Ophthalmic Surgery, Lasers and Imaging Retina

Technique 

Intraoperative Drainage of a Bullous Serous Pigment Epithelial Detachment

Robert A. Sisk, MD, FACS

Abstract

BACKGROUND AND OBJECTIVE:

To describe a novel, simple technique for surgically draining a bullous serous pigment epithelial detachment (PED).

PATIENTS AND METHODS:

Pars plana vitrectomy was performed with confirmed elevation of the hyaloid face. Proportional diathermy allowed stepwise entry into the PED superotemporally through an initially small, needle-point focus while providing control of any potential bleeding. Thick fluid was aspirated with a soft-tipped cannula, fluid-air exchange was performed, and intravitreal bevacizumab was injected before removing the cannulas.

RESULTS:

The PED was successfully completely drained intraoperatively and remained flat at 1 week postoperatively. However, the draining site ultimately closed, and continued exudation from choroidal neovascularization led to recurrent PED and eventual nonhemorrhagic retinal pigment epithelial tear despite aggressive treatment with aflibercept and photodynamic therapy. The early visual acuity benefit may relate to resolution of hyperopic shift.

CONCLUSION:

Serous PED can be surgically reduced without hemorrhagic complications, but long-term success depends upon control of the underlying choroidal neovascularization.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:510–513.]

Abstract

BACKGROUND AND OBJECTIVE:

To describe a novel, simple technique for surgically draining a bullous serous pigment epithelial detachment (PED).

PATIENTS AND METHODS:

Pars plana vitrectomy was performed with confirmed elevation of the hyaloid face. Proportional diathermy allowed stepwise entry into the PED superotemporally through an initially small, needle-point focus while providing control of any potential bleeding. Thick fluid was aspirated with a soft-tipped cannula, fluid-air exchange was performed, and intravitreal bevacizumab was injected before removing the cannulas.

RESULTS:

The PED was successfully completely drained intraoperatively and remained flat at 1 week postoperatively. However, the draining site ultimately closed, and continued exudation from choroidal neovascularization led to recurrent PED and eventual nonhemorrhagic retinal pigment epithelial tear despite aggressive treatment with aflibercept and photodynamic therapy. The early visual acuity benefit may relate to resolution of hyperopic shift.

CONCLUSION:

Serous PED can be surgically reduced without hemorrhagic complications, but long-term success depends upon control of the underlying choroidal neovascularization.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:510–513.]

Introduction

Pigment epithelial detachment (PED) is a round elevation separating the retinal pigment epithelium (RPE) from Bruch's membrane in conditions like exudative age-related macular degeneration (AMD), polypoidal choroidal vasculopathy, and central serous chorioretinopathy.1 PED associated with choroidal neovascularization (CNV) may be poorly responsive to anti-vascular endothelial growth factor (VEGF) intravitreal injections and photodynamic therapy (PDT).2 Severe forms of PED may lead to RPE tear with associated subretinal hemorrhage (SRH) and risk for severe vision loss despite aggressive conventional treatment.3,4

Case Report

A 76-year-old female presented with massive submacular hemorrhage associated with RPE tear from wet AMD in her left eye (OS) (Figure 1). She underwent successful displacement of SRH by vitrectomy, subretinal injection (tissue plasminogen activator [tPA], bevacizumab [Avastin; Genentech, South San Francisco, CA], and air), and gas-fluid exchange with 20% sulfur hexafluoride. Unfortunately, despite anatomic success and continued monthly anti-VEGF therapy, her vision remained finger counting at 3 feet. Eight months after surgery, her right eye (OD) developed new wet AMD (Figure 2) with gradually enlarging serous PED despite injections of intravitreal bevacizumab and aflibercept (Eylea; Regeneron, Tarrytown, NY) every 4 weeks, indocyanine green-guided reduced-fluence PDT, and off-label intravitreal dexamethasone implant (Ozurdex; Allergan, Dublin, Ireland) injection. Inspection 2 weeks after aflibercept injection showed worsening in PED height. The PED grew to a maximum height of 1,242 μm and was determined to be at high risk for spontaneous RPE tear. Visual acuity (VA) (including pinhole correction for induced hyperopia) deteriorated as the PED enlarged from 20/20 to 20/60. Given the poor visual outcome OS, surgical drainage of the serous PED by vitrectomy was offered. The surgical technique is described below. Postoperative day 1 spectral-domain optical coherence tomography (SD-OCT) demonstrated flattening of the PED and eccentric macular hole at the retinotomy site. Preoperative VA (20/125) improved postoperatively to 20/30 at 1 week. The PED recurred at 4 weeks postoperatively, and the patient was continued on aflibercept injections OD every 3 to 4 weeks. A late follow-up at 5 weeks showed dramatic worsening in PED height. Indocyanine green angiography-guided full fluence photodynamic therapy was performed to the nasal extrafoveal choroidal neovascularization (CNV) 2 weeks after aflibercept injection but was unfortunately complicated by RPE tear without subretinal hemorrhage. VA recovered from 20/125 to 20/60.

Spectral-domain optical coherence tomography horizontal nonfoveal raster scans and infrared registration images of a hemorrhagic retinal pigment epithelium tear (RPE) of the left eye before (A) and after (B) vitrectomy, with displacement of subretinal and sub-RPE hemorrhage. Fluorescein angiography of massive subretinal hematoma (C) shows extensive blockage without hyperfluorescent lesion. After displacement of subretinal hematoma, there was prominent window defect from RPE tear (D).

Figure 1.

Spectral-domain optical coherence tomography horizontal nonfoveal raster scans and infrared registration images of a hemorrhagic retinal pigment epithelium tear (RPE) of the left eye before (A) and after (B) vitrectomy, with displacement of subretinal and sub-RPE hemorrhage. Fluorescein angiography of massive subretinal hematoma (C) shows extensive blockage without hyperfluorescent lesion. After displacement of subretinal hematoma, there was prominent window defect from RPE tear (D).

Spectral-domain optical coherence tomography (SD-OCT) foveal raster scans and corresponding infrared (IR) registration images of the right eye before (A–C) and after (D–F) surgical drainage of the pigment epithelial detachment (PED). After first presentation of subretinal fluid from conversion to wet age-related macular degeneration (A), a serous PED gradually enlarged despite aggressive conventional treatment (B). The PED grew to a maximum height of 1,242 μm (C). Postoperative day 1 SD-OCT demonstrated flattening of the PED and eccentric macular hole at the retinotomy site (D). The PED recurred 4 weeks postoperatively, and despite continued conventional treatment RPE tear without subretinal hemorrhage developed (F). Indocyanine green angiography demonstrated nasal location of the choroidal neovascularization under the papillomacular bundle precluded laser photocoagulation. False color fundus image at 1 week postoperatively showing flattened PED and superotemporal retinotomy (G). SD-OCT raster scans and IR registration images through the retinotomy in the right eye (I, J) demonstrate closure was associated with recurrence of PED.

Figure 2.

Spectral-domain optical coherence tomography (SD-OCT) foveal raster scans and corresponding infrared (IR) registration images of the right eye before (A–C) and after (D–F) surgical drainage of the pigment epithelial detachment (PED). After first presentation of subretinal fluid from conversion to wet age-related macular degeneration (A), a serous PED gradually enlarged despite aggressive conventional treatment (B). The PED grew to a maximum height of 1,242 μm (C). Postoperative day 1 SD-OCT demonstrated flattening of the PED and eccentric macular hole at the retinotomy site (D). The PED recurred 4 weeks postoperatively, and despite continued conventional treatment RPE tear without subretinal hemorrhage developed (F). Indocyanine green angiography demonstrated nasal location of the choroidal neovascularization under the papillomacular bundle precluded laser photocoagulation. False color fundus image at 1 week postoperatively showing flattened PED and superotemporal retinotomy (G). SD-OCT raster scans and IR registration images through the retinotomy in the right eye (I, J) demonstrate closure was associated with recurrence of PED.

Technique

Pars plana vitrectomy (PPV) was performed with confirmed elevation of the posterior hyaloid face and scleral depressed inspection for retinal breaks. It was anticipated that surgical violation of the bullous PED could result in induced RPE tear with rapid retraction and SRH. Tissue plasminogen activator was prepared but not required. The intraocular pressure was elevated to 60 mm Hg before entering the RPE to limit hemorrhage. A superotemporal location was chosen for the retinotomy to perpendicularly enter into the bullously elevated RPE and obliquely angle above the choroid to engage the sub-RPE fluid and avoid aspirating the choroid (Supplemental Video below). Proportional diathermy allowed stepwise entry through the retina and RPE through an initially small, needle-point focus while providing control of any potential bleeding as the sub-RPE space was slowly entered, which released thick sub-RPE fluid. A 38-gauge subretinal cannula on an automated extrusion handpiece was unsuccessful at draining the fluid. However, a 23-gauge soft-tipped cannula was able to gently aspirate the sub-RPE fluid until the PED flattened completely. A fluid-air exchange was performed, and 1.25 mg in 0.05 mL of bevacizumab was injected into the vitreous cavity before removal of cannulas. The patient was placed in a 45° head-down position for the rest of the day.

Discussion

Surgical drainage of PED associated with wet AMD in two prior cases was incomplete when perfluorocarbon liquid (PFCL) was used,5,6 even with manual displacement with a scraper through a retinotomy. The thick sub-RPE fluid would not drain through a 38-gauge cannula but readily drained with a 23-gauge soft-tipped extrusion cannula. Laser retinopexy around the drainage was applied in both prior reports to prevent retinal detachment but was not necessary except to ablate extrafoveal CNV. The location of the CNV in the papillomacular bundle prevented laser photocoagulation. Posterior breaks are unlikely to result in rhegmatogenous retinal detachment. Leaving the hole open allowed a potential low-pressure outlet to the vitreous cavity from the subretinal and sub-RPE space. Unfortunately, the hole closed within the first month.

Case selection by SD-OCT characteristics is probably critical, favoring minimal hyperreflective material of CNV, hemorrhage, or subretinal scarring associated with the lesion. Because the drainage of PED does not treat the underlying CNV, long term success probably depends upon CNV control, and aggressive CNV treatment is recommended after the procedure. Given the rapid recurrence of PED, PDT ideally would be performed at 1 week postoperatively, when the PED remained collapsed and the risk of RPE tear is minimized. At least some of the short-term visual benefit observed was from reversal of the hyperopic shift. The long-term visual benefit of this technique is unknown due to the rapid recurrence of PED.

References

  1. Gass JD. Pathogenesis of tears of the retinal pigment epithelium. Br J Ophthalmol. 1984;68(8):513–519. doi:10.1136/bjo.68.8.513 [CrossRef]
  2. Fung AE, Lalwani GA, Rosenfeld PJ, et al. An optical coherence tomography-guided, variable dosing regimen with intravitreal ranibizumab (Lucentis) for neovascular age-related macular degeneration. Am J Ophthalmol. 2007;143(4):566–583. doi:10.1016/j.ajo.2007.01.028 [CrossRef]
  3. Chan CK, Abraham P, Meyer CH, et al. Optical coherence tomography-measured pigment epithelial detachment height as a predictor for retinal pigment epithelial tears associated with intravitreal bevacizumab injections. Retina. 2010;30(2):203–211. doi:10.1097/IAE.0b013e3181babda5 [CrossRef]
  4. Nagai N, Suzuki M, Uchida A, et al. Non-responsiveness to intravitreal aflibercept treatment in neovascular age-related macular degeneration: Implications of serous pigment epithelial detachment. Sci Rep. 2016;6:29619. doi:10.1038/srep29619 [CrossRef]
  5. Ernst BJ, Chiranand P, Akduman L. Surgical drainage of a pigment epithelial detachment in neovascular age-related macular degeneration. Retina. 2009;29(5):704–707. doi:10.1097/IAE.0b013e3181a2c1d9 [CrossRef]
  6. Li H, Xu D, Wang H, Wang F. Surgical treatment for neovascularized retinal pigment epithelial detachment in age-related macular degeneration. Int J Ophthalmol. 2013;6(1):108–109.
Authors

From Cincinnati Eye Institute, Cincinnati; the Department of Ophthalmology, University of Cincinnati, Cincinnati; and Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center, Cincinnati.

This technique will be presented at the 51st Annual Retina Society Meeting in San Francisco on September 12, 2018.

The author reports no relevant financial disclosures.

Address correspondence to Robert A. Sisk, MD, FACS, Cincinnati Eye Institute, 1945 CEI Drive, Cincinnati, OH 45242; email: rsisk@cincinnatieye.com.

Received: August 13, 2018
Accepted: January 17, 2019

10.3928/23258160-20190806-06

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