SUBFOVEAL FLUID RESOLVES SLOWLY

AFTER PARS PLANA VITRECTOMY FOR

TRACTIONAL RETINAL DETACHMENT
SECONDARY TO PROLIFERATIVE
DIABETIC RETINOPATHY
NAZANIN BARZIDEH, MD, T. MARK JOHNSON, MD, FRCSC

Purpose: To report delayed visual recovery resulting from slow resolution of subfoveal
subretinal fluid measured with optical coherence tomography (OCT) after pars plana
vitrectomy (PPV) for repair of tractional retinal detachment (TRD) involving the fovea
secondary to proliferative diabetic retinopathy (PDR).
Method: In this retrospective case series, charts of three patients with persistent
subfoveal fluid after PPV for TRD secondary to PDR were reviewed. All patients were
followed up for a minimum of 1 year after surgery, using OCT and serial ophthalmic
examination.
Results: Subfoveal fluid resolved completely after a minimum of 6 months after PPV as
measured by OCT. All three patients had improvement in visual acuity after subfoveal fluid
was completely resolved.
Conclusion: Persistent subfoveal fluid may take several months to resolve in patients
undergoing PPV to repair TRD secondary to PDR and account for delayed visual recovery.
OCT is an important tool in the follow-up of patients undergoing vitrectomy for TRD.
RETINA 27:740 –743, 2007

T he goal of retinal detachment surgery is complete

retinal reattachment with particular emphasis on
foveal reattachment to maximize visual outcome. Per-
for the follow-up of patients with persistent subfoveal
fluid after PPV.1,2,5,6
To our knowledge, persistent subfoveal fluid as a
sistent postoperative subfoveal fluid after pars plana cause of delayed visual recovery has not previously
vitrectomy (PPV) for repair of rhegmatogenous retinal been described in diabetic patients after PPV for repair
detachment and macular holes has been reported as a of tractional retinal detachments (TRDs). We describe
possible cause of delayed visual recovery.1– 6 Resolu- three such patients.
tion of subfoveal fluid can be a slow process, leading
to gradual improvement of visual acuity over many Methods
months after surgery.1 Optical coherence tomography
(OCT) has been observed to be a useful diagnostic test In a retrospective review of the charts all patients
who underwent PPV for repair of TRD secondary to
proliferative diabetic retinopathy (PDR) from 2001 to
From The National Retina Institute, Chevy Chase, Maryland. 2004 at our institution, three patients with delayed
Reprint requests: T. Mark Johnson, MD, FRCSC, The National
Retina Institute, 5530 Wisconsin Avenue, Suite 101, Chevy Chase, resolution of subretinal fluid and delayed visual re-
MD 20815; e-mail: [email protected] covery after vitrectomy were identified. All patients

740
 SUBFOVEAL FLUID RESOLUTION AFTER PPV FOR TRD FROM PDR ● BARZIDEH AND JOHNSON 741

had progressive TRDs extending into the macula. All

patients underwent 3-port 20-gauge PPV. Fibrovascu-
lar tissue was delaminated from the retinal surface
using a combination of a vitreoretinal pick, curved
horizontal scissors, and end-grasping forceps. The
posterior hyaloid was peeled to the vitreous base. All
patients underwent air–fluid exchange and tamponade
with 16% C3F8. In two cases, this was necessitated
because of iatrogenic retinal breaks that developed in
areas of ischemic retina inferonasal to the optic nerve.
In neither case was the iatrogenic break associated
with subretinal fluid that extended into the macula. In
one case, TRD was drained via a retinotomy at the
peripheral aspect of the detachment. All patients were
followed up for a minimum of 12 months after PPV.
ETDRS visual acuity was measured at each office
visit. Patients underwent complete dilated ophthalmic
examination and OCT (OCT, Version 3, Carl Zeiss
Meditec, Dublin, CA). OCT included 6 scans of di-
agonal slow, high density obtained at 30° intervals.
Fluorescein angiography was performed using scan-
ning laser ophthalmoscopy (Heidelberg System with
Heidelberg Eye Explorer software).

Case Reports

Case 1
A 47-year-old woman with a history of panretinal
photocoagulation for bilateral PDR presented with
new vitreous hemorrhage, active neovascularization
elsewhere, and progressive TRD extending into the
macula. Visual acuity was 20/50. The patient under-
went the surgical procedure described above. No rheg-
matogenous detachment was encountered during sur-
gery. The retina was flat at the conclusion of the
operation. The patient maintained a head-down posi-
tion for 2 weeks postoperatively. At 8 weeks after
vitrectomy, the retina was attached without evidence
Fig. 1. A, Optical coherence tomography (OCT) performed 8 weeks
of subretinal fluid shown by biomicroscopy. Vision after surgical repair of tractional retinal detachment shows subfoveal
was 20/160. OCT at that visit revealed persistent sub- fluid and macular edema. Visual acuity is 20/160. B, OCT of the same
foveal fluid (Fig. 1A). Three months after PPV, the eye after cataract surgery with posterior chamber intraocular lens
implantation 3 months after pars plana vitrectomy. The subfoveal fluid
patient developed a progressive posterior subcapsular persists, and visual acuity is 20/60. C, OCT performed 11 months after
cataract and underwent uncomplicated cataract extrac- surgical repair demonstrates complete resolution of subfoveal fluid.
tion and posterior chamber intraocular lens implanta- Visual acuity is 20/30. D, OCT performed 28 months after surgical
repair. No subretinal fluid is present, and visual acuity is 20/25.
tion. Visual acuity improved to 20/60. Repeated OCT
at that time showed persistent subfoveal fluid. At the
6-month follow-up, subfoveal fluid decreased as re-
Case 2
vealed by OCT (Fig. 1B), and fluorescein angiography
showed no evidence of leakage. Eleven months after A 57-year-old woman with a history of PDR pre-
PPV, subfoveal fluid resolved completely, and visual viously treated with panretinal photocoagulation and
acuity stabilized at 20/30 (Fig. 1C). At 28 months after visual acuity of 20/100 presented with new onset of
surgery, visual acuity was 20/25 without evidence of TRD involving the fovea. She underwent the surgery
subretinal fluid (Fig. 1D). described above. No rhegmatogenous retinal detach-
742 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES ● 2007 ● VOLUME 27 ● NUMBER 6

Fig. 2. A, Optical coherence

tomography (OCT) per-
formed 6 weeks after surgical
repair of tractional retinal de-
tachment demonstrates the
presence of localized subfo-
veal fluid. Visual acuity is 20/
50. B, OCT performed 10
months after surgical repair
shows minimal subfoveal
fluid. C, Fluorescein angiog-
raphy (late phase) demon-
strates no leakage in the fo-
veal region. D, OCT
performed 13 months after
surgical repair. Visual acuity
is 20/40, and subfoveal fluid
has resolved completely.

ment was encountered during surgery. At the conclu- the 4-month postoperative visit by OCT, and visual
sion of the operation, the fovea was attached, and the acuity improved to 20/200. Fluorescein angiography
retina was completely flat. At postoperative week 8, showed no evidence of macular leakage. The subreti-
visual acuity improved to 20/63. The retina was flat nal fluid was completely resolved at the 5-month
without evidence of subretinal fluid during clinical postoperative visit. No recurrence of fluid was noted 8
examination. OCT showed localized subfoveal fluid, months after vitrectomy (Fig. 3B). Visual acuity re-
and visual acuity was 20/50 (Fig. 2A). Localized mained 20/200. Fluorescein angiography revealed
subretinal fluid remained at the 6-month and 10-month capillary nonperfusion in the macula.
visits without a change in visual acuity (Fig. 2B).
Fluorescein angiography did not demonstrate macular
leakage at either visit (Fig. 2C). At the 13-month visit,
visual acuity was stable at 20/40 with resolution of
subretinal fluid (Fig. 2D). Twenty months after PPV,
no subfoveal fluid was present by OCT, and vision
remained stable.

Case 3
A 62-year-old woman with a history of PDR pre-
viously treated with panretinal photocoagulation pre-
sented with TRD involving the macula. Visual acuity
was 20/125. OCT confirmed progressive subretinal
fluid extending under the fovea. The patient under-
went the surgical procedure described above, and no
rhegmatogenous detachment was encountered. At the
completion of the surgery, complete retinal attach-
ment was noted. Eight weeks after the operation,
visual acuity was 20/250. The retina was flat without
evidence of residual subretinal fluid during clinical
examination. A small area of subfoveal fluid was Fig. 3. A, Optical coherence tomography (OCT) performed 8 weeks
shown by OCT (Fig. 3A). The patient received a after surgical repair shows diffuse subfoveal fluid and macular edema.
Visual acuity is 20/250. B, OCT performed 8 months after surgical
posterior sub–Tenon space injection (40 mg) of triam- repair demonstrates complete resolution of subfoveal fluid and macular
cinolone acetonide. Subfoveal fluid was decreased at edema. Visual acuity is stable at 20/200.
 SUBFOVEAL FLUID RESOLUTION AFTER PPV FOR TRD FROM PDR ● BARZIDEH AND JOHNSON 743

Discussion either persistence of the subretinal fluid associated

with the tractional detachment or exudative fluid aris-
This series describes three patients undergoing vit-
ing from surgical manipulation or in response to ad-
rectomy and membrane peeling for progressive mac-
ditional panretinal photocoagulation. Given the ab-
ular detachments secondary to PDR. All patients were
sence of persistent leakage shown by fluorescein
observed to have localized areas of subretinal fluid in
angiography, it seems unlikely that the fluid represents
the central fovea that were detected by OCT but could
an exudative response. Given that tractional detach-
not be detected by biomicroscopy. In all cases, per-
ments in these cases were slowly progressive, the
sistence of subretinal fluid appeared to be associated
subretinal fluid may have been of a higher viscosity
with delayed visual recovery after surgery.
that impeded the rate of postoperative reabsorption of
Persistent subretinal fluid has been observed after
fluid in the central macula.
repair of rhegmatogenous retinal detachment. In a
In summary, persistent subretinal fluid may be ob-
case series of 16 eyes undergoing an initial scleral
served by OCT after repair of macula involving trac-
buckle procedure for macula-off rhegmatogenous ret-
tional diabetic retinal detachments. This fluid is not
inal detachment, 11 eyes had evidence of persistent
evident by clinical examination and does not appear to
subretinal fluid in the fovea 1 month after surgery.2
be associated with retinal vascular leakage shown by
The subretinal fluid was detected only by OCT and
fluorescein angiography. We speculate that it may
could not be observed with fluorescein angiography or
represent residual viscous subretinal fluid secondary
clinical biomicroscopic examination. Subretinal fluid
to the original TRD. The fluid appears to spontane-
persisted in 8 eyes at month 6 and 1 eye at month 12.
ously reabsorb, but this process may be prolonged.
The presence of persistent fluid was associated with
The reabsorption appears to be associated with pro-
poorer visual recovery compared with patients with
gressive improvement in visual acuity. Persistent sub-
complete foveal reattachment.2 A second case series
retinal fluid detectable by OCT should be considered
of 15 patients undergoing scleral buckle surgery for
in patients with delayed visual recovery after vitrec-
macula-off rhegmatogenous retinal detachment noted
tomy for tractional diabetic retinal detachment.
7 eyes and 1 eye with persistent subretinal fluid by
OCT at months 1 and 12, respectively. Clinical exam- Key words: proliferative diabetic retinopathy, sub-
ination did not demonstrate any residual subretinal foveal fluid, tractional retinal detachment.
fluid or detachment. Visual acuity was noted to im-
prove with resolution of subretinal fluid.3 Recently,
ultrahigh-resolution OCT was also used to detect per- References
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with delayed visual recovery after retinal detachment detachment occurs faster after vitrectomy than after buckle
repair.4 surgery. Ophthalmology 2004;111:1340–1343.
Although persistent subretinal fluid has been de- 2. Wolfensberger T, Gonvers M. Optical coherence tomography
in the evaluation of incomplete visual recovery after macula-
scribed after repair of macula involving rhegmatog-
off retinal detachments. Graefes Arch Clin Exp Ophthalmol
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