Photoreceptor disruption related to persistent submacular fluid after successful scleral buckle surgery

Abstract

Purpose: To investigate serial changes in photoreceptor status and associated visual outcome in patients with persistent submacular fluid after successful scleral buckle surgery for macula-off rhegmatogenous retinal detachment.

Methods: This was a prospective observational case series including 76 consecutive patients who underwent successful scleral buckle surgery for macula-off rhegmatogenous retinal detachment with symptom duration ≤90 days at a single tertiary hospital. Optical coherence tomography (OCT) and visual acuity examination were performed at one month and three months postoperatively and at three-month intervals until the submacular fluid disappeared. Main outcome measures were postoperative photoreceptor status on OCT and visual acuity.

Results: Forty-two patients (55.3%) showed persistent submacular fluid at postoperative one month. Of 42 patients with persistent submacular fluid, three (7.1%) showed photoreceptor disruption on OCT. None of the 34 patients without persistent submacular fluid showed photoreceptor disruption. Two patients (4.8%) had progressive photoreceptor disruption, and one patient (2.4%) had early photoreceptor disruption. All three patients showed photoreceptor reappearance and limited visual restoration after absorption of submacular fluid. Final visual acuities were significantly worse in these three patients (20 / 1000, 20 / 133, and 20 / 133) compared to those of the other patients (mean, 20 / 30) with persistent submacular fluid and intact photoreceptors.

Conclusions: Even after successful scleral buckle surgery for rhegmatogenous retinal detachment, photoreceptor disruption can occur related to persistent submacular fluid and may be a cause of poor visual outcome.

Keywords: Optical coherence tomography; Photoreceptor cells; Retinal detachment; Sclera buckling; Subretinal fluid.

Fig. 1

Serial changes of typical time-domain optical coherence tomography (horizontal scans) in a case with persistent submacular fluid after successful scleral buckle surgery for rhegmatogenous retinal detachment. The images were obtained preoperatively and at 1, 3, 6, and 9 months postoperatively, from top to bottom. There were no signs of photoreceptor disruption throughout the follow-up periods.

Fig. 2

Optical coherence tomography findings (horizontal scans) of cases 1-3 (A-C). Arrows indicate the disrupted photoreceptor inner and outer segment line. (A) Case 1 at 1, 3, 6, 9, 12, and 18 months postoperatively, from top to bottom. Best-corrected visual acuities (BCVAs) were 20 / 40, 20 / 67, 20 / 333, 20 / 500, 20 / 1,000, and 20 / 1,000 at the respective follow-up periods. (B) Case 2 at 1, 3, 6, 9, 12, and 15 months postoperatively. BCVAs were 20 / 1,000, 20 / 250, 20 / 333, 20 / 333, 20 / 500, and 20 / 133. In cases 1 and 2, the foveal photoreceptor inner and outer segment disappeared progressively, while the amount of submacular fluid gradually decreased. (C) Case 3 at 1, 2, 3, 6, 9, and 54 months postoperatively. BCVAs were 20 / 333, 20 / 333, 20 / 200, 20 / 250, 20 / 250, and 20 / 133, respectively. The photoreceptor inner and outer segment junction line in the fovea disappeared initially and reappeared as the submacular fluid was absorbed.

Fig. 3

Optical coherence tomography (OCT) findings of fovea in cases 1 (A-C) and 2 (D-F). Early signs of progressive photoreceptor disruption (a focal defect in inner and outer segment junction layer) on Stratus OCT (vertical scans) are indicated with arrows in A (case 1) and D (case 2) at postoperative one month. Spectral-domain OCT findings (horizontal scans) of case 1 at 12 (B, Spectralis OCT) and 21 (C, Spectralis OCT) months and case 2 at 9 (E, Cirrus OCT) and 21 (F, Spectralis OCT) months show disruption and partial restoration of the photoreceptor layer on the fovea. Long arrows indicate the external limiting membrane, and arrowheads indicate the inner and outer segments of photoreceptors.

Fig. 4

Serial changes of best-corrected visual acuity (BCVA) in patients with persistent submacular fluid detected on optical coherence tomography one month after successful scleral buckle surgery for macula-off rhegmatogenous retinal detachment. The error bars indicate 95% confidence intervals of BCVA in the intact photoreceptor group (n = 39). Cases 1 and 2 showed progressive photoreceptor disruption postoperatively and case 3 showed early disruption. The final BCVAs of the three cases were significantly worse than those of the intact photoreceptor group (p < 0.001 by one-sample t-test). logMAR = logarithm of the minimum angle of resolution; pre-op = preoperative.