When Retina is not detached anymore. Alexandra Mouallem, Agnès Glacet-Bernard Service du Professeur Souied Le 19/03/2014

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1 When Retina is not detached anymore, Agnès Glacet-Bernard Service du Professeur Souied Le 19/03/2014

2 Medical History Mr V. 57 yo man December 2013 : Bullous superior retinal detachment caused by 2 retinal breaks located at 10 and 11 o clock in the left eye Surgical treatment : - Vitrectomy / perfluorocarbon / laser / gas tamponade with C2F6 - Post operative position Post operative examination : BVCA : Counting fingers with a transversal scotoma affecting central vision field

7 OCT

8 Post operative aspect

9 OCT at day 8 reconstruction of the foveal aspect

10 What you need to know about macular folds

11 Epidemiology - Most articles are about isolated case reports - in 1984 Pavan and al estimated the incidence at 2,8% after surgery for retinal detachement in a consecutive series of 137 cases - Evolution of surgery technique with progression of Vitrectomy associated with gas tamponnade ; this complication is under-estimated

Physiopathology Retinal Folds following Retinal Detachment Surgery Heinrich Heimann, Silvia Bopp Ophthalmologica 2011 Heavy liquid reattaches the central retina and pushes subretinalfluid anteriorly.

12 Physiopathology Retinal Folds following Retinal Detachment Surgery Heinrich Heimann, Silvia Bopp Ophthalmologica 2011 Heavy liquid reattaches the central retina and pushes subretinalfluid anteriorly. Most of the subretinal fluid is drained internally through the break. some subretinal fluid, is pushed into the subretinal space anterior to the break Fluid-air exchange. The air pushes the subretinal fluid down towards the break where it can be drained with a fluid needle. some fluid will be shifted towards the posterior pole with increasing influx of air. The wave of subretinal fluid has reached the posterior pole, where it is now trapped by the air bubble pressing against the retina. The result is a compression fold at the macula.

13 Risk factors Retinal detachment : - Recent onset of retinal detachment - Superior bullous detachment - Retinal detachment running through the fovea Surgical technique: - Use of an intraocular gas tamponade - Incomplete internal drainage of subretinal fluid especially when performing primary vitrectomy - Non respect of post operative position

Treatment and classification Roger Wong et

Am J Ophthalmol 2012) Roger Wong defines 3

14 Treatment and classification Roger Wong et al (Longitudinal study of macular folds by spectral-domain optical coherence tomography. Am J Ophthalmol 2012) Roger Wong defines 3 types of Macular folds Ripple / no surgery Tacos / no surgery displacement/ surgery

15 Surgical treatment No standard treatment / Surgical indication when the fold is important and including the fovea Macular translocation with balanced salt solution injection under the retina is the most described surgical technique

16 Surgical treatment, other example L Trinh and al described an other case ( Pli maculaire complicant la chirurgie du decollement de rétine J Fr Ophtalmologie 2006) Macular translocation + Laser

17 Surgical treatment - El-Amir and al ( Repair of macular fold follo-wing retinal reattachment surgery. Clin Experiment Ophthalmol2007) describe a surgical technique similar but associated with a final gas tamponade - Isaico and al (Macularfolds after retinal detachment surgery: the possible impact of outpatient surgery. Graefes Arch Clin Exp Ophthalmo 2011) realise a peeling of the internal limiting membrane

Long term follow up - Ali Osman Saatci and al (Long-Term Follow-Up of

with Air Tamponade Case Reports in Ophthalmological Medicine Volume

18 Long term follow up - Ali Osman Saatci and al (Long-Term Follow-Up of the Postoperative Macular Fold following the Vitreoretinal Surgery with Air Tamponade Case Reports in Ophthalmological Medicine Volume 2013, Article ID ) describe a long term follow up of 6 years of a macular fold. No surgery was done and after 6 years the fold can only be seen in autofluorescent images but not anymore in fundus examination

19 Conclusion - Macular folds represent a classical complication of retinal detachment surgery, it is probably under-estimated - No standard treatment - Identification of risk factors may improve post operative results of retinal detachement surgery

Tractional detachments

Retinal detachment: Surgery and post op care Tractional detachments Causes: diabetes, sickle cell, trauma, von Hippel Lindau disease. Sam S. Dahr, M.D. Retina Center of Oklahoma Key principles Remove the