Epiretinal membrane development after submacular perfluorocarbon liquid removal.

Optical coherence tomography of submacular perfluorocarbon liquid and its safe removal with a small gauge cannula have been presented in the report. This case was complicated by development of an epiretinal membrane, though visual acuity was preserved.

Introduction

Submacular perfluorocarbon liquid (PFCL) can lead to functional visual loss, central scotoma and irreversible retinal structural damage.[1] We discuss optical coherence tomography (OCT) features of submacular PFCL and its management using small-gauge aspiration needle.

Case Report

A 24-year-old male with posttraumatic inferior retinal detachment in the right eye underwent 25G vitreoretinal surgery with the use of PFCL and silicone oil tamponade. The left eye was normal. Visual acuity improved from counting fingers close to face to 5/60 after 2 weeks. Although retina was well attached, a dome-shaped elevation was noted beneath fovea suggestive of submacular PFCL [Figure 1a]. OCT revealed a well-defined cyst-like hyporeflective lesion in the subfoveal space with a central macular thickness of 919 μ. The retina above the cystic lesion was thinned out [Figure 1b].

Figure 1

(a) Fundus photograph of the right eye showing attached retina under silicone oil and submacular perfluorocarbon liquid bubble (white arrow). A retinotomy scar is also seen superiorly above the temporal arcade (black arrow). (b) Optical coherence tomography image of the right eye showing perfluorocarbon liquid bubble in the subretinal space with overlying retinal thinning (white arrow). (c) Fundus photograph 6 weeks after aspiration of perfluorocarbon liquid bubble showing epimacular membrane and attached retina (white arrow). (d) Optical coherence tomography image after aspiration of perfluorocarbon liquid bubble showing the macular epiretinal membrane with absent foveal contour, gross distortion of outer retinal layers, and discontinuous inner segments-outer segments junction

Another 25G vitreoretinal surgery was done for submacular PFCL removal. After silicone oil removal, retina was punctured at the inferotemporal margin of the subretinal PFCL bubble using a 25G needle with 41G flexible tip and the PFCL aspirated. The remnant PFCL bubble was removed using active suction with a 25G cannula. 14% C3F8 gas was injected after fluid air exchange.

After 6 weeks, vision had improved to 6/12. The retina was well attached, but an epiretinal membrane (ERM) had developed over the fovea [Figure 1c]. The foveal contour was found to be absent on OCT with gross distortion of outer retinal layers and discontinuous inner segments-outer segments junction [Figure 1d]. Follow-up was advised in view of good vision and no metamorphopsia.

Discussion

PFCL enters the subretinal space through retinal breaks/posterior retinotomy during surgery. Quick removal of submacular PFCL is advocated as visual prognosis depends on duration of its contact with retinal structures.[1] Displacement of submacular PFCL to peripheral retina may be done using gas or other positioning techniques,[2] however, such maneuvers work only in the early postoperative period.[3]

Complete removal can be achieved by direct aspiration through juxtafoveal retinotomy or therapeutic macular holes,[3] sometimes aided by inducing therapeutic retinal detachment,[4] followed by the use of small gauge cannulas or aspiration with microcannulas.[5] Good visual acuity and stable retinal architecture have been achieved with smaller therapeutic macular holes[3] but involves the risk of scotoma development. Creating a therapeutic retinal detachment is challenging and may be complicated by the occurrence of macular hole in the thin retina.[34]

Small gauge cannula is a good instrument as it allows the creation of self-sealing puncture sites, allows induction of local retinal detachment if needed, and can aspirate PFCL bubbles easily. Thin retina over the PFCL bubble makes the puncture easy, and PFCL removal can be safely done with controlled infusion pressure and direct aspiration.

While other studies have reported macular hole, submacular hemorrhage, enlargement of the juxtafoveal retinotomy, or damage to the macular photoreceptor or RPE cells, and submacular fibrosis,[4] we observed the development of ERM postoperatively, which could be due to the perifoveal retinal puncture, aggravated by gas tamponade, and a predisposition in young patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.