Bilateral identical intervals between phacoemulsification procedures performed 23 years before retinal detachment.

We aim to present a case of bilateral rhegmatogenous retinal detachment (RRD) after successful phacoemulsification procedures performed 23 years before RRD onset and surgical management. A 57-year-old female presented with blurred vision due to floaters in the left eye. The patient was followed up with dilated fundus examination. The patient underwent bilateral uneventful cataract extraction 23 years before the baseline visit with the use of phacoemulsification. Dilated fundus examination revealed RRD in the left eye that was managed with a 25G pars plana vitrectomy, cryopexy, and 16% C3F8 expandable gas. Thirty-three days following the procedure in the left eye, the patient presented with RRD in the right eye. Management included a 25G pars plana vitrectomy with cryopexy and 20% SF6 expandable gas. Phacoemulsification ultrasound energy appears to bring about changes in the peripheral vitreous and retina that may manifest several decades following uncomplicated cataract extraction.

Introduction

Bilateral rhegmatogenous retinal detachment (RRD) is a relatively rare clinical entity with a reported incidence ranging between 2.3% and 20%.[12]

RRD in a fellow eye has always been recognized as a risk factor for RRD and that risk appears to increase in pseudophakic as well as in aphakic eyes.[13] Regarding the onset of RRD, the interval between the two eyes varies between simultaneity and several years.[4]

Vitreous detachment has been known to facilitate the creation of retinal tears which, in turn, may lead to RRD. In patients suffering from RRD, peripheral retinal degenerative changes can be detected in the vast majority of patients (63%–90%), while retinal breaks with no RRD in the fellow eye can be detected in a significant percentage of the patient population (20%).[1]

We report a case of bilateral RRD, without any prior peripheral retinal degenerations, after successful phacoemulsification (and implantation of a 10-mm optic diameter intraocular lens) performed 23 years before RRD onset and surgical management.

Case Report

A 57-year-old Caucasian female was referred with blurred vision due to floaters in the left eye for the previous 9 days. The patient underwent bilateral uneventful cataract extraction in Munich, Germany, 23 years before the baseline visit (left eye: October 1990, right eye: November 1990) with the use of phacoemulsification. Her personal history revealed no predisposing factors for RRD (e.g., myopia, previous ocular trauma). There was no family history of retinal detachment. Anterior segment examination revealed one-piece posterior chamber polymethylmethacrylate intraocular lenses (IOLs) in the bag in both eyes (Adatomed 75 ST)[5] [Figure 1]. This particular IOL was characterized by a 10-mm optic diameter and not a 12.5–13 mm diameter, the rule in contemporary designs. Dilated fundus examination revealed RRD in the left eye: two horseshoe breaks were observed at the equator (in the 9.30 and 10 h). Visual acuity was 20/20. No significant findings were observed in the right eye. RRD was managed with a 25G pars plana vitrectomy, cryopexy, and 16% C3F8 expandable gas. One-week follow-up was uneventful. Thirty-three days following the procedure in the left eye, the patient presented with RRD in the right eye (between 12 and 2.30 h): A horseshoe break was located adjacent to the equator in the 12.30 h. As the macula was not involved, visual acuity was 20/20. Management included a 25G pars plana vitrectomy with cryopexy and 20% SF6 expandable gas. Ten days later, the patient presented with a recurrent RRD (probably due to pre and intraoperatively undetected inferior retinal holes) in the left eye with PVR Grade C1 that was managed with a 25G pars plana vitrectomy, cryopexy, and 5000 cst silicone oil. Four months later, both eyes appeared to be stable with visual acuity being 20/20.

Figure 1

Posterior chamber polymethylmethacrylate intraocular lenses in the bag in the right (a) and left (b) eye 23 years following uneventful phacoemulsification procedures

Discussion

Previous cataract extraction has been established as a risk factor for RRD. Phacoemulsification may contribute to vitreous changes[6] that include increased vitreal traction postoperatively. These changes, in turn, may facilitate retinal break formation. According to a recent study, significantly elevated risk for pseudophakic retinal detachment was observed even up to 10 years following cataract extraction. The authors concluded that there may be a causative relationship between RRD and cataract surgery.[6]

In this case, bilateral RRD was observed 23 years after uncomplicated bilateral phacoemulsification. It must be taken into consideration that standard phacoemulsification energy employed at the time was considerably greater (5–10-fold) compared to modern surgical practice and that the operation was carried out without the use of viscoelastics. The implanted IOL was characterized by a nonfoldable 7-mm biconvex optic and a total diameter of 10 mm. Despite the smaller, by contemporary standards (12.5–13 mm), IOL diameter, the 75 ST appeared to be centered in both eyes with no apparent significant vitreal traction. There were no related predisposing factors (e.g., lattice degeneration, Nd:YAG laser capsulotomy) observed in both eyes. However, relevant experimental research in rabbit eyes revealed that ultrasound energy, even at low intensities, resulted in photoreceptor outer and inner segment damage which, in turn, correlated with definite pigment changes, while higher energy levels resulted in retinal blanching or even a full-thickness retinal defect.[7] In relevant clinical studies in humans, the cumulative probability ratio for RD was reported to be 4.7%, 15 years following phacoemulsification.[68] In our patient, this statistic risk appeared to be comparable in both eyes as the interval between phacoemulsification and RRD onset was almost identical.

As clear lens extraction (CLE) is more commonly employed, potential long-term side effects should also be considered. According to Colin et al., the risk for RRD following CLE was 2% at 4 years and increased significantly (8.1%) at 7 years.[9] Moreover, patients younger than 60 years were at higher risk for RD compared to older patients.[8] As there are no similar long-term studies regarding RRD incidence following CLE, our case may be an indication of such a risk; given the age, this patient underwent cataract extraction.

In our patient, breaks were horseshoe shaped, a finding consistent with the patient's age. Multiple round holes have been associated with younger age, while horseshoe breaks have been observed in older patients.[10] Horseshoe tears suggest areas of localized vitreoretinal traction that usually occur with lattice degeneration or other peripheral retinal degeneration, although that this may not always be the case. Moreover, in both eyes, breaks were located in the superior temporal quadrant, a common finding in RRD patients according to the literature.[2]

The notable feature of this report is that identical intervals between phacoemulsification procedures performed exactly 23 years before RRD onset and surgical management were observed in both eyes. As there was no visible traction observed, it can be hypothesized that break formation could be attributed to peripheral retinal changes manifesting several decades following uncomplicated cataract extraction and brought about by phacoemulsification ultrasound energy. Phacoemulsification ultrasound energy may bring about changes in the peripheral vitreous and retina that could manifest several decades following uncomplicated cataract extraction. It is conceivable that, as phacoemulsification procedure numbers increase, the incidence of late-onset pseudophakic RRD (several decades following cataract extraction) may increase as well. Further, prospective studies on long-term retinal changes after cataract extraction are required in order to elucidate the potential effect of phacoemulsification in the retinal periphery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.