Influence of Persistent Submacular Fluid on Visual Outcome After Successful Scleral Buckle Surgery for Macula-off Retinal Detachment JE HYUN SEO, SE JOON WOO, KYU HYUNG PARK, YOUNG SUK YU, AND HUM CHUNG ● PURPOSE: To determine the influences of the extent and duration of persistent submacular fluid on final visual outcome after successful scleral buckle surgery for acute macula-off rhegmatogenous retinal detachment (RD). ● DESIGN: Prospective observational case series. ● METHODS: Forty-four consecutive patients (44 eyes) who underwent successful scleral buckle surgery for macula-off rhegmatogenous RD were enrolled patients underwent thorough ophthalmologic tests including best-corrected visual acuity (BCVA) assessments and optical coherence tomography (OCT) at one, three, six, nine, and 12 months postoperatively, until at least six months after the disappearance of subretinal fluid (SRF). Patients with persistent submacular fluid one month after surgery were assigned to group A and those without submacular fluid, to group B. In group A, patients whose submacular fluid disappeared before six months were assigned to group A1; the others, to group A2. The natural course of persistent SRF and associations between the extent and duration of SRF and postoperative BCVA were investigated. ● RESULTS: Twenty-three eyes (52.3%) were in group A and 21 eyes (47.7%) in group B. Twelve eyes (52.2%) were in group A1 and 11 eyes (47.8%) in group A2. SRF disappeared within 12 months after surgery without reoperation in all patients. No significant differences in final visual acuity (VA) were found among groups A, B, A1, and A2. Final VA was not found to be associated with SRF extent or duration. ● CONCLUSIONS: The presence and extent of submacular fluid after successful scleral buckle surgery for acute macula-off rhegmatogenous RD did not influence final VA or anatomic attachment. (Am J Ophthalmol 2008; 145:915–922. © 2008 by Elsevier Inc. All rights reserved.)
Accepted for publication Jan 7, 2008. From the Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea (J.H.S., S.J.W., Y.S.Y., H.C.); the Seoul Artificial Eye Center, Seoul National University Hospital Clinical Research Institute, Seoul, Korea (J.H.S., S.J.W., K.H.P., Y.S.Y., H.C.); and the Department of Ophthalmology, Seoul National University Bundang Hospital, Bundang, Gyeonggi-do, Korea (S.J.W., K.H.P.). Inquiries to Kyu Hyung Park, Department of Ophthalmology, Seoul National University Bundang Hospital, #300 Gumi-dong, Bundang-gu, Seongnam Gyeonggi-do 463-707, Korea; e-mail:
[email protected] 0002-9394/08/$34.00 doi:10.1016/j.ajo.2008.01.005
©
2008 BY
R
ECENTLY, OPTICAL
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(OCT) has been successfully employed to obtain in vivo cross-sectional retinal images of 10-m resolution.1,2 OCT can detect minute amounts of residual fluid under the fovea that are quite difficult to detect using standard modalities such as binocular indirect ophthalmoscopy or slit-lamp biomicroscopy. The presence of persistent submacular fluid by OCT after successful scleral buckle surgery for retinal detachment (RD) has been reported on a number of occasions.3–11 The incidence of persistent subretinal fluid (SRF) at four to six weeks after surgery ranges from 27% to 78%. However, while some authors have proposed that persistent submacular fluid does not influence visual outcome,6,11 others have disagreed.4,5 These contradictory results may have been caused by small case numbers, nonstringent case selection, short follow-up periods, or a lack of quantification of SRF. Furthermore, concepts of final visual outcome vary among studies. Therefore, no report issued to date has provided adequate decision-making information concerning the need for additional treatment to treat persistent SRF after successful surgery. The purpose of the present study is to determine the influence of the extent and duration of SRF, after successful scleral buckle surgery for macula-off RD, on final visual outcome, which is defined as best-corrected visual acuity (BCVA) acquired at least six months after the disappearance of persistent SRF.
METHODS PATIENTS WHO UNDERWENT SCLERAL BUCKLE SURGERY
for primary acute spontaneous RD with peripheral breaks and foveal detachment at Seoul National University Bundang Hospital from May 1, 2003 to May 30, 2006 were recruited in this study. During the study period, 124 patients received scleral buckling procedure and 73 patients underwent vitrectomy for treatment of rhegmatogenous RD. Of the 124 patients who received primary scleral buckling procedure, 80 patients who did not meet the enrollment criteria were excluded. Fortyfour eyes of 44 consecutive patients were finally in-
ELSEVIER INC. ALL
RIGHTS RESERVED.
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FIGURE 1. Measurement of the extent of persistent subretinal fluid (SRF) after successful scleral buckle surgery for macula-off retinal detachment (RD). (Top) SRF heights were measured using “Caliper length” in StratusOCT. (Bottom) SRF areas were determined using the method described by VanRoekel and associates12: SRF areas were outlined using the Lasso tool in Adobe Photoshop v. 7.0 and the total number of pixels in SRF areas were obtained from software-produced histograms. In the case shown, the pixel number was 10,119 (scan length 4 mm), which was equivalent to an area of 10,624.95 m2.
cluded in this study. One experienced retinal surgeon (P.K.H.) performed all scleral buckle surgeries. Inclusion criteria were: 1) patients with symptoms of acute onset (within seven days) and an early postoperative course of successful retinal reattachment; 2) patients who completed a follow-up examination at least six months postoperatively; and 3) patients with persistent SRF under the macula who were followed for at least six months after complete SRF disappearance. Exclusion criteria were: 1) patients who underwent immediate reoperation attributable to failed scleral buckle surgery; 2) patients with a trauma history; 3) those with a preexisting macular pathology, such as age-related macular degeneration, macular hole, or macular edema; 4) patients with a condition likely to influence retinal flattening after RD surgery, such as proliferative vitreoretinopathy, epiretinal membrane, vitreomacular traction syndrome, and combined traction 916
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detachment attributable to diabetes; 5) patients with uveitis, glaucoma, or retinal vascular occlusive diseases; 6) patients who did not cooperate at the time of OCT; and 7) patients with a history of ocular surgery, other than an uncomplicated cataract operation. All patients underwent thorough ophthalmologic examinations including BCVA (according to the Snellen VA chart), binocular indirect ophthalmoscopy, fundus photography using a digital fundus camera (Model CF50UVi; Canon Inc, Utsunimiya, Japan), and OCT (Stratus OCT; Carl Zeiss Ophthalmic System, Dublin, California, USA) at one month postoperatively and at intervals of three months up to 15 months postoperatively. OCT was performed by one experienced technician. When fixation was problematic, an external fixator was used, and scans were repeated until good fixation was obtained. Only OCT images with signal strengths of OF
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TABLE 1. Demographic and Clinical Characteristics of Patients in Groups A and B who Underwent Scleral Buckle Surgery for Macula-off Rhegmatogenous Retinal Detachment
Age (years) Gender, male (%) Laterality, right eye (%) Preoperative BCVA (logMAR) Preoperative IOP Refractive error Follow-up period (months) Duration of symptoms (days) Break numbers Type of detachment Tear Hole Dialysis Clock hours of detachment 1 to 3 4 to 6 7 to 9 10 to 12 Location of RD Superior Inferior External SRFD Phakic status Phakia (%)
Group A (n ⫽ 23)
Group B (n ⫽ 21)
P value*
43.6 ⫾ 16.5 56.5
37.7 ⫾ 16.3 52.3
.234 .789
60.8
52.3
.578
0.94 ⫾ 0.59 12.5 ⫾ 3.4 ⫺3.5 ⫾ 3.9
0.90 ⫾ 0.57 11.4 ⫾ 3.6 ⫺2.5 ⫾ 3.1
.813 .307 .327
14.9 ⫾ 7.5
14. 7 ⫾ 7.2
.830
4.3 ⫾ 2.6 1.7 ⫾ 1.0
4.1 ⫾ 2.3 1.9 ⫾ 0.6
.731 .586 .746
13 9 0
14 6 1
1 18 2 2
1 13 3 4
8 (34.7%) 8 (34.7%) 3 (13.04%)
4 (19.0%) 7 (33.3%) 1 (4.76%)
.251 .917 .351
85.7
.087
.281
100
BCVA ⫽ best-corrected visual acuity; IOP ⫽ intraocular pressure; RD ⫽ retinal detachment; SRF ⫽ subretinal fluid; SRFD ⫽ subretinal fluid drainage. Continuous data are presented as means ⫾ standard deviations. Group A: Persistent SRF one month after scleral buckle surgery. Group B: No persistent SRF one month after scleral buckle surgery. *P value by Independent t test, Chi-square test, and Fisher exact test.
ⱖ5 were accepted for analysis. When an OCT image showed persistent SRF postoperatively, the maximal height of foveal detachment was measured by OCT using a caliper in “retinal thickness analysis mode.” SRF areas were determined by calculating the pixel numbers of localized SRF images using Photoshop 7.0 (Adobe Systems Inc, San Jose, California, USA), as described by VanRoekel and associates (Figure 1).12 In brief, SRF areas were outlined using the Lasso tool in the Adobe VOL. 145, NO. 5
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FIGURE 2. A survival graph of persistent SRF in all 44 patients after scleral buckle surgery for macula-off rhegmatogenous RD. At one month, 23 (52.2%) of patients had persistent SRF; at three months, 18 eyes (40.9%); at six months, 11 eyes (25%); at nine months, six eyes (13.6%) had persistent SRF.
Photoshop program and total numbers of pixels in the SRF area were obtained from software-produced histograms. Pixel numbers were converted into areas (m2). Patients were classified into two groups according to OCT findings at one month postoperatively; those who showed persistent SRF by OCT were assigned to group A and those who showed no SRF and an attached macula were assigned to group B. We further subdivided group A into subgroups A1 and A2 according to the duration of SRF; that is, A1, one month ⱕ SRF duration ⬍ six months; A2, six months ⱕ SRF duration ⬍ 12 months. For groups A1 and A2, we continued with follow-up for at least six months after SRF disappeared. Final visual acuity (VA) was defined as VA at least six months after SRF disappearance. We considered it reasonable to assume that VA would not change significantly six months after the disappearance of SRF. Correlations between the extent of SRF and postoperative BCVA were analyzed using the Pearson correlation test. To determine the effect of SRF duration on VA, we compared the final BCVA values of groups A (A1, A2) and B using the t test and one-way analysis of variance (ANOVA). To compare the clinical features of groups, parametric and nonparametric tests of significance were performed when appropriate. Continuous data are presented as means ⫾ standard deviations. Results were taken to be statistically significant when P values were ⬍ .05;
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FIGURE 3. Serial changes of SRF heights and areas in patients showing persistent SRF till one month (Top, n ⴝ 5), three months (Upper middle, n ⴝ 7), six months (Lower middle, n ⴝ 5), and nine months (Bottom, n ⴝ 6) after scleral buckle surgery for macula-off rhegmatogenous RD.
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TABLE 2. Comparisons of Preoperative and Postoperative Best-Corrected Visual Acuities (Logarithm of the Minimum Angle of Resolution Scale) Among Study Groups who Underwent Scleral Buckle Surgery for Macula-off Rhegmatogenous Retinal Detachment Preoperative
1 mo
3 mos
6 mos
9 mos
12 mos
Final
Group A (n ⫽ 23)
0.94 ⫾ 0.59
0.53 ⫾ 0.32
0.37 ⫾ 0.26
0.32 ⫾ 0.22
0.29 ⫾ 0.21
0.29 ⫾ 0.19
0.22 ⫾ 0.16
Group A1 (n ⫽ 12)
0.64 ⫾ 0.53
0.58 ⫾ 0.38
0.36 ⫾ 0.28
0.35 ⫾ 0.26
0.27 ⫾ 0.23
0.33 ⫾ 0.29
0.20 ⫾ 0.18
Group A2 (n ⫽ 11)
1.26 ⫾ 0.49
0.47 ⫾ 0.25
0.38 ⫾ 0.26
0.27 ⫾ 0.23
0.32 ⫾ 0.20
0.25 ⫾ 0.13
0.25 ⫾ 0.13
A1 vs A2 (P value)*
.007
.437
.885
.530
.570
.365
.499
Group B (n ⫽ 21)
0.90 ⫾ 0.57
0.58 ⫾ 0.38
0.34 ⫾ 0.32
0.21 ⫾ 0.20
0.18 ⫾ 0.17
0.18 ⫾ 0.17
0.18 ⫾ 0.17
A vs B (P value)*
.813
.651
.733
.111
.063
.053
.416
A1 vs A2 vs B (P value)†
.131
.612
.873
.147
.194
.163
.626
Mos ⫽ months. Values are presented as means ⫾ standard deviations. Group A: Subretinal fluid persisted at postoperative one month. Group A1: Subretinal fluid disappeared before six months. Group A2: Subretinal fluid persisted at six months and disappeared before 12 months. Group B: No subretinal fluid at postoperative one month. *Independent t test. † One-way analysis of variance (ANOVA).
P values of .05 to .07 were defined to indicate borderline significance. Statistical analyses were performed using SPSS v.12.0 software (SPSS Inc, Chicago, Illinois, USA).
RESULTS FORTY-FOUR EYES OF 44 CONSECUTIVE PATIENTS WERE
included in this study. There were 20 male patients (45.5%) and 24 female patients (54.5%), with ages ranging from 13 to 73 years (40.8 ⫾ 16.5). The mean follow-up period was 14.7 months. Descriptive statistics for the clinical characteristics of groups A and B are presented in Table 1. There were no statistically significant differences between these two group in terms of clinical features of preoperative BCVA (logarithm of the minimum angle of resolution [logMAR], 0.94 ⫾ 0.59 in group A and 0.90 ⫾ 0.57 in group B; P ⫽ .813). Figure 2 presents a survival graph of persistent SRF in all patients during follow-up. At one month postoperatively, 23 of the 44 eyes (52.3%, group A) showed subfoveal SRF on OCT, and in 12 of these eyes (52.2%, group A1) SRF disappeared before six months postoperatively, whereas SRF disappeared in the other 11 eyes (47.8%, group A2) between six and 12 months postoperatively. In all patients, SRF disappeared before 12 months postoperatively without reoperation. Temporal changes in SRF height and area are illustrated in Figure 3. VOL. 145, NO. 5
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FIGURE 4. A scatter plot showing preoperative and postoperative best-corrected visual acuities (BCVAs, logarithm of the minimum angle of resolution [logMAR]) after scleral buckle surgery for macula-off RD. In most patients, postoperative visual acuities (VAs) were better than preoperative VAs in all groups. (Group A) Persistent SRF one month after scleral buckle surgery. (Group A1) SRF disappeared before six months postoperatively. (Group A2) SRF disappeared between six and 12 months postoperatively. (Group B) No SRF one month after scleral buckle surgery.
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FIGURE 5. Serial changes of BCVAs and logMAR before and after scleral buckle surgery for macula-off RD. BCVAs were measured preoperatively and postoperatively at one, three, six, nine, 12, and final months of follow-up in groups A and B (Left) and in groups A1 and A2 (Right). Final BCVAs were not significantly different between the groups. (Group A) SRF persisted at postoperative one month. (Group A1) SRF disappeared before six months postoperatively. (Group A2) SRF disappeared between six and 12 months postoperatively. (Group B) No SRF at postoperative one month.
TABLE 3. Correlations Between Postoperative Best-Corrected Visual Acuities and Extent (Areas and Heights) of Persistent Subretinal Fluid at Each Follow-up Period After Scleral Buckle Surgery for Macula-off Rhegmatogenous Retinal Detachment
1-month SRF area 1-month SRF height 3-months SRF area 3-months SRF height
1 mo VA
3 mos VA
6 mos VA
9 mos VA
12 mos VA
Final VA
r ⫽ 0.21 P ⫽ .331 r ⫽ 0.20 P ⫽ .370
r ⫽ 0.31 P ⫽ .157 r ⫽ 0.40 P ⴝ .067* r ⫽ 0.40 P ⫽ .115 r ⫽ 0.56 P ⴝ .018†
r ⫽ 0.34 P ⫽ .115 r ⫽ 0.41 P ⴝ .052* r ⫽ 0.35 P ⫽ .153 r ⫽ 0.44 P ⴝ .071* r ⫽ 0.44 P ⫽ .153 r ⫽ 0.55 P ⴝ .063*
r ⫽ 0.11 P ⫽ .634 r ⫽ 0.30 P ⫽ .171 r ⫽ 0.11 P ⫽ .668 r ⫽ 0.27 P ⫽ .285 r ⫽ 0.35 P ⫽ .262 r ⫽ 0.49 P ⫽ .104
r ⫽ ⫺0.54 P ⫽ .806 r ⫽ 0.14 P ⫽ .518 r ⫽ ⫺0.83 P ⫽ .744 r ⫽ 0.07 P ⫽ .789 r ⫽ 0.10 P ⫽ .752 r ⫽ 0.24 P ⫽ .462
r ⫽ 0.007 P ⫽ .976 r ⫽ 0.02 P ⫽ .924 r ⫽ 0.06 P ⫽ .818 r ⫽ 0.21 P ⫽ .402 r ⫽ 0.18 P ⫽ .577 r ⫽ 0.41 P ⫽ .190
6-months SRF area 6-months SRF height
Mos ⫽ months; SRF ⫽ subretinal fluid; VA ⫽ visual acuity. P value by Pearson correlation test; r ⫽ correlation coefficient. *P value ⱕ .07, ⱖ .05 with borderline significance. † P value ⬍ .05 with significance.
SRF heights were relatively stable at approximately 100 m until SRF disappeared: SRF heights in patients with persistent SRF in group A were 108 ⫾ 79 m at one month, 111 ⫾ 78 m at three months, 104 ⫾ 102 m at six months, and 135 ⫾ 156 m at nine months. Mean extents of SRF at one month postoperatively were not significantly different in groups A1 and A2 (SRF height, 98 ⫾ 59 m in group A1 and 117 ⫾ 99 m in group A2 [P ⫽ .833, Mann–Whitney U test]; SRF area 21,014 ⫾ 22,025 m2 in group A1 and 21,397 ⫾ 44,621 m2 in group A2 [P ⫽ .211, Mann–Whitney U test]). After scleral buckle surgery, a significant improvement in BCVA was observed in groups A and B (Table 2; 920
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Figures 4 and 5). In most patients, postoperative VAs were better than preoperative VAs in all groups. The BCVAs at one, three, and six months were not significantly different in these two groups, whereas group B had marginally better BCVA at nine and 12 months than group A (P ⫽ .063 and P ⫽ .053, respectively). However, final BCVAs were not significantly different (logMAR, 0.22 ⫾ 0.16 for group A vs 0.18 ⫾ 0.17 for group B; P ⫽ .416). For groups A1 and A2, preoperative BCVAs were significantly different (logMAR, 0.64 ⫾ 0.53 in group A1 vs 1.26 ⫾ 0.49 in group A2; P ⫽ .007). However, the final BCVAs were not different (logMAR, 0.20 ⫾ 0.18 in group A1 vs 0.25 ⫾ 0.13 in group A2; P ⫽ .499). OF
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We cannot find any association between final VA and SRF extent (maximal height and area) at the fovea by OCT in group A at one month postoperatively (P ⫽ .924 for SRF height and P ⫽ .976 for SRF area; Table 3). However, SRF height at one month was found to be marginally correlated with BCVA at three months (P ⫽ .067) and six months (P ⫽ .052). The following were found to be significantly or marginally related: SRF height and BCVA at three months (P ⫽ .018); SRF height at three months and BCVA at six months (P ⫽ .071); and SRF height with BCVA at six months (P ⫽ .063).
DISCUSSION IN THE PRESENT STUDY, WE DID NOT FIND ANY ASSOCIA-
tion between the height or area of persistent SRF and final VA. The presence and extent of persistent SRF was found to have some association with early visual outcome, but this correlation was not definite throughout the follow-up period, as shown in Figure 5; Tables 2 and 3. More subjects would be required to reveal definite correlations between the extent of persistent SRF and early visual recovery. The patients with persistent SRF showed delayed visual recovery at postoperative months nine and 12 compared to the patients with no persistent SRF, with borderline significance (Figure 5, Left). However, final VAs after complete SRF absorption did not show significant difference between these two groups. Furthermore, the SRF height at one month postoperatively was not found to be associated with time of SRF disappearance, which suggests that the presence and extent of SRF may affect visual recovery but not eventual SRF disappearance or final visual outcome. In the present study, because patients with persistent SRF had submacular detachment of less than 12 months’ duration and of approximately 100 m in height, our results suggest that persistent SRF of this type does not cause apparent photoreceptor damage or VA loss. Lecleire-Collet and associates proposed that postoperative infraclinical foveal detachment does not influence final postoperative VA, but that final VA is negatively correlated with the preoperative RD height at the fovea and with the duration of macular detachment.13 However, in this previous study, acute and chronic RDs were mixed and no information was provided about the actual time of SRF disappearance; thus, nine-months-postoperative follow-up data were inadequate in terms of determining final visual outcomes. In the recent study, which included a large number of cases of macula-on and macula-off RD, Benson and associates11 concluded that residual SRF delays visual recovery and that SRF height at six weeks does not correlate with final VA. However, median follow-up was only 4.5 months, which is too short to assess full visual recovery. Baba and associates also suggested that the presence of residual SRF does not influence visual recovery within six months after surgery,6 but visual outcomes were not thought VOL. 145, NO. 5
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to be the final ones. Thus, even though the results of the above-mentioned studies concur with those of the present study, objective comparisons between studies are not possible because of the different definitions of final visual outcome used. Based on our results regarding postoperative VA change in Figure 5, most of the visual recovery took place throughout the postoperative six months. Moreover, the patients having persistent SRF (group A) showed delayed visual recovery compared to those without persistent SRF (group B). Therefore, we suggest that to determine the visual outcome, the VAs should be checked at least six months after complete disappearance of SRF. Previous studies have also produced contrary results. Wolfensberger and associates4 reported that postoperative visual recovery of eyes with foveal detachment at one month postoperatively is poorer than that of eyes with complete foveal reattachment. However, their study was limited by small case numbers, the lack of a comparison group, no information on the extent of SRF, and a six-month postoperative follow-up, which was too short to determine final visual outcome. In the present study, we included a relatively large number of cases (44 eyes) with acute (within seven days of onset) macula-off RD and followed them for a mean of 14.7 months and more than six months after complete SRF absorption. In a study on the postoperative macular profile of RD by OCT, a postoperative lack of a junction line between photoreceptor-cell inner and outer segments was reported to be associated with poorer final VA.13 In another study on macula-off RD, disruption and loss of photoreceptor-cell outer segments were evident.14 SRF is believed to induce photoreceptor-cell outer segment damage by blocking diffusion of oxygen and nutrients, and thereby to reduce VA.15 Therefore, the definitions of the tolerable range of persistent SRF and of infraclinical foveal detachment are of considerable importance, and in part, our observation that persistent SRF of approximately 100-m height within 12 months is tolerable goes some way toward meeting a definition. However, we could not determine the upper limit of the tolerable range, which should be addressed by a large prospective randomized trial. The present study describes the incidence and the natural course of persistent SRF, as shown in Figures 2 and 3. About half of our patients with macula-off RD had persistent SRF at one month postoperatively, and half of our patients with persistent SRF at this time maintained it at six months postoperatively. However, persistent SRF disappeared in all of these patients before 12 months postoperatively, which is useful information from clinical and prognostic perspectives. To the best of our knowledge, these temporal characteristics of persistent SRF, its correlation with final visual outcome, and the tolerability shown to SRF extent and duration have not been previously reported. Preoperative VA in group A1 was better than in group A2, but no difference was observed between groups A and B. Although we do not know the reason for this finding, it
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tially adverse effects of persistent SRF. Second, no preoperative OCT information was available on macular status, which may have influenced final visual outcome. However, preoperative OCT was not usually available because of the need for an emergency operation or the bullous nature of RD. Thirdly, the onset of RD was mainly determined based on symptom onset, which introduces the possibility of bias. However, to reduce this bias, we selected patients who were able to precisely recall the time of symptom onset. Fourth, OCT was performed at threemonth intervals; thus, we were not able to determine precisely the time of SRF disappearance. In conclusion, the presence and extent of persistent submacular fluid after successful scleral buckle surgery for acute macula-off rhegmatogenous RD did not influence final VA or anatomic attachment. These findings suggest that no additional procedure may be needed to accelerate the removal of persistent SRF after a successful scleral buckling procedure.
is possible that preoperative retinal changes could be associated with the characteristics of RD and affect the natural course of persistent SRF. Preoperative OCT findings might have provided clues on this issue, but unfortunately OCT was not performed preoperatively. Some limitations of the present study should be considered. First, the BCVA, which was used as the main outcome measurement in our study, might not be enough to evaluate the detailed visual function. Experimental RD study14 showed photoreceptor apoptosis within a few days. A recent study16 using spectral domain OCT on eyes with central serous chorioretinopathy showed elongation of photoreceptor outer segments and decreased thickness of the outer nuclear layer, which was not correlated with BCVA. It might be, therefore, inadequate to evaluate the postoperative visual function only by VA. Future study using VA and other measurement of visual function such as contrast sensitivity, color vision, visual field, and multifocal electroretinogram can better evaluate other poten-
THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN CONCEPTION AND design (S.J.H., W.S.J., P.K.H., Y.S.Y., C.H.); analysis and interpretation (S.J.H., W.S.J., P.K.H.); data collection (S.J.H., W.S.J., P.K.H.); statistical expertise (S.J.H., W.S.J.); literature search (S.J.H., W.S.J., P.K.H.); technical support (S.J.H., W.S.J., P.K.H.); and preparation, review, and approval of the manuscript (S.J.H., W.S.J., P.K.H., Y.S.Y., C.H.). The Institutional Review Board of Seoul National University Bundang Hospital approved the study protocol, and all study subjects provided informed consent. All procedures used were consistent with the tenets of the Helsinki Declaration. Drs Je Hyun Seo and Se Joon Woo equally contributed to this article.
9. Gibran SK, Alwitry A, Cleary PE. Foveal detachment after successful retinal reattachment for macula on rhegmatogeneous retinal detachment: an optical coherence tomography evaluation. Eye 2006;20:1284 –1287. 10. Panazzo G, Parolini B, Mercanti A. OCT in the monitoring of visual recovery after uneventful retinal detachment surgery. Semin Ophthalmol 2003;18:82– 84. 11. Benson SE, Schlottmann PG, Bruce C, et al. Optical coherence tomography analysis of the macula after scleral buckle surgery for retinal detachment. Ophthalmology 2007; 114:108 –112. 12. VanRoekel RC, Bower KS, Burka JM, et al. Anterior segment measurements using digital photography: a simple technique. Optom Vis Sci 2006;83:391–395. 13. Lecleire-Collet A, Muraine M, Menard JF, et al. Evaluation of macular changes before and after successful retinal detachment surgery using stratus-optical coherence tomography. Am J Ophthalmol 2006;142:176 –179. 14. Mervin K, Valter K, Maslim J, et al. Limiting photoreceptor death and deconstruction during experimental retinal detachment: the value of oxygen supplementation. Am J Ophthalmol 1999;128:155–194. 15. Schocket LS, Witkin AJ, Fujimoto JS, et al. Ultrahighresolution optical coherence tomography in patients with decreased visual acuity after retinal detachment repair. Ophthalmology 2006;113:666 – 672. 16. Matsumoto H, Kishi S, Otani T, Sato T. Elongation of photoreceptor outer segment in central serous chorioretinopathy. Am J Ophthalmol 2007;145:162–168.
REFERENCES 1. Puliafito CA, Hee MR, Lin CP, et al. Imaging of macular diseases with optical coherence tomography. Ophthalmology 1995;102:217–229. 2. Fujimoto JG, Huang D, Hee MR, et al. Physical principles of optical coherence tomography. In: Schuman JS, Puliafito CA, Fujimoto JG, editors. Optical coherence tomography of ocular diseases. 2nd ed. Thorofare, New Jersey: Slack Inc, 2004:677– 698. 3. Hagimura N, Iida T, Suto K, Kishi S. Persistent foveal retina detachment after successful rhegmatogenous retinal detachment surgery. Am J Ophthalmol 2002;133:516 –520. 4. Wolfensberger TJ, Gonvers M. Optical coherence tomography in the evaluation of incomplete visual acuity recovery after macula-off retinal detachments. Graefes Arch Clin Exp Ophthalmol 2002;240:85– 89. 5. Hagimura N, Suto K, Iida T, Kishi S. Optical coherence tomography of the neurosensory retina in rhegmatogenous retinal detachment. Am J Ophthalmol 2000;129:186 –190. 6. Baba T, Hirose A, Moriyama M, Mochizuki M. Tomographic image and visual recovery of acute macula-off rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol 2004;242:576 –581. 7. Lecleire-Collet A, Muraine M, Menard JF, et al. Predictive visual outcome after macula-off retinal detachment surgery using optical coherence tomography. Retina 2005;25:44 –53. 8. Wolfensberger TJ. Foveal reattachment after macular-off retinal detachment occurs faster after vitrectomy than after buckle surgery. Ophthalmology 2004;111:1340 –1343.
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Biosketch Je Hyun Seo, MD, is a Chief Resident of Ophthalmology at Seoul National University Hospital. Dr Seo received a MD from Seoul National University College of Medicine in 2003. He completed an internship and a residency at Seoul National University Hospital in 2007. His current research interests include ocular imaging with optical coherence tomography in retinal detachment, Leber’s hereditary optic neuropathy (LHON), and Albinism.
VOL. 145, NO. 5
INFLUENCE
OF
SUBMACULAR FLUID
ON
VA
922.e1
