Spectral domain OCT used to view and quantify choroidal vascular congestion in new subretinal fluid following scleral buckling.

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1 Spectral domain OCT used to view and quantify choroidal vascular congestion in new subretinal fluid following scleral buckling. Robert Gizicki MD, Mohamed Haji, Flavio Rezende Retina Service, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada Introduction Known complications of scleral buckling surgery for primary rhegmatogenous retinal detachment include choroidal detachment, vortex vein compression, cystoid macular edema and anterior segment ischemia. Post-operative persistent subretinal fluid following scleral buckling surgery is thought to occur in as many as 55% of cases. Likely mechanisms include impaired RPE function, altered subretinal fluid composition, choroidal ischemia, incomplete drainage of subretinal fluid and altered choroidal blood flow. ICG angiography, laser Doppler velocimetry and scanning laser Doppler flowmetry have showed altered choroidal blood flow, pulsatile ocular blood flow and choroidal venous drainage after scleral buckling. Presenting History and Exam 16 year old female, myopic (OD -4.00, OS -4.75), presented with chronic inferotemporal retinal detachment OS with two small holes in the 5h30 meridian. BCVA was OD 20/20, OS 20/50 (PH 20/25). Macula was not detached. There was mild vitreous hemorrhage. IOP was within normal limits. She underwent scleral buckling under general anesthesia 3 weeks later. No per-operative complications were noted. Post-operative course 1 week post-op, new submacular fluid was clinically visible. Spectral domain OCT confirmed confluent subretinal fluid, and showed increased choroidal thickness (reference OD: 205 µm) and significant vascular congestion. Both decreased parallelly over time. (Figure A-D) Final BCVA was OS 20/25. Case Relevance Discussion SD-OCT is a valid, reliable and non-invasive tool to measure choroidal thickness. Previous time domain OCT technology did not permit to adequately assess choroidal thickness. The incidence of persistent subretinal fluid following scleral buckling has been reported as being as high as 55% and can persist for several months. The appearance or persistence of subretinal fluid post-operatively could be in part caused by vascular congestion. Increased choroidal vascular resistance and decreased venous drainage are contributing factors. Both seem to normalize over time following vascular redistribution. Choroidal vascular congestion and increased choroidal thickness has been linked to subretinal fluid in cases of central serous chorioretinopathy, nanophthalmos, idiopathic uveal syndrome and impaired retinal pigment epithelium function in the experimental animal model. Conclusions New subretinal fluid following scleral buckling surgery can be caused by choroidal congestion induced by the encircling silicone band. Spectral domain OCT can be used to evaluate choroidal vascular changes following scleral buckling surgery. Vascular redistribution occurs over the coming weeks to months, with resorption of subretinal fluid and concomitant normalization of choroidal thickness and vascular caliber. In most cases, visual acuity is ultimately restored. Recognition of this process is important for the understanding of an unusual post-operative course and for patient counseling for scleral buckling surgery. References 1. We describe a case of new submacular fluid accumulation following scleral buckling for a macula on retinal detachment. Whereas similar cases have been described in the past, in this case, we used spectral domain OCT (Cirrus HD-OCT, software , Carl Zeiss Meditec Inc, Dublin, CA) to evaluate and track changes in choroidal vasculature. 2. Conclusions A. Post-op 1 week B. Post-op 6 weeks Specifically, we examined choroidal thickness and the caliber of the choroidal vasculature C. Post-op 22 weeks D. Post-op 38 weeks Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG. Optical coherence tomography analysis of the macula after scleral buckle surgery for retinal detachment. Ophthalmology 2007;114: 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;240:85-9 Theodossiadis PG, Georgalas IG, Emfietzoglou J, et al. Optical coherence tomography findings in the macula after treatment of rhegmatogenous retinal detachments with spared macula preoperatively. Retina 2003;23:69-75 Takahashi K, Kishi S. Remodeling of choroidal venous drainage after vortex vein occlusion following scleral buckling for retinal detachment. Am J Ophthalmol 2000;129: Seo JH, Woo SJ, Park KH, Yu YS, Chung H. Influence of persistent submacular fluid on visual outcome after successful scleral buckle surgery for macula-off retinal detachment. Am J Ophthalmol 2008;145: Veckeneer M, Derycke L, Lindstedt EW, et al. Persistent subretinal fluid after surgery for rhegmatogenous retinal detachment: hypothesis and review. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie Sugawara R, Nagaoka T, Kitaya N, et al. Choroidal blood flow in the foveal region in eyes with rhegmatogenous retinal detachment and scleral buckling procedures. Br J Ophthalmol 2006;90: Branchini L, Regatieri CV, Flores-Moreno I, Baumann B, Fujimoto JG, Duker JS. Reproducibility of choroidal thickness measurements across three spectral domain optical coherence tomography systems. Ophthalmology 2012;119:

2 Introduction We describe a case of new submacular subretinal fluid following scleral buckling. Whereas similar cases have been described in the past, in this case, we used spectral domain OCT (Cirrus HD-OCT, software , Carl Zeiss Meditec Inc, Dublin, CA) to evaluate and track changes in choroidal vasculature. Specifically, we examined choroidal thickness and the caliber of the choroidal vasculature.

3 Case Description Ü 16 year old female, myopic (OD -4.00, OS -4.75), presented with chronic infero-temporal retinal detachment OS with two small holes in the 5h30 meridian. BCVA was OD 20/20, OS 20/50 (PH 20/25). Macula was not detached. There was mild vitreous hemorrhage. IOP was within normal limits. She underwent scleral buckling under general anesthesia 3 weeks later. No per-operative complications were noted 1 week post-op, new submacular fluid was clinically visible. Spectral domain OCT confirmed confluent subretinal fluid, and showed increased choroidal thickness (reference OD: 205 µm) and significant vascular congestion. Both decreased parallelly over time. (Figure A-D) Final BCVA was OS 20/25.

4 Post-operative Course Choroidal thickness A. Post-op 1 week B. Post-op 6 weeks C. Post-op 22 weeks D. Post-op 38 weeks

5 Discussion SD-OCT is a valid, reliable and non-invasive tool to measure choroidal thickness. Previous time domain OCT technology did not permit to adequately assess choroidal thickness. The incidence of persistent subretinal fluid following scleral buckling has been reported as being as high as 55% and can persist for several months. The appearance or persistence of subretinal fluid postoperatively could be in part caused by vascular congestion. Increased choroidal vascular resistance and decreased venous drainage are contributing factors. Both seem to normalize over time following vascular redistribution. Choroidal vascular congestion and increased choroidal thickness has been linked to subretinal fluid in cases of central serous chorioretinopathy, nanophthalmos, idiopathic uveal syndrome and impaired retinal pigment epithelium function in the experimental animal model.

6 Conclusion New subretinal fluid following scleral buckling surgery can be caused by choroidal congestion induced by the encircling silicone band. Spectral domain OCT can be used to evaluate choroidal vascular changes following scleral buckling surgery. Vascular redistribution occurs over the coming weeks to months, with resorption of subretinal fluid and concomitant normalization of choroidal thickness and vascular caliber. In most cases, visual acuity is ultimately restored. Recognition of this process is important for the understanding of an unusual post-operative course and for patient counseling for scleral buckling surgery.

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