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| CASE REPORT |
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| Ahead of print publication |
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Subfoveal perfluorocarbon liquid droplet can be removed without puncturing the retina
Tatsuhiko Sato
Department of Ophthalmology, Hayashi Eye Hospital, Fukuoka, Japan
| Date of Submission | 13-Jan-2022 |
| Date of Acceptance | 28-Mar-2022 |
| Date of Web Publication | 27-May-2022 |
Correspondence Address:
Tatsuhiko Sato,
Hayashi Eye Hospital, 4-23-35 Hakataekimae Hakata-ku, Fukuoka 812-0011
Japan
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/tjo.tjo_22_22
Subfoveal perfluorocarbon liquid (PFL) is a vision-threatening complication that requires removal as safely as possible. We experienced a surgical case of proliferative vitreoretinopathy, in which a subfoveal PFL droplet was removed through the fovea, without puncturing the retina. In this case, although the retina was completely attached after primary vitrectomy and cataract removal, a subfoveal PFL droplet was found. At the second surgery, after peeling the internal limiting membrane, the droplet was passively aspirated by placing a 25-gauge blunt needle on the surface of the retina. This useful technique avoids puncturing the retina and does not require the patient to maintain a specific position postoperatively.
Keywords: Internal limiting membrane, perfluorocarbon, proliferative vitreoretinopathy, vitrectomy
| Introduction | |  |
Perfluorocarbon liquid (PFL) is commonly used as an intraoperative adjuvant to stabilize and/or flatten the retina in complicated vitreoretinal pathologies, such as retinal detachment with giant tear and proliferative vitreoretinopathy (PVR). Subretinal PFL is a well-known postoperative complication after PFL-assisted vitrectomy. In particular, subfoveal PFL is vision threatening and should be removed as quickly and safely as possible.
Several techniques for subfoveal PFL removal have been reported. However, some techniques could potentially harm the sensory retina as well as subretinal tissues such as the retinal pigment epithelium,[1],[2] while other techniques are cumbersome.[3] In this case report, we present a surgical case of PVR after traumatic 360° retinal dialysis, in which a subfoveal PFL droplet was removed through the fovea without involving a retinal puncture.
| Case Report | | |
A 59-year-old male patient visited our hospital for possible surgical intervention for his left eye 6 months after a traffic accident. On examination, the best-corrected visual acuity was hand motion, and his intraocular pressure was 2 mmHg. No fundus view was obtained by slit-lamp examination due to iris synechia and white cataract in this eye. B-mode ultrasound examination revealed a mass in the vitreous cavity, which was attributed to a detached retina [Figure 1]a. | Figure 1: (a) The preoperative B-mode ultrasound image showing a mass in the vitreous cavity, probably reflecting a detached retina. (b) An intraoperative image taken during the primary surgery. The retina was torn 360° at the periphery and crumpled up at the posterior pole. (c) An intraoperative image taken during the additional surgery when gas/fluid exchange was performed and the subfoveal PFL droplet was removed. Although the retina was completely attached, a subfoveal PFL droplet was noted (white arrowhead). (d) An ultrawide-field fundus photograph taken after the additional surgery. The retina was completely attached, although subretinal droplets remained (white arrow). (e) An en face swept-source optical coherence tomography image acquired after the additional surgery. The blue horizontal line indicates the scanning location of (f), assumed to include the aspiration site of the subfoveal PFL droplet. The black arrowhead indicates the remaining PFL droplet corresponding to the one in d. (f) A B-scan swept-source optical coherence tomography image acquired after the additional surgery, showing no subfoveal PFL droplet. PFL: Perfluorocarbon liquid
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To prevent phthisis bulbi development and maintain the remaining vision as much as possible, a 25-gauge vitrectomy combined with cataract extraction was performed [Figure 1]b. After flattening the retina with PFL and performing laser photocoagulation at the peripheral edge of the retina, the vitreous cavity was filled with perfluoropropane gas at the end of surgery.
After 2 weeks, the gas/fluid exchange was performed to prevent excessive mechanical damage to the retina by continuous gas contact with it,[4] and the fundus was examined. The retina was completely attached. However, several subretinal PFL droplets were encountered, including a subfoveal PFL droplet [Figure 1]c. The internal limiting membrane (ILM) was peeled with the aid of Brilliant Blue G dye. Then, the subfoveal PFL droplet was passively aspirated, using the pressure difference between the inside and outside of the eye, by placing a 25-gauge Grieshaber Disposable Backflush Blunt needle (Alcon Laboratories, Inc., Fort Worth, TX, USA), with the soft silicone tip removed, on the retinal surface (Video 1: https://www.dropbox.com/s/yqbqioz3o0xok9a/Video%201.mp4?dl=0). No air or gas was used.
Postoperatively, the retina was successfully attached. No further subfoveal PFL was detected and no macular hole developed, although extrafoveal PFL droplets remained [Figure 1]d, [Figure 1]e, [Figure 1]f. Visual acuity remained at hand motion, while the intraocular pressure returned to normal.
| Discussion | | |
Herein, we present a case of traumatic PVR, in which a subfoveal PFL droplet could be removed using a 25-gauge blunt needle placed on the retinal surface without puncturing the retina. We arrived at this novel concept based on a previous experience in an accidental subretinal injection of PFL when flattening the posterior retina in a case of proliferative diabetic retinopathy with tractional retinal detachment, accompanied by subretinal strands [Figure 2]. After peeling the ILM with the help of indocyanine green dye, PFL was injected into the vitreous cavity and strayed into the subretinal space. This was performed without causing any apparent retinal breaks (Video 2: https://www.dropbox.com/s/e28gbrt0llmntwf/Video%202.mp4?dl=0; The four white arrows in Video 2 indicate the margin of subretinal PFL). | Figure 2: Pre-(a and b), intra-(c and d), and post-(e and f) operative images of a 44-year-old female with proliferative diabetic retinopathy with tractional retinal detachment, in which PFL injected into the vitreous cavity strayed into the subretinal space without causing any apparent retinal breaks. (a and b) A preoperative ultrawide-field fundus photograph and an optical coherence tomography image of the operated eye. Images showed proliferative diabetic retinopathy with tractional retinal detachment, accompanied by subretinal strands (white arrowheads). The best-corrected visual acuity was 20/200. (c) An intraoperative image showing subretinal PFL. The white arrows indicate the margin of subretinal PFL.(d) An intraoperative image showing subretinal PFL (black arrowhead) that could be detected through an intentional hole made for removing subretinal strands.(e and f) A postoperative ultrawide-field fundus photograph and an optical coherence tomography image. The retina was totally attached, with pan-retinal photocoagulation scars. Subretinal PFL was completely removed through inferior holes made intentionally to remove subretinal strands. Visual acuity improved to 20/100. PFL: Perfluorocarbon liquid
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There are some possible mechanisms by which PFL could penetrate the retina, from the subretinal space into the vitreous cavity, and vice versa. One mechanism is the decreased retinal stiffness caused by ILM peeling. Wollensak et al. demonstrated that the ILM, which is the basement membrane of Muller cells, contributes to half of retinal stiffness.[5] Okanouchi et al. reported a surgical technique for subretinal injection through the retinal site where the ILM was focally peeled without puncturing the retina.[6] Based on the previous literature and our own experience, we conceived the surgical technique of subretinal PFL droplet removal without retinal puncture.
Another way by which PFL could penetrate the retina without a puncture involves a decrease in retinal stiffness due to severe pathological retinal conditions, such as long-standing retinal detachment and/or chronic retinal ischemia. In this case report, the subfoveal PFL droplet was passively aspirated in an eye with a long-standing PVR. In our previous experience, PFL migration into the subretinal space occurred in an eye with proliferative diabetic retinopathy with chronic tractional retinal detachment. Therefore, if subfoveal PFL droplets require removal after vitrectomy in eyes with relatively healthy retinal conditions, such as acute-onset retinal detachment, an alternative technique, for example, active rather than passive droplet aspiration, may be needed.
The surgical technique described in this case report seems safer and simpler than those previously reported.[1],[2],[3] This technique may minimize damage to the sensory retina as well as to the subretinal tissues because the retina does not need to be punctured.[1],[2] However, in this case report, it is possible that a nonvisible, tiny break occurred when passively aspirating the subfoveal PFL or when injecting PFL into the vitreous cavity; the break could have been transient and spontaneously closed. Using this surgical technique, surgeons do not need to change the patient's head position or shake the patient's head during surgery to facilitate the separation of the PFL from the retina.[3] In addition, patients do not need to maintain a specific position postoperatively.[1],[3]
The most important consideration when using PFL is performing gentle surgical maneuvers to prevent PFL from breaking up into small droplets. However, once subfoveal PFL is detected after surgery, it should be removed as quickly and safely as possible. The surgical technique introduced in this report would be helpful in that situation. Nevertheless, further studies are warranted to establish good indications for this surgical technique.
Ethical Statement
The procedures adhered to the tenets of the Declaration of Helsinki, and the Institutional Review Board approved this case report (approval number 2022-ST-2).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
The author declares that there are no conflicts of interests of this paper.
| References | | |
| 1. | Le Tien V, Pierre-Kahn V, Azan F, Renard G, Chauvaud D. Displacement of retained subfoveal perfluorocarbon liquid after vitreoretinal surgery. Arch Ophthalmol 2008;126:98-101.  |
| 2. | García-Arumí J, Castillo P, López M, Boixadera A, Martínez-Castillo V, Pimentel L. Removal of retained subretinal perfluorocarbon liquid. Br J Ophthalmol 2008;92:1693-4. |
| 3. | Takahashi K, Kimura S, Hosokawa MM, Shiode Y, Doi S, Matoba R, et al. Release and extraction of retained subfoveal perfluorocarbon liquid facilitated by subretinal BSS, vibration, and gravity: A case report. BMC Ophthalmol 2020;20:427. |
| 4. | Doi M, Ning M, Semba R, Uji Y, Refojo MF. Histopathologic abnormalities in rabbit retina after intravitreous injection of expansive gases and air. Retina 2000;20:506-13. |
| 5. | Wollensak G, Spoerl E, Grosse G, Wirbelauer C. Biomechanical significance of the human internal limiting lamina. Retina 2006;26:965-8. |
| 6. | Okanouchi T, Toshima S, Kimura S, Morizane Y, Shiraga F. Novel technique for subretinal injection using local removal of the internal limiting membrane. Retina 2016;36:1035-8. |
[Figure 1], [Figure 2]
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