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Macular Hole Eruption after Pars Plana Vitrectomy
Journal of Clinical and Experimental Ophthalmology

Journal of Clinical and Experimental Ophthalmology
Open Access

ISSN: 2155-9570

+44 1223 790975

Case Report - (2015) Volume 6, Issue 1

Macular Hole Eruption after Pars Plana Vitrectomy

Emily Gosse1, Jonathan Lochhead2* and Paul Rainsbury3
1Department of Ophthalmology, Nottingham University Hospitals, Nottingham, Notts, UK
2Department of Ophthalmology, St. Mary’s Hospital, Parkhurst Rd, Newport, Isle of Wight, UK
3Department of Ophthalmology, Queen Alexandra Hospital, Portsmouth, Hants, UK
*Corresponding Author: Jonathan Lochhead, Department of Ophthalmology, Queen Alexandra Hospital, Portsmouth Hants, UK, Tel: 0044 23 9228 6000, Fax: 00441962712145 Email:

Abstract

Macular hole eruption is a previously unreported complication of vitrectomy for full thickness macular hole (FTMH) repair.

Keywords: Macular hole; Plana vitrectomy; FTMH repair

Case Report

An 83 year old male presented with a full thickness macular hole. The visual acuity was 6/24 in the right eye, measured using a standard 6 m Snellen chart. A standard 25-Gauge 3-port (non-valved) pars plana vitrectomy, internal limiting membrane (ILM) peel and gas tamponade was performed on the right eye (Figure 1A). The procedure was performed using the Alcon Constellation system, with the infusion pressure set at 25-35 mmHg throughout the procedure. This machine incorporates an automated IOP stabilisation system, which significantly reduces fluctuations in intraocular pressure perioperatively. After vitrectomy the ILM was stained with Dual Blue dye (under fluid). Peeling of the ILM was then commenced, without any adjustment of the IOP setting of the vitrectomy machine. During the peel stage, irrigation fluid surged from the infusion port following removal of the ILM forceps, resulting in a jet of fluid directly entering the macular hole, causing it to visibly erupt. On re-inserting the forceps the flow of fluid through the eye was stabilised.

clinical-ophthalmology-outer-retina

Figure 1: Preoperative (A) and postoperative (B) OCT scans. Postoperatively the macular hole closed, but significant disruption of the ellipsoid zone of the outer retina resulted in no improvement in visual acuity compared to preoperatively.

The FTMH was noted to have torn inferiorly and superiorly and a small area of localised retinal detachment was noted around the hole (Figure 2A and B). The ILM peeling was then carefully completed with removal of approximately 2 disc diameters of ILM from around the centre of the macular hole (see supplementary online video), followed by routine fluid/air/gas (C3F8 18%) exchange. No additional procedures were required for the localised retinal detachment which flattened with the intraocular gas tamponade. Postoperatively the FTMH closed (Figure 1B) and the patient achieved 6/24 vision.

clinical-ophthalmology-Macular-hole

Figure 2: Macular hole torn inferiorly and superiorly (A). Changes outlined (B); black lines showing localised retinal detachment, white lines showing tears, grey line showing original extent of macular hole.

Comment

Position and angle of infusion cannula during vitrectomy is known to be an important factor in intraoperative complications such as serous retinal detachment and choroidal haemorrhage [1,2]. More specifically during macular hole surgery there is evidence that FAX can be associated with visual field defects corresponding with the position and direction of this cannula [3-5].

We routinely use valved 25-Gauge vitrectomy trochars. Since valved trocars were unavailable on this occasion, a 25-Guage non-valved system was used. The valved system allows irrigation into, but not out of, the eye (Figure 3A). Fluid influx is therefore controlled by the vitrectomy machine. With non-valved systems fluid can freely exit the eye following removal of instruments, until a plug is inserted into the ports. If the ports are left open, fluid can continuously flow through the eye. The infusion rate in this case was set at 25-35 mmHg. We believe that this port was angled steeply, allowing a jet of Balanced Salt Solution (BSS) to be inadvertently aimed directly at the macular hole (Figure 3B). In this case the macular hole eruption occurred after staining the ILM in a BSS filled eye. Some surgeons however, stain the ILM in an air-filled eye to avoid dye dispersion, allowing a better stain. If this additional step is performed, a further air/fluid exchange is required to remove the dye before ILM peeling. Other authors have reported retinal damage during this air/fluid exchange [6], however to the best of our knowledge, this is the first time retinal damage has been reported in a BSS filled eye.

clinical-ophthalmology-outer-retina

Figure 3: Valved vitrectomy ports regulate fluid entry into the eye (A). Valveless ports do not, and high pressure fluid may therefore enter the macular hole if the cannula is directed steeply (B).

Whilst non-valved trocars are commonly used worldwide, this appears to be a rare complication. We feel that it was the combination of a sudden surge of infusion fluid in a non-valved system that was responsible for this complication, and that the use of non-valved cannulas on their own without a surge of fluid is unlikely to result in this problem. We would like to highlight this potential complication to surgeons using non-valved vitrectomy ports during macular hole surgery. We suggest consciously directing the infusion port during set up, away from the macula towards the nasal retina.

Conflict of Interest

The authors declare no conflict of interest. The data has been presented at the British and Eira Association of Vitreoretinal Surgeons annual conference in 2013.

References

  1. Tarantola RM, Folk JC, Shah SS, Boldt HC, Abràmoff MD et al. (2011) Intraoperative choroidal detachment during 23-gauge vitrectomy. Retina 31:893-901.
  2. Thompson JT (2011) Advantages and limitations of small gauge vitrectomy. Surv Ophthalmol 56:162-172.
  3. Hirata A, Yonemura N, Hasumura T, Murata Y, Negi A (2000) Effect of infusion air pressure on visual field defects after macular hole surgery. Am J Ophthalmol 130:611-616.
  4. Welch JC (1997) Dehydration injury as a possible cause of visual field defect after pars plana vitrectomy for macular hole. Am J Ophthalmol 124: 698-699.
  5. Ohji M, Nao-I N, Saito Y, Hayashi A, Tano Y (1999) Prevention of visual field defect after macular hole surgery by passing air used for fluid-air exchange through water. Am J Ophthalmol 127:62-66.
  6. Yang SS, McDonald HR, Everett AI, Johnson RN, Jumper JM et al. (2006)Retinal damage caused by air-fluid exchange during pars plana vitrectomy. Retina. 26:334-338.
Citation: Gosse E, Lochhead J, Rainsbury P (2015) Macular Hole Eruption after Pars Plana Vitrectomy. J Clin Exp Ophthalmol 6:389.

Copyright: © 2015 Rainsbury P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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