Bilateral exudative retinal detachment due to retinal pigment epithelial tears successfully treated by vitrectomy and scleral window surgery


Akito Hirakata, MD
Kyorin Eye Center
Kyorin University School of Medicine
6-20-2 Shinkawa
Mitaka, Tokyo 181-8611
Tel: + 81 422 47 5511 ext 2606
Fax: + 81 422 46 9309

Dear Editor,

Retinal pigment epithelial (RPE) tears develop by an excessive stretching of the RPE layer (Gass 1984). Exudative retinal detachments (RDs) may rarely be associated with RPE tears (Serels et al. 1991; Laidlaw & Poynter 1998). We report the findings of a patient who developed bilateral exudative RD causing angle-closure glaucoma associated with spontaneous multiple RPE tears. Vitrectomy, endolaser photocoagulation and silicone oil tamponade with/without scleral window were used to treat this complicated RD.

A 68-year-old man complained of blurred vision in his left eye. He had had prophylactic laser iridotomy and persistent pleuritis of unknown origin, but had not had steroid therapy. He also did not have renal dysfunction. His visual acuity was 20/40 OD and 20/200 OS. Ophthalmoscopy of the left eye showed an inferior bullous RD involving the macula without a retinal break, but with large RPE tears (Fig. 1A). An old retinal branch vein occlusion was found in the superior temporal arcade of the right eye. Fluorescein angiography showed hyperfluorescence in the areas of the RPE tears and leakage from the RPE tears in the left eye (Fig. 1B). The axial length was 21 OD and 22 mm OS.

Figure 1.

 Panoramic photograph of the fundus of the left eye of a patient with multiple retinal pigment epithelial (RPE) tears (arrowheads) at the first visit (A). Fluorescein angiography showed hyperfluorescence corresponding to the RPE tears and exudative retinal detachment (RD) (B). One month later, a total RD pushed the lens anteriorly causing angle-closure glaucoma (C). Simultaneously, multiple RPE tears (arrowheads) and bullous RD developed in the right eye (D). Postoperative panoramic photographs of the same patient after vitrectomy (E: left eye, F: right eye). Retina is attached under silicone oil with multiple RPE tears (arrowheads) surrounded by laser scars.

Although we expected a spontaneous resolution of the RD, 1 month later, a total bullous RD developed pushing the lens anteriorly causing angle-closure glaucoma in the left eye (Fig. 1C). At this time, many RPE tears and a RD were found in the right eye (Fig. 1D).

The patient underwent lensectomy with preservation of the posterior lens capsule, external drainage of the subretinal fluid (SRF) and vitrectomy in the left eye. Multiple RPE tears were noted under the RD. The RPE tears were photocoagulated by endolaser, and silicone oil was injected as a tamponade. A reduction in the RD was achieved, but exudation gradually increased leading to an increase in the intraocular pressure (IOP).

The patient underwent a second vitrectomy with removal of the posterior lens capsule, additional photocoagulation and silicone oil tamponade in the left eye. Postoperatively, the IOP was reduced to normal levels, and the amount of SRF decreased. However, both the RD and IOP of the right eye had increased. Lensectomy and vitrectomy were performed on the right eye, and two large RPE tears were observed. The angle-closure glaucoma was resolved, and the amount of SRF decreased.

Two months later, the RD in the right eye increased again because of new RPE tears and the IOP increased to 40 mmHg. The patient underwent scleral window surgery with a 4 × 5 mm, full thickness scleral flap in the inferotemporal quadrant. This was performed to prevent early SRF accumulation following the vitrectomy and to obtain a photocoagulation scar. The SRF was drained through the scleral window during silicone/perfluo-octane exchange. The new RPE tears were endophotocoagulated, and the retina was tamponaded with silicone oil.

The optical coherence tomographic images showed a complete retinal reattachment without a thickening of the choroid after last surgery in both eyes. Because no recurrence was observed after 1 year (Fig. 1E,F), the silicone oil was removed. His best corrected visual acuity (BCVAs) were 20/40 OD and 20/50 OS at his last visit.

There are several pathological conditions associated with RPE tears (Gass 1984; Serels et al. 1991; Laidlaw & Poynter 1998). Our patient had RD with multiple large RPE tears, but none of the findings provided any clues on the aetiology of the RPE tears.

The efficacy of scleral window surgery has been reported for patients with uveal effusion (Gass 1983). The results from our patient suggest that vitrectomy with silicone oil tamponade and/or scleral window surgery may be used to treat the severe exudative RD caused by multiple RPE tears.