Ophthalmic Surgery, Lasers and Imaging Retina

Case Report 

Posterior Pigment Deposition as a Marker of Persistently Open Retinectomy Edge Following Retinal Detachment Repair

Archana A. Nair, MD, MS; Saagar Pandit, MD, MPH; Dean Eliott, MD; Yasha S. Modi, MD

Abstract

Posterior pigment dispersion is a rare ophthalmic finding that has been reported in patients undergoing retinectomy with silicone oil placement and in patients who underwent significant anterior segment manipulation and vitrectomy. The pigment release is believed to occur from retinal pigment epithelium (RPE) cells in the former and the posterior iris in the latter. The exact timing of this pre-retinal pigment deposition is unknown but typically is mild and occurs over several months. A rapid progression of diffuse preretinal pigmentation is uncommon and may be suggestive of persistent RPE release from an open break or continued iris trauma with posterior pigment release. This report describes a case of profound posterior pigment deposition more than 4 months after retinectomy and oil in a patient with a persistently open retinectomy edge with anterior retinal detachment. The rapidity of pigment deposition was the clue to recognizing this subtle anterior detachment under silicone oil.

[Ophthalmic Surg Lasers Imaging Retina. 2021;52:47–49.]

Abstract

Posterior pigment dispersion is a rare ophthalmic finding that has been reported in patients undergoing retinectomy with silicone oil placement and in patients who underwent significant anterior segment manipulation and vitrectomy. The pigment release is believed to occur from retinal pigment epithelium (RPE) cells in the former and the posterior iris in the latter. The exact timing of this pre-retinal pigment deposition is unknown but typically is mild and occurs over several months. A rapid progression of diffuse preretinal pigmentation is uncommon and may be suggestive of persistent RPE release from an open break or continued iris trauma with posterior pigment release. This report describes a case of profound posterior pigment deposition more than 4 months after retinectomy and oil in a patient with a persistently open retinectomy edge with anterior retinal detachment. The rapidity of pigment deposition was the clue to recognizing this subtle anterior detachment under silicone oil.

[Ophthalmic Surg Lasers Imaging Retina. 2021;52:47–49.]

Introduction

Posterior pigment deposition is an uncommon ocular finding. It has been previously described in eyes with retinal detachment and proliferative vitreoretinopathy (PVR) following retinectomy and placement of silicone oil, with histopathology demonstrating that this pigment is due to retinal pigment epithelium (RPE) cell migration and phagocytosis of emulsified silicone oil droplets.1 However, the spectrum is not limited to this, as it may occur in post-vitrectomized eyes after anterior segment manipulation and pigment dispersion from the iris. The case herein describes rapid and significant posterior pigment dispersion from a persistently open break after retinectomy with RPE release.

Case Report

An 83-year-old pseudophakic Caucasian woman presented with hand motion vision and a recurrent retinal detachment with PVR after undergoing initial scleral buckling and vitrectomy 2 months prior. She underwent membrane peeling, inferior retinectomy, and 1,000-centistoke silicone oil placement. On follow-up visits, her uncorrected vision improved to 20/400 and she was noted to have increasing preretinal pigment deposits that were accumulating on the inferior hemiretina (Figures 1A and 1B). She was lost to follow-up during the COVID-19 pandemic and returned 4 months after oil placement with extensive preretinal pigment deposition. Examination anterior to the buckle revealed an open retinectomy edge, PVR, and pigment granules near the retinectomy edge (Figure 2). She underwent anterior membrane peeling and extension of her retinectomy to address the localized recurrent retinal detachment (Figure 3).

(A) Widefield fundus photo (Optos, Marlborough, MA) of the right eye demonstrates a posteriorly attached retina, inferior retinectomy, and silicone oil fill. There is extensive preretinal pigment deposition on the inferior hemiretina. The temporal margin of the retinectomy is elevated with extensive pigment release around the edge (arrow). There is a temporal retinal detachment anterior to the buckle (*) (B) Eidon (CenterVue, Padova, Italy) photograph of fundus imaging provides a higher magnification image highlighting the extent of preretinal pigment deposition.

Figure 1.

(A) Widefield fundus photo (Optos, Marlborough, MA) of the right eye demonstrates a posteriorly attached retina, inferior retinectomy, and silicone oil fill. There is extensive preretinal pigment deposition on the inferior hemiretina. The temporal margin of the retinectomy is elevated with extensive pigment release around the edge (arrow). There is a temporal retinal detachment anterior to the buckle (*) (B) Eidon (CenterVue, Padova, Italy) photograph of fundus imaging provides a higher magnification image highlighting the extent of preretinal pigment deposition.

Spectral-domain optical coherence tomography imaging showing mild macular edema and epiretinal membrane. Focal dark areas on the near-infrared image highlight the preretinal pigment deposits.

Figure 2.

Spectral-domain optical coherence tomography imaging showing mild macular edema and epiretinal membrane. Focal dark areas on the near-infrared image highlight the preretinal pigment deposits.

Widefield fundus photo following extension of the retinectomy temporally. The preretinal pigment deposits have improved following surgery.

Figure 3.

Widefield fundus photo following extension of the retinectomy temporally. The preretinal pigment deposits have improved following surgery.

Discussion

Posterior pigment dispersion is a rare finding seen primarily in post-vitrectomized eyes. Sachdeva et al. described a series of patients undergoing large retinectomies that had progressive posterior pigment deposition. Ultrastructural analysis of preretinal focal pigment deposits and epiretinal membranes in some of their patients identified that dispersed RPE cells containing phagocytized emulsified oil droplets (due to direct contact of silicone oil with RPE cells) was the source of this pigment.1 They hypothesized that oil emulsification may enhance the pigment deposition. Rowlands et al. subsequently described posterior pigment dispersion in eyes without a history of retinal detachment. These cases occurred after anterior segment manipulation in eyes with prior vitrectomy, such that removing both the anterior and posterior hyaloid allowed iris pigment to disperse and settle posteriorly.2 In the series by Rowlands et al., one patient had extensive posterior pigment deposition due to iris atrophy from a malpositioned intraocular lens. The commonality of these posterior pigment dispersion cases involves a prior vitrectomy with release of pigment and/or pigmented cells from the posterior iris or the RPE.

Although preretinal pigment dispersion may be a subtle finding in a PVR detachment with retinectomy and oil, the rapid rate of pigment deposition may be important to signal a persistent source of pigment release. In the case described herein of a Caucasian patient, the rapid pigment deposition over 4 months was particularly unusual and served as a valuable clue to identify the open retinectomy edge with localized anterior retinal detachment. This case emphasizes the importance of recognizing this unusual complication and conducting a meticulous peripheral retinal exam to evaluate for the source of persistent pigment release.

References

  1. Sachdeva MM, Jakobiec FA, Stagner AM, Papakostas A, Eliott D. Clinical and Ultrastructural Studies of Epiretinal Pigmentary Deposits after Retinectomy with Silicone Oil. Ophthalmology. 2016;123(12):2595–2602. doi:10.1016/j.ophtha.2016.08.049 [CrossRef] PMID: 27769586
  2. Rowlands MA, Kaden TR, Weiss MJ, et al. Retinal Pigment Deposition Secondary to Iatrogenic Pigment Dispersion. Ophthalmol Retina. 2019;3(6):536–538. doi:10.1016/j.oret.2018.12.005 [CrossRef] PMID: 31174679
Authors

From the Department of Ophthalmology, NYU Langone Health, New York University, New York, New York (AAN, SP, YSM); and the Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts (DE).

Supported by an unrestricted grant from Research to Prevent Blindness and NIH R01-EY013178.

Dr. Eliott is a consultant for Alcon, Allergan, Dutch Ophthalmic, Genentech, Glaukos, and Aldeyra Therapeutics outside the submitted work. Dr. Modi is a consultant for Alimera, Allergan, Thea, and Zeiss outside the submitted work. Drs. Nair and Pandit report no relevant financial disclosures.

Address correspondence to Yasha S. Modi, MD, 222 E. 41st Street, 3rd Floor, New York, NY 10017; email: yasha.modi@gmail.com.

Received: September 07, 2020
Accepted: November 09, 2020

10.3928/23258160-20201223-09

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