Graefes Arch Clin Exp Ophthalmol (2009) 247:1147–1150

DOI 10.1007/s00417-009-1087-5

CASE REPORT

Intravitreal injection of 0.3 ml of SF6 gas for persistent

subfoveal fluid after scleral buckling for rhegmatogenous
retinal detachment
Hirotaka Itakura & Shoji Kishi

Received: 13 January 2009 / Revised: 26 March 2009 / Accepted: 6 April 2009 / Published online: 25 April 2009
# Springer-Verlag 2009

Abstract reported a 47% incidence of residual foveal detachment

Purpose To determine the efficacy of intravitreal injection after successful scleral buckling [1]. Wolfensberger
of sulphur hexafluoride (SF6) gas for reducing persistent reported that OCT examinations 1 month after buckle
subfoveal fluid after scleral buckling surgery for macula-off surgery showed a small subclinical area of subfoveal fluid
rhegmatogenous retinal detachments. in 67% of patients, and the fluid was still present in 45% of
Methods We injected 0.3 ml of SF6 gas into the vitreous cases at 6 months postoperatively and in 11% of cases
cavity of two eyes of two patients with persistent macular 12 months postoperatively [2].
retinal detachment 3 and 5 months after successful scleral To displace persistent subfoveal fluid after scleral
buckling. Optical coherence tomography was performed buckling and improve the vision, we treated two eyes with
before and after surgery. injection of 0.3 ml of sulphur hexafluoride (SF6) gas into
Results Subfoveal fluid was displaced peripheral to the the vitreous cavity.
fovea immediately after gas injection and the fluid was
absorbed gradually in both eyes.
Conclusions Persistent subfoveal fluid after scleral buck- Methods
ling may be treated with intravitreal SF6 gas injection.
We examined the retinal images using spectral domain
Keywords Gas injection . Rhegmatogenous retinal OCT (Cirrus OCT; Carl Zeiss Meditec, Dublin, CA. USA,
detachment . Scleral buckling and three-dimensional OCT-1000; Topcon, Tokyo, Japan)
in two eyes of two patients with a persistent foveal retinal
detachment before and after buckle surgery for a macula-off
Introduction rhegmatogenous retinal detachment. The fundi were
scanned in a 6.0-mm line along the horizontal and vertical
Optical coherence tomography (OCT) recently showed that axes through the fovea.
foveal retinal detachments often persist after successful We retrospectively studied decimal visual acuity (VA),
scleral buckling to treat macula-off retinal detachments in the fundus appearance, and the details of the scleral
which the fovea appeared to be attached on ophthalmosco- buckling surgery from the medical records. VA was
py [1–3]. The residual foveal detachment may delay visual converted into log MAR units as the international standard
recovery [1, 3], In their OCT study, Hagimura et al. by an approximate value.
To treat persistent subfoveal fluid after scleral buckle
The authors have no proprietary interest in any aspect of this report surgery, 0.3 ml of pure SF6 gas was injected into the
H. Itakura (*) : S. Kishi vitreous cavity through the pars plana 3.5 mm posterior to
Department of Ophthalmology, Gunma University, the limbus, using a 27-gauge needle, after lowering the
School of Medicine,
intraocular pressure by anterior chamber paracentesis. The
3-39-15 Showa-machi,
Maebashi, Gunma 371-8511, Japan patients were instructed to maintain a facedown position for
e-mail: [email protected] about 3 or 4 days after gas injection.
1148 Graefes Arch Clin Exp Ophthalmol (2009) 247:1147–1150

Fig. 1 Optical coherence to-

mography shows that the sub-
foveal fluid was persistent until
3 months after surgery (a, b).
Seven days after sulphur hexa-
fluoride gas injection, the sub-
foveal fluid has decreased
dramatically (c). The fluid has
been absorbed completely after
4 months (d). The fundi were
scanned in a 6.0-mm line along
the horizontal axis through the
fovea (arrow)

Fig. 2 Optical coherence to-

mography shows persistent sub-
retinal fluid with no change for
5 months after surgery (a, b).
After gas injection, a persistent
foveal retinal detachment is im-
mediately displaced to the pe-
riphery and the fluid is absorbed
gradually (c–e). The fundi were
scanned in a 6.0-mm line along
the horizontal axis through the
fovea (arrow)
Graefes Arch Clin Exp Ophthalmol (2009) 247:1147–1150 1149

Results reattachment [6]. Using OCT, Hagimura et al. reported that

a persistent foveal detachment may account for the delayed
Case 1 visual recovery [1]. Subretinal fluid tends to stay in the
subfovea after buckle surgery to treat macula-off and
A 42-year-old man underwent local buckling for a retinal macula-on retinal detachments [7]. In eyes with extramacular
detachment involving the inferior quadrant and the macula, branch retinal vein occlusion, distant retinal vascular leakage
resulting from an inferior retinal atrophic hole in the lattice causes a serous retinal detachment in the macula [8], which
degeneration, without a posterior vitreous detachment is predisposed to collect subretinal fluid. In the two cases in
(PVD) in the phakic right eye. A silicone sponge exoplant the current study, the subretinal fluid in the macula remained
was placed on the sclera with a mattress suture. Transscleral the same for several months. When the SF6 gas was
cryopexy was applied around the hole. No subretinal fluid injected, absorption of the fluid began and ultimately the
was drained and no gas was injected. The corrected VA was fluid disappeared completely in both cases. Gas tamponade
0.0 before surgery and had not changed at 2 weeks and may displace the fluid laterally with a greater force on the
3 months after surgery. Although the retina appeared retina and then can be absorbed by retinal pigment
attached ophthalmoscopically, OCT showed subfoveal epithelium, which might be better than in the macula.
fluid, which had not been absorbed for at least 3 months Foveal reattachment occurs faster after vitrectomy than
after surgery (Fig. 1a,b). To displace the subfoveal fluid, we after scleral buckling in patients with macula-off retinal
injected SF6 gas. Seven days after injection of the SF6 gas, detachments [2]. In our study, case 1 had a retinal
the subfoveal fluid decreased dramatically (Fig. 1c) and detachment due to an atrophic hole in the lattice degener-
was absorbed completely by 4 months (Fig. 1d). The ation without a PVD. Scleral buckling is usually indicated
corrected VA sligthtly improved from 0.0 to −0.1. for a retinal detachment resulting from an atrophic hole
with no PVD. In such cases, it has been reported that the
Case 2 intraocular gas injection can induce secondary breaks and
re-detachments [9]. The eye of case 1 was treated with a VA
A 65-year-old man underwent local buckling for a macula- of log MAR 0.0. To treat an eye with attached vitreous and
off bullous retinal detachment resulting from a superior such a good VA with gas injection may be controversial
retinal tear with PVD in the phakic right eye. Scleral against the background of the risks. Although the surgeon
buckling with a silicone sponge exoplant was performed in expected earlier attachment of the retina anatomically in
the same way as in case 1. Transscleral cryotherapy was case 1, it should be considered whether the benefit of the
applied around the tear, and 0.3 ml of air was injected into gas injection is greater than the risk.
the vitreous cavity during surgery. No subretinal fluid was Case 2 had a retinal tear with a PVD. Either vitrectomy
drained. Although the corrected VA improved from +2.0 to or scleral buckling was appropriate in that case. In case 2,
+0.3, OCT showed persistent subretinal fluid that did not the tear was in the far peripheral retina in a phakic eye with
change for 5 months after surgery (Fig. 2a, b). After SF6 no cataract, so we elected to perform buckle surgery.
gas injection, a persistent foveal retinal detachment was The results of these two cases showed that intravitreal
displaced immediately to the periphery, and the fluid was injection of 0.3 ml SF6 gas promoted absorption of the
gradually decreased and absorbed completely by 7 months subretinal fluid in the macula after successful buckle
(Fig. 2c–e). The corrected VA slightly improved to +0.2. surgery. Gas injection for persistent foveal detachments
after retinal detachment surgery may encourage anatomical
attachment of the fovea immediately. A larger study should
Discussion be conducted.

A residual foveal detachment may delay visual recovery

after scleral buckling surgery, and result in a lower final References
visual outcome. In the detached retina, photoreceptor
apoptosis causes retinal dysfunction [4]. OCT has shown 1. Hagimura N, Iida T, Suto K, Kishi S (2002) Persistent foveal retinal
detachment after successful rhegmatogenous retinal detachment
elongation of the photoreceptor outer segments and surgery. Am J Ophthalmol 133:516–520. doi:10.1016/S0002-9394
decreased thickness of the outer nuclear layer in persistent (01)01427-1
central serous chorioretinopathy [5]. In our study, we 2. Wolfensberger TJ (2004) Foveal reattachment after macula-off
showed that persistent subretinal fluid after scleral buckling retinal detachment occurs faster after vitrectomy than after buckle
surgery. Ophthalmology 111:1340–1343. doi:10.1016/j.ophtha.2003.
can be treated with injection of intravitreal gas. 12.049
After scleral buckling surgery, the visual recovery is 3. Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG
delayed occasionally, despite the appearance of retinal (2007) Optical coherence tomography analysis of the macula after
1150 Graefes Arch Clin Exp Ophthalmol (2009) 247:1147–1150

scleral buckle surgery for retinal detachment. Ophthalmology 7. Gibran SK, Alwitry A, Cleary PE (2006) Foveal detachment after
114:108–112. doi:10.1016/j.ophtha.2006.07.022 successful retinal reattachment for macula on rhegmatogenous
4. Hisatomi T, Sakamoto T, Goto Y, Yamanaka I, Oshima Y, Hata Y, retinal detachment: an ocular coherence tomography evaluation.
Ishibashi T, Inomata H, Susin SA, Kroemer G (2002) Critical role Eye 20:1284–1287. doi:10.1038/sj.eye.6702098
of photoreceptor apoptosis in functional damage after retinal 8. Otani T, Yamaguchi Y, Kishi S (2004) Serous macular detachment
detachment. Curr Eye Res 24:161–172. doi:10.1076/ceyr.24.3. secondary to distant retinal vascular disorders. Retina 24:758–762.
161.8305 doi:10.1097/00006982-200410000-00012
5. Matsumoto H, Kishi S, Otani T, Sato T (2008) Elongation of 9. Rezende FA, Kapusta MA, Burnier MN Jr, Costa RA, Scott IU
photoreceptor outer segment in central serous chorioretinopathy. (2007) Preoperative B-scan ultrasonography of the vitreoretinal
Am J Ophthalmol 145:162–168. doi:10.1016/j.ajo.2007.08.024 interface in phakic patients undergoing rhegmatogenous retinal
6. Gundry MF, Davies EW (1974) Recovery of visual acuity after detachment repair and its prognostic significance. Graefes Arch Clin
retinal detachment surgery. Am J Ophthalmol 77:310–314 Exp Ophthalmol 245:1295–1301. doi:10.1007/s00417-007-0541-5