Acta Ophthalmologica 2009

Case Report

Submacular fluid after encircling

buckle surgery for inferior
macula-off retinal detachment
in young patients
Hana Abouzeid,1 Klio Becker,2 Frank G. Holz2 and
Thomas J. Wolfensberger1
1
Jules-Gonin Eye Hospital, University of Lausanne, Switzerland
2
Department of Ophthalmology, University of Bonn, Germany

ABSTRACT. (OCT)-based studies have shown a

Purpose: Characterization of persistent diffuse subretinal fluid using optical further possible postoperative factor
coherence tomography (OCT) after successful encircling buckle surgery for characterized by long-term persistence
inferior macula-off retinal detachment in young patients. of subfoveal fluid after buckle surgery,
Methods: Institutional retrospective review of six young patients (mean age which may be associated with limited
31 ± 6 years; five female, one male) with spontaneous inferior rhegmatoge- postoperative visual acuity recovery
nous macula-off retinal detachment. All patients were treated with encircling (Wolfensberger & Gonvers 2002;
Lecleire-Collet et al. 2005). It appears
buckle surgery and five out of six underwent additional external drainage of
that this OCT phenomenon may be
subretinal fluid. Mean follow-up was 37 ± 25 months (range 17–75 months)
much less common in patients oper-
and included complete ophthalmic and OCT examination. ated on with vitrectomy (Wolfens-
Results: At 6 months, 100% of patients showed persistence of subretinal fluid berger & Gonvers 2002). The role of
on OCT. Four patients had diffuse fluid accumulation, whereas two patients residual vitreous gel and of the surgi-
showed a ‘bleb-like’ accumulation of fluid. This fluid was present independent cal technique in the creation and
of whether or not patients had been treated with external fluid drainage. Sub- maintenance of this residual fluid
retinal fluid only started to disappear on OCT between 6 and more than remains unclear to date. In order to
12 months after surgery. investigate a specific subgroup of
Conclusion: Young patients with inferior macula-off retinal detachments and a patients with a less liquefied vitreous
marginally liquefied vitreous may show persisting postoperative subclinical gel and usually subacute RD, we per-
fluid under the macula for longer periods of time than described previously. formed an OCT-based study of per-
sistent subretinal fluid after buckle
Key words: optical coherence tomography – retinal detachment – submacular fluid – surgery of surgery for inferior macula-off RD
retinal detachment with and without external fluid drain-
age in young patients.
Acta Ophthalmol. 2009: 87: 96–99
ª 2008 The Authors
Journal compilation ª 2008 Acta Ophthalmol
Materials and Methods
We studied a group of six young
doi: 10.1111/j.1755-3768.2008.01196.x
patients (five female, one male; mean
age 31 ± 6 years) who were operated
several pre- and postoperative factors on within a 2-year period for a spon-
Introduction such as preoperative visual acuity, taneous unilateral inferior macula-off
Despite successful surgery for macula- duration of the detachment, postoper- retinal detachment caused by one
off retinal detachment (RD) and total ative cystoid macular oedema and (three patients) or multiple (three
retinal reattachment on fundus exami- epiretinal membrane development patients) inferior peripheral breaks.
nation, visual recovery may remain (Abouzeid & Wolfensberger 2006). Re- All patients were phakic, four patients
incomplete. This may be caused by cently, optical coherence tomography were myopic, one was emmetropic

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 Acta Ophthalmologica 2009

Table 1. Description of patients.

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

Age (years) 30 40 33 24 32 26
Refraction
OD )4.75 )2.50 )5.50 )9.25 +2.50 0⁄0⁄0
OS )4.75 0⁄0⁄0 )6.00 )11.25 +1.25 0⁄0⁄0
Preoperative LogMAR VA 0.5 0.5 0.4 0.1 0.5 1.8
Final LogMAR VA 0.1 0.1 0 0.3 0.2 1.0
RD duration (days) 60 2 15 20 3 30
RD extension (meridian) 3:00–6:30 5:00–9:00 3:00–7:00 2:30–7:00 3:30–7:30 1:30–8:00
OCT (postoperative) Diffuse SRF ‘Bleb-like’ SRF Diffuse SRF Diffuse SRF Diffuse SRF ‘Bleb-like’ SRF
Flat retina on final OCT Yes Yes Yes Yes Yes Yes
Range of delay during which retinal 6–9 12–20 11–30 6–75 6–63 6–18
flattening on OCT occurred
(months postoperative)*
External drainage of SRF Yes Yes No Yes Yes Yes
Follow-up (months) 17 20 30 75 63 18

OD, right eye; OS, left eye; VA, visual acuity; SRF, subretinal fluid; OCT, optical coherence tomography; RD, retinal detachment.
* Time-span between second-last and last OCT examination.

and one hypermetropic (Table 1). The
mean preoperative logMAR visual
acuity was 0.63 ± 0.59 and the mean
duration of retinal detachment was
22 ± 21 days. The logMAR equiva-
lent of counting fingers visual acuity
was determined to be 1.8 according
to the visual standards resolution
adopted by the International Council
of Ophthalmology. All patients were
operated on using a 240 silicone encir-
cling band and cryotherapy; five out
of six patients underwent external
drainage of subretinal fluid. Postoper-
ative follow-up included a complete
ophthalmic examination and OCT
imaging using a cross-hair protocol
(Stratus OCT 3; Zeiss Meditec,
Dublin, CA, USA) at 6 months and
at 11 or more months after surgery.
Results
The primary postoperative retinal
reattachment rate was 100%. Mean
follow-up was 37 ± 25 months with
a range of 17–75 months. Mean
final postoperative visual acuity was
0.28 ± 0.37. Postoperative OCT
examination showed two categories of
images: four patients with a diffuse
shallow detachment of the macula
(Table 1; Fig. 1) and two patients
with a circumscribed foveal detach-
ment with residual subretinal fluid
(Table 1; Fig. 2). Both types of lesions
were not visible clinically. The elapsed
time period between the observation
of persistent retinal fluid on OCT and a
flattened retina varied from 6 to more
than 12 months (Table 1). At the end
of the follow-up period, all patients
showed an attached fovea on OCT.
Discussion
Residual subretinal fluid – visible only
on OCT – occurring after buckling
surgery for macula-off retinal detach-
ment has been reported to be present
in 55–68% of cases (Wolfensberger &
Gonvers 2002; Benson et al. 2007).
The mechanism behind these OCT
findings is still not completely clear.
Hypotheses have included retinal
redundancy (Wolfensberger & Gon-
vers 2002), reduced choroidal blood
flow, which may be induced by the
encircling buckle (Diddie & Ernest
1980, Sugawara et al. 2006), retinal
pigment epithelium (RPE) dysfunction
in the macular region (Benson et al.
2007) and residual viscous fluid, which
the RPE finds difficult to absorb
(Wolfensberger & Gonvers 2002; Ben-
son et al. 2007).
The findings of the present study
confirm a previous more generalized
observation that inferior retinal
detachments may take longer to
absorb subretinal fluid (Singh et al.
2006). Furthermore, we observed that
subretinal fluid may persist in young
patients after successful buckle surgery
for macula-off retinal detachment for
many more months than described
previously in older patients. This
persistence of fluid appears to be

(A) (B)

Fig. 1. (A) Optical coherence tomography (OCT) image of the left eye of patient 1, 1 month after inferior retinal detachment treated with buckle
surgery and external fluid drainage. Note the subfoveal hyporeflective band that extends to the edge of the image, representing a diffuse shallow
elevation of the retina. LogMAR visual acuity was 0.5. (B) OCT image 17 months after surgery showing complete reattachment of the fovea,
which occurred between 6 and 9 months after surgery. LogMAR visual acuity was 0.1.

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Acta Ophthalmologica 2009
(A)
Fig. 2. (A) Optical coherence tomography (OCT) image of patient 2, 6 months after buckle surgery and external subretinal fluid drainage for
inferior retinal detachment. Note the voluminous circumscribed subfoveal fluid accumulation corresponding to the ‘bleb-like’ subfoveal hypore-
flectivity. LogMAR visual acuity was 0.1. (B) OCT image 20 months after treatment showing complete reattachment of the fovea, which occurred
between 12 and 20 months after surgery. LogMAR visual acuity remained 0.1.
independent of whether or not exter-
nal drainage of subretinal fluid was
performed. The fact that we observed
a delay of 6 and more months after
encircling buckle surgery before the
first patient reattached the retina com-
pletely on OCT is in stark contrast
with previously published time-frames
(Wolfensberger & Gonvers 2002; Wol-
fensberger 2004). In a series of 16
patients operated on with buckle sur-
gery for macula-off RD with a much
higher mean age (54 ± 4 years) (Wol-
fensberger & Gonvers 2002), up to
44% of patients showed a flat retina
on OCT 6 months after surgery. This
observation was confirmed in a fur-
ther study (Wolfensberger & Gonvers
2002) with an even higher mean age
(65 ± 3 years) in which up to 55% of
patients had a flat retina on OCT
6 months after surgery. This suggests
a much slower rate of subretinal fluid
resorption among the presented series
of young patients with inferior RDs.
Several phenomena may explain this
observation. Firstly, young patients
have been described as having a less
liquefied and more viscous vitreous
whose absorption in the subretinal
space may take longer. Secondly, infe-
rior retinal detachments have often
been present for a long period of time
before being operated on, because
they produce a superior field defect
that is often unremarkable or not
alarming to patients. Therefore, it
appears that it is not only the localiza-
tion of the detachment per se that is
determinant but the association of
inferior RDs with a longer duration
of the detachment before the field
defect becomes clinically significant.
In our series, four out of six patients
had an RD duration of more than
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(B)
15 days. In this context, it has been
suggested that the presence of vitreous
in the subretinal space for a long per-
iod of time may cause a modification
of protein concentration and composi-
tion leading to a reduced velocity of
subretinal fluid resorption by the RPE
(Takeuchi et al. 1996). Shallow retinal
detachments can thus persist for sev-
eral months. It has also been pro-
posed that proteinases may play a
role in slower-than-normal subretinal
fluid resorption, because these
enzymes may contribute to RPE cell
migration into subretinal fluid (Immo-
nen et al. 1996) and this may delay
fluid resorption by impeding RPE and
blood–retinal barrier integrity.
It could be argued that the
described OCT findings are caused
exclusively by the inferior location of
often long-standing retinal detachment
and that they are not causally linked
to the young age of the patients
(Singh et al. 2006). However, an anal-
ysis of a subgroup within a previously
published series (Wolfensberger &
Gonvers 2002) shows that 100% of
young patients with superior retinal
detachments also have postoperative
subfoveal fluid on OCT at 1 month
postoperatively. This is in contrast to
the findings in older subjects with
superior RD, which showed such sub-
foveal fluid in only two thirds of all
cases at 1 month after surgery. Look-
ing at inferior retinal detachments in
the older age group of the same series
(Wolfensberger & Gonvers 2002)
showed that up to half of the older
patients present a completely flat
fovea on OCT at 1 month postopera-
tively. In a recent series with 98
patients, Benson et al. (2007) found
subclinical fluid on OCT after buckle
surgery in 55% of patients with an
age range of 20–73 years. However,
no particular subgroups of young
patients or patients with inferior reti-
nal detachment were analysed in detail
in this particular study.
In summary, our series of patients
shows that young individuals with infe-
rior macula-off retinal detachments
may show persisting postoperative sub-
clinical fluid under the macula for much
longer periods of time than described
previously in older patients. Whether
this persisting fluid has a direct effect
on postoperative visual acuity recovery
is still a matter of debate.
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 Acta Ophthalmologica 2009

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