closed based on OCT imaging. All 12 eyes underwent subsequent vitreous surgery and the retina remained attached through the follow-up period.

Clinical Characteristics and Postoperative Outcomes of Patients With RRDs

Table 2:

Clinical Characteristics and Postoperative Outcomes of Patients With RRDs

Discussion

RRD is one of the most serious complications of MH surgery. Despite advances in surgical technique for MH repair, there remains a risk of postoperative RRD. In this cohort, 3.6% of eyes receiving MH surgery subsequently developed RRDs. This rate is consistent with previous studies, which have reported rates varying from 0% to 17%.2–7 Eyes with MH may have an abnormal vitreoretinal interface that may predispose them to subsequent tears and detachment.8 Tears associated with MH surgery tend to occur in the peripheral retina, particularly inferiorly.2 Reducing the risk of RD for patients undergoing MH surgery is achieved by thorough preoperative and intraoperative inspection of the peripheral retina for breaks and tears and laser retinopexy (LR) prophylaxis.2,9 However, despite a thorough evaluation for tears or precursor pathology in our case series, there was still the development of retinal detachments after MH surgery.

This study was the first to document the association of postoperative RRDs and APHAs. During MH repair surgery, the posterior hyaloid face must be separated from the retina, an inherent risk factor for RRD. When PPV is performed, the vitreous typically separates to the vitreous base. During this process, retinal tears can be diagnosed and subsequently treated intraoperatively. However, we have found that eyes with APHAs do not achieve complete separation of the vitreous interface. In these eyes, the retinal breaks appear to occur postoperatively due to delayed completion of the vitreous separation. The presence of a gas bubble and residual vitreous can augment tractional forces, especially of the inferior retina. These APHAs may be related to the strong vitreomacular adhesions that are a hallmark of MHs.10

There are several limitations to this study. This was a retrospective study and the overall incidence of APHA in MH patients undergoing surgery is not established. However, we encountered this condition in several patients who later developed RRD and had no other rhegmatogenous precursor abnormality.

The authors believe that completion of vitreous separation should be attempted in all cases with endolaser retinopexy to any rhegmatogenous sequelae. In cases of APHA, prophylactic LR at the margin of the attached hyaloid, especially inferiorly is a consideration. Further studies should address the incidence of APHA in MH to better characterize the relationship between APHA and postoperative RD.

References

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Demographics and Clinical Characteristics of Patients With Postoperative RRD AfterSurgical Repair of Stage 3 MHs

n%

Number of Patients12
  Female758.3
  Male541.7

Mean Age at Presentation With MH (Years)63.3 (SD ± 8.73; range: 48–80)

Mean Preoperative IOP (mm Hg)16.7 (SD ± 3.85; range: 13–28)

Surgical Technique
  Pars plana vitrectomy with injection of SF612100
  Endolaser photocoagulation433.3

Intraoperative Observation
  Lattice433.3
  Augmented posterior hyaloid adhesion758.3

Clinical Characteristics and Postoperative Outcomes of Patients With RRDs

n%

Mean postoperative time to RRD (days)55.2 (SD ± 62.5, range 11–196)

Closure of MH1083.3

Location
  Inferior1083.3
  Superior216.7

Mean Improvement of VA (Lines)1.40 (SD ± 2.12)
Authors

From New York University School of Medicine, Department of Ophthalmology, New York (DML, RDL, KJW); and New York Eye and Ear Infirmary of Mount Sinai, Department of Ophthalmology, New York (MRC).

Paper presented at the Association for Research in Vision and Ophthalmology 2018 Annual Meeting, Honolulu, Hawaii, April 29, 2018.

The authors report no relevant financial disclosures.

Address correspondence to Michael R. Chua, MD, New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, 6th Floor South, New York, NY 10003; email: michael.chua@mountsinai.org.

Received: July 23, 2018
Accepted: March 25, 2019

10.3928/23258160-20191009-06

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