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Arch Ophthalmol. 2001;119:1379-1380.

One of the most serious complications of macular hole surgery is retinal detachment, which is usually treated promptly with a second surgery. Recently, 4 cases of spontaneous resolution of retinal detachment following macular hole surgery were reported. The authors proposed several possible mechanisms for postsurgical retinal detachment in the absence of a clinically detectable retinal break. We present the first report, to our knowledge, of a patient with concurrent peripheral annular choroidal and inferior bullous retinal detachment noticed 1 week after macular hole surgery. After observation for 7 weeks, both resolved spontaneously. This case provides evidence that the cause of retinal detachment after macular hole surgery may be exudative.

Macular holes in stage 2, 3, or 4 are now widely managed with pars plana vitrectomy, posterior hyaloid peeling, and intravitreal perfluorocarbon gas tamponade.¹ Complications of macular hole surgery include cataract, retinal pigment epithelial changes, visual field loss, endophthalmitis, choroidal neovascularization, cystoid macular edema, and retinal detachment.^2-3 The latter has been recognized to occur secondary to iatrogenic or postoperative peripheral retinal breaks. Recently, retinal detachment following macular hole surgery has been reported to resolve spontaneously in the absence of any clinically detectable retinal tear.⁴ Several hypotheses were proposed: (1) small occult breaks that ultimately close, (2) a postsurgical temporary increase in fluid flow through the macular hole, or (3) subretinal exudation caused by surgery.

Report of a Case
A 69-year-old African American man with hypertension and hyperlipidemia was seen for a 1-year history of central distortion in the right eye. Best-corrected visual acuity was 20/400 OD and 20/30 OS. Intraocular pressure was 14 mm Hg in both eyes. Findings from slitlamp examination revealed bilateral nuclear sclerotic cataracts with cortical spokes. Fundus examination of the right eye revealed a stage 3 macular hole with surrounding neurosensory detachment and a mild epiretinal membrane. The patient underwent pars plana vitrectomy, peeling of the posterior hyaloid from the disc to the periphery with a soft-tip silicone cannula, perifoveal epiretinal membrane removal using a soft-tip diamond-dusted silicone cannula, and intravitreal 14% perfluoropropane gas tamponade. The posterior hyaloid membrane was extremely adherent to the disc, and multiple attempts were required to separate it in this location. No adjuvant for hole closure was used. Careful examination of the peripheral retina was performed immediately prior to the fluid-air exchange, identifying no disease. Intraocular pressure 2 and 4 hours postoperatively was 19 and 21 mm Hg, respectively. On postoperative day 1 the vitreous cavity was filled 80% with gas, the retina appeared flat, and intraocular pressure was 21 mm Hg.

One week later, the patient reported no new symptoms and was noticed to have a 360° peripheral annular choroidal detachment of moderate height accompanied by an inferior bullous retinal detachment extending from the 4- to the 8-o'clock position with shifting subretinal fluid. The vitreous cavity was filled 60% with gas. No peripheral retinal tears were seen. The patient continued receiving topical 1% prednisolone acetate 4 times a day. Two weeks later the choroidal detachment resolved. On postoperative week 6, the retinal detachment decreased in extent, and 1 week later it resolved completely. The macular hole was closed, with visual acuity of 20/200 OD. Three months later, the patient underwent phacoemulsification with posterior chamber intraocular lens implantation, and visual acuity improved to 20/50 OD.

Comment
This is the first report, to our knowledge, of choroidal detachment after macular hole surgery, concurrent with a bullous retinal detachment that showed spontaneous resolution. Akduman et al⁴ reported several cases of retinal detachment occurring after macular hole surgery that spontaneously resolved. The authors proposed that retinal detachment may be secondary to (1) small occult breaks that ultimately close when traction on the vitreous base from the intraocular gas bubble decreases as the gas reabsorbs; (2) a temporary increase in flow of fluid from the vitreous cavity through the macular hole after the cortical vitreous is surgically removed; or (3) subretinal exudation from tissue stress caused by the surgery.

This patient provides strong evidence that the cause of retinal detachment in some cases is exudative. Although this is supported by its bullous appearance, inferior localization, and shifting subretinal fluid, the coexistence of the retinal detachment with a choroidal detachment, both showing spontaneous resolution, reaffirms exudation as the most likely underlying mechanism. The cause for postsurgical choroidal and subretinal exudation may be related to intraoperative and/or perioperative transient hypotony and/or surgical tissue trauma with consequent release of chemomodulators. The only feature in this patient's intervention that sets him apart from the usual macular hole surgery case is the considerable effort required to separate the posterior hyaloid from the disc. It is possible that this played a role in causing subretinal and choroidal exudation from the optic disc and peripapillary region. This case stresses the need for close patient observation instead of an immediate reoperation when retinal detachment following macular hole surgery does not show a clear rhegmatogenous origin.

AUTHOR INFORMATION

Enrique Garcia-Valenzuela, MD, PhD; Dean Eliott, MD
Detroit, Mich

Corresponding author: Dean Eliott, MD, Kresge Eye Institute, 4717 St Antoine, Detroit, MI 48201.

REFERENCES
1. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes: result of a pilot study. Arch Ophthalmol. 1991;109:654-659. ABSTRACT 2. Park SS, Marcus D, Duker JS, et al. Posterior segment complications after vitrectomy for macular hole. Ophthalmology. 1995;102:775-781. ISI | PUBMED 3. Banker AS, Freeman WR, Kim JW, et al. Vision-threatening complications of surgery for full-thickness macular holes: Vitrectomy for Macular Hole Study Group. Ophthalmology. 1997;104:1442-1453. ISI | PUBMED 4. Akduman L, Del Priore LV, Kaplan HJ. Spontaneous resolution of retinal detachment occurring after macular hole surgery. Arch Ophthalmol. 1998;116:465-467. FREE FULL TEXT

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