Scleral buckling in rhegmatogenous retinal detachment with concomitant full-thickness macular hole.

A 67-year-old woman complained of progressive decrease of visual acuity within a period of several months accompanied by a visual field defect on the right eye since 3 days. Visual acuity was hand movement OD and 20/40 OS. Ophthalmic examination disclosed incipient cataract formation on both eyes and a rhegmatogenous retinal detachment (RD) on the right eye from 5 to 1 o`clock with macular involvement (Fig. 1A). Peripheral retinal breaks were found at 7, 9 and 10 o′clock, and a macular hole (MH) was assumed. Optical coherence tomography (OCT) confirmed a full-thickness hole (Fig. 1E). Additionally, proliferative vitreoretinopathy (PVR) became evident because of a full-thickness retinal involvement with retinal star fold formation at 12 o`clock, classified as PVR Cp1. After discussing with the patient the surgical alternatives of a vitrectomy and a scleral buckling procedure, a selective buckling of the peripheral breaks was performed with a circumferential buckle and additional mild cryopexy of the retinal breaks. A sponge of 4 mm diameter was applied from 6:30 to 10:30 to cover the retinal breaks at 7, 9 and 10 o`clock. (A) Fundus drawing: Rhegmatogenous retinal detachment of the right eye with macular hole, and peripheral retinal breaks at 7, 9 and 10 o`clock. PVR with a full-thickness retinal star fold is present at 12 o`clock, classified as PVR Cp1. (B) Fundus drawing: 2 days after scleral buckling surgery without puncture. The retina is totally attached, and the star fold as well as the macular hole are still present; blue area: residual retinal detachment at the star fold; yellow: mild cryopexy at the retinal breaks. (C) Fundus drawing: 2 months after surgery, the retina is attached, the star fold has resolved and the macular hole is closed. (D) Red-free image: 2 weeks after surgery, the MH is still present. (E) OCT (Stratus OCT, Carl Zeiss, Germany): preoperatively, the image demonstrates the elevated retina with a full-thickness macular hole. (F) OCT (Stratus OCT): two weeks after surgery, the retina is attached in the macular area with persistence of the macular hole. (G) high resolution OCT (RTVue-OCT, Optovue inc., CA, USA): 2 months after surgery, the image demonstrates the attached retina in the macular area and the closure of the macular hole. The retina attached completely after 2 days (Fig. 1B). Visual acuity improved to 20/100 and no complications developed during a follow-up of 6 months. The star fold at 12 o`clock resolved over a period of 3 months (Fig 1C). Postoperatively, the MH was followed by OCT and fundusphotography. The closure of the MH could be demonstrated 2 months after surgery (Fig. 1G). It is widely accepted that MH do not cause rhegmatogenous RD. Thus, if a MH is seen in the presence of a rhegmatogenous RD, the treatment should focus on the retinal breaks. The MH is interpreted as a lamellar hole [correction added after online publication 2 June 2011: ‘pseudohole’ was corrected to lamellar hole] and not as full-thickness hole [Harvey Lincoff, personal communication]. In this case, the presence of a full-thickness MH was verified by OCT. Nevertheless, we could demonstrate that selective treatment of the peripheral breaks is sufficient to reattach the retina. Additionally, the closure of the MH was seen during the follow-up. Pars plana vitrectomy is an alternative treatment to reattach the retina and to perform surgery to treat the MH by removing the inner limiting membrane (ILM). However, we should take into account that PVR may occur after surgery in 10–40% depending on the original disease (Kirchhof 2004). On the other hand, the extraocular surgical approach to treat RD has been demonstrated to reduce PVR formation (Kreissig et al. 1994; Sivkova & Kreissig 2002). In our case, PVR formation was already present. This is why buckling surgery was chosen. Today, pars plana vitrectomy allows the treatment of the RD and also the repair of the MH. However, ppV is an intraocular procedure which includes the risk of inducing MH (Benzerroug et al. 2008; Rahman et al. 2010). Even with ppV, a lamellar MH (pseudohole) may progress to a full-thickness MH because of the surgical trauma or when drainage is performed at the lamellar MH. As the patient complained of visual decrease for several months, we assumed that this was caused by early stage MH. Vitreous detachment without ILM peeling has been shown to be sufficient to treat MH. As a rhegmatogenous RD is caused by a retinal break that is typically followed by a posterior vitreous detachment, we decided to follow this case by short-term visits performing OCT. We could demonstrate that the MH closed within 8 weeks. In case of MH persistence, a vitrectomy with ILM peeling would have been recommended, because it has been shown to be beneficial especially in MH stage 4 (Meyer et al. 2008). Summary and recommendation: When a RD is caused by a MH, as typically seen in high myopia, the treatment is focused on the closure of the causative MH (Li et al. 2009). In rhegmatogenous RD with concomitant MH, even in the presence of a full-thickness MH, the treatment of the peripheral breaks is sufficient to reattach the retina. OCT is effective to visualize preoperatively whether a pseudohole or a full-thickness MH is present. We have to consider that performing ppV comprise the risk of a full-thickness MH, especially when a pseudohole is present and central drainage is performed. In the presence of a pseudohole, extraocular buckling surgery addressed to the peripheral breaks is a possible treatment option to preserve macular structures.