Resolution of the hole-related subclinical retinal detachment following barrage and sectorial laser photocoagulation in ischemic branch retinal vein occlusion

OpenAlex İngilizce

Branch retinal vein occlusion (BRVO) is the second most common vascular disease affecting the posterior segment of the eye following diabetic retinopathy.[1] Retinal breaks related to rhegmatogenous with or without tractional retinal detachment are rarely encountered in association with BRVO when compared to more frequent sight-threatening complications such as macular edema, epiretinal membrane, retinal neovascularization, vitreous hemorrhage, and rubeosis iridis.[2] Moreover, the adhesion status of the posterior vitreous cortex and related vitreomacular interface abnormalities have been suggested among the causes of BRVO formation.[1] We described a case having the ischemic type of superior BRVO characterized by a traction-induced subclinical retinal detachment and illustrated the almost total resolution of the subretinal fluid following the administration of sectorial laser photocoagulation performed at two sessions. A 51-year-old woman was examined with a mild visual disturbance in her left eye enduring for approximately a year. She had diabetes mellitus and essential systemic hypertension for four years and had been on oral antidiabetic and antihypertensive drugs. Uncorrected Snellen’s visual acuity was 10/10 bilaterally. Slit-lamp examination was unremarkable in both eyes, and intraocular pressure was 16 mmHg with Goldmann applanation tonometry OU. While dilated fundus examination revealed no abnormalities in the right eye, there was a mild vitreomacular surface irregularity, a few dot-blot hemorrhages, ghost vessels, and a localized retinal detachment measuring approximately 4-disc diameter over the superior temporal vascular arcade with no signs of diabetic retinopathy [Figure 1a]. Fundus autofluorescence imaging (Heidelberg Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the left eye demonstrated the detached region as the localized, well-demarcated hypoautofluorescent area with some hyperautofluorescent dots in it [Figure 1b]. Fluorescein angiography (Heidelberg Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the left eye exhibited extensive nonperfused area at the superotemporal macula with some collateral vessels [Figure 2a]. Concurrently, large areas of ischemia were observed on superficial and deep capillary plexus slabs of 12 × 12 optical coherence tomography (OCT) angiography (Triton, Topcon Inc., Oakland, New Jersey, USA) [Figure 2b]. On spectral-domain OCT (Heidelberg Spectralis, Heidelberg Engineering, Heidelberg, Germany), the left foveal contour was relatively normal only with subtle vitreomacular surface abnormality [Figure 3a], but the OCT section passing through the detached retina depicted a meaningful amount of subretinal fluid and a full-thickness hole related to the existing traction [Figure 3b].Figure 1: Left eye, at admission. Color fundus image (a) demonstrating a few dot-blot hemorrhages (red arrow), ghost vessels, and a localized retinal detachment (blue arrows). Corresponding fundus autofluorescence image (b) revealing the well-demarcated hypoautofluorescent area with some hyperautofluorescent dotsFigure 2: Left eye, at admission. Fluorescein angiogram (a) and superficial capillary plexus slab of 12 × 12 optical coherence tomography angiography (b) revealing the extensive nonperfused area at the superotemporal macula with some collateral vesselsFigure 3: Left eye, at admission. Spectral-domain optical coherence tomographic sections. Foveal contour was relatively normal only with a subtle vitreomacular surface abnormality (a); there was a considerable amount of subretinal fluid and a full-thickness hole related to the tractional forces (b)The diagnosis of hole-related subclinical retinal detachment in the setting of ischemic type of BRVO was reached out. The detached area was surrounded by barrage, and sectorial laser photocoagulation was also administered all over the ischemic retina avoiding the collaterals to reduce the risk of additional vitreoretinal traction-related complications. A short course of prednisolone acetate and nepafenac drops were given following the procedure. One month later, there was a significant reduction of the subretinal fluid with a partial resolution of the retinal detachment. The recently attached area bordering the hole was photocoagulated. Two months after the initial laser treatment, left visual acuity was still 10/10. No changes were observed in the anterior segment of the left eye. Left intraocular pressure was within normal limits. Fundus examination of the treated left eye showed that laser scars were evident, and the size of the detachment area was shrunken [Figure 4a and b]. While the appearance of the left fovea looked unchanged [Figure 5a]; an OCT scan passing through the hole showed that there was almost a near-total closure of the full-thickness hole with some residual fluid [Figure 5b].Figure 4: Left eye, at the last visit. Color fundus picture (a) demonstrating the laser scars and fundus autofluorescence image (b) depicting the shrunken detachment areaFigure 5: Left eye, at the last visit. The appearance of the fovea was unchanged (a) and almost a near-total closure of the full-thickness hole with significantly reduced subretinal fluid (b) was seen on optical coherence tomographic sectionsRetinal breaks and retinal detachment following the BRVO are rarely observed. In a study involving 358 BRVO patients by Joondeph and Joondeph,[2] the incidence of posterior tractional break and rhegmatogenous retinal detachment was reported as 1.6% and 0.6%, respectively. In another publication, Kir et al.[3] evaluated 230 eyes of 214 patients with BRVO and reported a 3% incidence of retinal breaks and a 1.3% incidence of rhegmatogenous retinal detachment. Vitreoretinal traction was incriminated by many authors in the pathogenesis of BRVO-associated retinal breaks and detachment.[1,4] Moreover, Ascaso et al.[1] documented the presence of vitreovascular traction at the occlusion site in 25% of BRVO cases using spectral-domain OCT and suggested that the attached posterior vitreous cortex might play a role in the BRVO formation. Two types of BRVO-associated retinal breaks have been described: holes without any traction and tears with vitreous traction with or without accompanying retinal neovascular component.[2] Gutman and Zegarra[4] emphasized that the ischemic and atrophic changes in the distribution of an occluded vein might have increased the vulnerability of the retina to vitreoretinal traction. Therefore, the occurrence of traction-related retinal breaks in the absence of concurrent retinal neovascularization might be more common than previously anticipated, especially in cases with the ischemic type of BRVO.[3] Treatment options for rhegmatogenous retinal detachment associated with BRVO include scleral buckling, pars plana vitrectomy with or without endotamponade, and barrier laser photocoagulation for the subclinical detachment with retinal tears.[3] Ilhan et al.[5] evaluated six patients with rhegmatogenous retinal detachment associated with BRVO and reported a 66.7% anatomic success rate (two patients were treated with scleral buckling only and the remaining four, pars plana vitrectomy with scleral buckling). All retinal breaks were located posteriorly; therefore, they concluded that vitrectomy techniques might be required for the cases with rhegmatogenous retinal detachment in eyes with BRVO. Most notingly, when the retinal breaks are detected early as it was evident in our case, laser photocoagulation may be sufficient to achieve a treatment success and even the area of detachment may be dramatically reduced. Patients with BRVO should be closely monitored for the possible occurrence of retinal breaks and/or detachment as the retinal break formation with or without retinal detachment may be fraught with severe visual loss. Declaration of patient consent The authors have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.