Bullous Retinal Detachment Research Articles

Acute Angle-Closure Glaucoma Resulting From Spontaneous Hemorrhagic Retinal Detachment in Age-related Macular Degeneration: Case Reports and Literature Review

Purpose: Acute angle-closure glaucoma resulting from massive subretinal hemorrhage is a rare and catastrophic complication in age-related macular degeneration. Anticoagulant usage had been strongly correlated with this complication in previously reported cases. Methods: Four patients (4 eyes), 3 men and 1 woman, developed angle-closure glaucoma with diffuse subretinal hemorrhage and total hemorrhagic retinal detachment. Results: Serial funduscopic examinations and echographic studies in 2 eyes showed that the blood gradually accumulated in the subretinal space. It took more than 10 days for the bleeding to build up to bullous hemorrhagic retinal detachment and secondary glaucoma. Anti-glaucomatous agents were given and sclerotomy was performed in 3 of the 4 patients. Phthisical changes were observed subsequently in these 3 eyes. The eye that received early drainage of blood was an exception, and a small degree of residual acuity was retained. Three of the 4 patients had diabetes mellitus, and hypertension and vascular diseases were also present in the same 3 patients. Conclusions: Diabetes mellitus might be a predisposing factor for the impaired hemostasis. Anti-glaucomatous agents were of no effect in the management of intraocular pressure. Sclerotomy and drainage of blood help control intraocular pressure and relieve ocular pain. Poor final visual acuity is inevitable. However, phthisical changes might be prevented with early sclerotomy and drainage of blood.

Ciliochoroidal Detachment Following Scleral Buckling Surgery for Rhegmatogenous Retinal Detachment

Purpose and Methods: We observed the peripheral choroid, ciliary body, and depth of the anterior chamber by ultrasound biomicroscopy (UBM) in 31 eyes with rhegmatogenous retinal detachment before and after scleral buckling surgery. Scleral encircling was performed in 11 eyes and segmental scleral buckling in 20 eyes. Results: With UBM, ciliochoroidal detachment was detected in all eyes (100%) following scleral encircling and in 8 eyes (40.0%) following segmental scleral buckling. After scleral encircling procedure, the eyes with preoperatively bullous and wide retinal detachment showed a severe ciliochoroidal detachment and edema of the ciliary body. Shallowing of the anterior camber occurred in all 11 eyes (100%) after scleral encircling and in 12 of 20 eyes (60.0%) after segmental scleral buckling. Marked shallowing with closure of the angle and elevated intraocular pressure occurred in 2 eyes. Conclusion: The results showed that careful postoperative examinations for the anterior segments, chamber angle, and intraocular pressure are necessary with slit-lamp examination and applanation tonometry after scleral buckling surgery.

Intravascular lymphoma presenting as bilateral panophthalmitis and retinal detachment in a dog

A seven-year-old, spayed female boxer was presented for sudden blindness and red eyes of one week's duration. Ophthalmic examination revealed bilateral uveitis with complete bullous retinal detachments. Initial diagnostic testing failed to reveal evidence of systemic disease. Cytopathology of subretinal aspirates confirmed the presence of macrophages with intracytoplasmic retinal pigment, epithelial and choroidal pigment, and monocytes. Tentative diagnoses were idiopathic uveitis and retinal detachment. The dog was treated with immunosuppressive doses of prednisone. The retinas reattached and vision returned. By two months, the dog became blind and systemically ill. Postmortem and histopathological examinations revealed intravascular lymphoma in multiple organs, including the eyes.

Bullous variant of idiopathic central serous chorioretinopathy

BACKGROUNDSpontaneous bullous serous retinal detachment (RD) with subretinal exudation complicating idiopathic central serous chorioretinopathy (ICSC) is a rare and infrequently described clinical entity. Clinical observations are described on this variant...

Facoemulsificação: resultados e complicações nos primeiros 100 olhos

Purpose: To analyze outcomes and incidence of compli-cations in 100 eyes submitted to phacoemulsification perfor-med by surgeons at the start of their career at the Hospital do Servidor Publico Estadual de Sao Paulo. Methods: The first 100 consecutive cataract operations performed by five surgeons, in patients of the HSPE, using phacoemulsification were evaluated. The surgical technique included a scleral tunnel, continuous curvilinear capsulo-rhexis, nucleus removal by phacoemulsification using a peristaltic pump and intraocular lens implantation, under peribulbar anesthesia. Results: The incidence of complications was 15.2%: posterior capsule tear in 8.7%, vitreous loss in 5.4% and one case of posterior dislocation of the nucleus. Posterior chamber IOL were implanted in 96.7% of the eyes, 70.8% of these being in the capsular bag, 28% in the sulcus and 1.2% were fixed superiorly. The final visual acuity was 20/40 or better in 89% of the cases. None of them developed bullous keratopathy or retinal detachment. Conclusion: The complication rate was comparable to that of the literature, suggesting that this technique may be learned during the residency program.

Therapeutic options for capillary papillary hemangiomas

PurposeTo describe the results and therapeutic complications of treatment of papillary capillary hemangiomas over the last 13 years. DesignRetrospective, noncomparative, interventional case series. ParticipantsFive cases of unilateral capillary papillary hemangiomas were reviewed. Three patients had von Hippel-Lindau disease, and two had no associated familial or systemic disease. MethodsTwo patients were treated with argon green laser, one patient received argon green and diode photocoagulation, and two patients underwent argon green photocoagulation and diode transpupillary thermotherapy (TTT); two eyes also underwent vitreoretinal surgery. Follow-up ranged from 1 to 13 years. Main outcome measuresThe presence of exudative retinal detachment associated with the activity of the hemangioma and the visual acuity were the two main parameters. ResultsPrompt argon green laser treatment was the most effective therapy; TTT was ineffective. Vitreoretinal surgery, transscleral drainage, and argon endolaser photocoagulation in one case resolved bullous retinal detachment secondary to tumor exudation. Pretreatment visual acuity (VA) levels ranged from 20/25 to counting fingers; posttreatment VA levels ranged from 20/25 to light perception. ConclusionsIf left untreated, papillary hemangiomas may evolve to exudative retinal detachment and marked VA decreases. Although we have not established an ideal therapy, we recommend appropriate treatment on diagnosis. Close follow-up and multiple treatments with argon laser are likely the best therapeutic course.

COATS' DISEASE AND PERSISTENT HYPERPLASTIC PRIMARY VITREOUS: Role of MR Imaging and CT

Coats' disease is an idiopathic disorder in which telangiectatic and aneurysmal retinal vessels leak a lipoproteinaceous exudate, with consequent bullous retinal detachment. It is a diagnostic challenge, and CT and MR imaging provide valuable information to differentiate it from other pathologies, particularly from retinoblastoma. Typical, advanced Coats' disease shows on CT a denser substance posterior to the vitreous, which on MR is hyperintense on all pulse sequences. Contrast administration on both CT and MR might give slight linear enhancement at the boundary between vitreous and exudation. Persistent hyperplastic primary vitreous (PHPV) is a unilateral disorder in a microphthalmic eye, seen in full-term infants. PHPV rarely is bilateral in patients with Norrie's disease, Warburg syndrome, or patients with retinal dysplasia. Persistent fetal vasculature leads to fibrosis, resulting in elongation of the ciliary processes, retinal detachment, and spontaneous cataracts. The CT appearance in the disorder is quite variable; however, MR imaging may be superior in demonstrating the enhancing retrolental mass and the elongated ciliary processes.

Bilateral Bullous Exudative Retinal Detachment in Renal Failure

Bilateral bullous exudative retinal detachment has been reported in patients with renal failure, but the etiology and appropriate treatment at this type of retinal detachment are debatable. We present our experience with a patient with renal failure and bilateral bullous exudative retinal detachment. His renal disease was membrano-proliferative glomerulonephritis, which is immunologically mediated. The etiology of exudative retinal detachment associated with renal failure is discussed, and the roles of hypertension, fluid retention, electrolyte imbalance and immune-comples deposition in the presence and resolution of exudative retinal detachment in the patient are investigated. Clinical study indicated that immune-comples deposition or hypertension or both might have been the cause of retinal detach-ment in this patient. The resolution of resolution of retinal detachment was correlated with correction of fluid reten-tion and dilutional hyponatremia, but unrelated to the level of blood pressure. The effect of systemic corticosteroid therapy remains unclear.

Management of Moderate to Advanced Coats’ Disease

Sixteen patients (16 eyes) with Coats’ disease who had either total bullous exudative retinal detachment or macular involvement and/or at least two quadrants of exudative retinal detachment were followed for a mean period of 60.6 months. Three patients with no light perception received no treatment. Ten eyes received cryotherapy on one or more occasions and two had laser photocoagulation. One eye underwent subretinal fluid drainage, intraocular infusion and cryotherapy. In those patients who could be tested, all the treated eyes retained their initial visual acuities. All 16 eyes had an acceptable cosmesis and none progressed to painful neovascular glaucoma or phthisis bulbi. Patients with late onset disease had a more benign course.

Choroidal lesions and surgical treatment of bullous retinal detachment

To define choroidal lesions of bullous retinal detachment, we performed indocyanine green angiography (IA) on 20 eyes of 10 patients with bullous retinal detachment. Four of these eyes were treated with sclerectomy and sclerostomy (Gass), and the benefit was evaluated. IA showed the following choroidal abnormalities: choroidal filling delay in the macular region (6 of 18 eyes, 33%) and underneath the leaking sites (9 of 18 eyes, 50%), localized (1 eye, 5%) and extended (18 eyes, 90%) choroidal venous dilatation, and intrachoroidal hyperfluorescence (all eyes, 100%). After the surgical treatment, retinal detachments resolved within 9 weeks (mean 5.3 weeks). Since choroidal filling delay, choroidal venous dilatation and intrachoroidal hyperfluorescence were observed, it is suggested that choroidal congestion plays a causative role in bullous retinal detachment. Sclerectomy and sclerostomy seemed to be beneficial in treatment of this condition.

Primary vitrectomy for bullous rhegmatogenous retinal detachments due to complex breaks.

The role of vitrectomy for the treatment of uncomplicated retinal detachments has not been clearly defined. This study reports the results of a series of eyes with bullous rhegmatogenous retinal detachment (RRD) due to complex breaks that were managed by primary vitrectomy. The study consisted of a consecutive series of 22 eyes (22 patients) with a bullous RRD not complicated by proliferative vitreoretinopathy (PVR) associated with large, multiple, or posterior breaks. All eyes underwent vitrectomy, injection of perfluorocarbon liquid (PFCL), cryopexy and gas tamponade as the primary procedure. Encircling scleral bands were placed in all cases. Follow-up ranged from 6 to 24 months (mean 10.9 +/- 6.5 months). Anatomical retinal re-attachment was achieved in all eyes after one operation. Best-corrected final visual acuity was improved in all cases. Complications included progressive posterior subcapsular and nucleosclerotic cataract in four (22%) of the 18 phakic eyes and epiretinal membrane in one patient. These results, together with the relatively low incidence of complications, lead us to conclude that this technique is an effective method for treatment of bullous RRD not complicated by PVR associated with technically difficult breaks. A controlled, prospective, randomized study would be necessary to thoroughly assess the advantages of vitrectomy over scleral buckling alone in these cases.

Experimental preretinal neovascularization by laser-induced venous thrombosis in rats

PURPOSE. Retinal ischemia and neovascularization (NV) are important components of many retinal disorders. To facilitate further investigation of retinal ischemia and neovascularization, we sought to develop a reproducible in vivo experimental model of venous occlusion by photodynamic thrombosis in rats. METHODS. After anesthesia, 27 eyes of pigmented rats received an intraperitoneal injection of 0.2 ml of 10% sodium fluorescein 15 minutes prior to laser treatment. With a blue-green argon laser, selected venous sites next to the optic nerve head were photocoagulated indirectly with a 78 diopter lens. Venous occlusion was accomplished using laser parameters of 1.0 second, 50 µm, and 50–100 mW. For a control group, 10 eyes were coagulated on the retina between major vessels using the same parameters after fluorescein injection. For a second control group, 1% sodium hyaluronate was injected into the subretinal space to make a long-standing retinal detachment in 5 eyes. RESULTS. With 1–8 laser impulses, each venous occlusion was obtained and was associated with extreme venous constriction and tortuousity. Retinal edema became evident 10–30 minutes after treatment in the sectors associated with the occluded veins. This edema became a bullous retinal detachment (RD) within 12 hours and intra-retinal hemorrhage was observed. The retinal edema continued for 3–10 days and the retinas reattached spontaneously. Prior to or after retinal reattachment 70% (19/27) of eyes developed retinal NV and tractional RD. Of these, 11 developed NV of the optic disc (NVD), 6 developed NV elsewhere (NVE), and 2 developed NVD and NVE. In 30% (8/27) of the eyes, retinal edema resolved without evidence of NV. In control groups no eyes showed either circulatory disorders or evidence of NV. CONCLUSIONS. This is a new model of retinal ischemia and associated neovascularization established by venous thrombosis that is easily reproducible. Many aspects of rat retinal physiology are known and this model has promise as an avenue for further investigation.

Detached retina affects morphologic and biochemical changes in the retina adjacent to bullous retinal detachment in rabbits

PURPOSE. Long-term results, more than 10 years after successful retinal detachment surgery, have shown gradually decreasing visual acuity in some cases. It is unclear if reduced functional recovery postoperatively is caused by anatomic changes or biochemical disorders. To determine the etiology of the reduced visual acuity, we cytochemically examined the changes in the cellular responses of the edges of retinal detachments. METHODS. We histochemically studied the glucose-6-phosphatase (G6P) and 5'-nucleotidase (5'-Nase) activity in the rabbit retina. Experimental rhegmatogenous retinal detachment was produced in a rabbit model after partial vitrectomy, followed by retinal tear formation. RESULTS. Although 5'-Nase activity gradually decreased during the period of detachment, activity was still detectable after 24 weeks. G6P activity increased in the region of the detached neural retina. Around the border of the detached retina, the decrease in 5'-Nase activity extended approximately 140 micrometers into the adjacent attached retina at 2 weeks after detachment and 270 micrometers at 24 weeks. CONCLUSIONS. These observations suggest that some anatomical and biochemical damages may occur in the retina adjacent to bullous retinal detachment and may explain the reduction in postoperative vision in some clinical cases.

Primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment.

Pars planta vitrectomy has evolved as an alternative method in the treatment of more complicated rhegmatogenous retinal detachments. We report a series of patients who underwent primary vitrectomy with gas tamponade without the use of additional scleral buckling. A retrospective study of 53 patients with a follow-up of 6-45 months (mean 17.8 months) was carried out. Preoperative findings included unusual, multiple or large breaks, vitreous haemorrhage, proliferative vitreoretinopathy and bullous retinal detachment. Preoperative visual acuity was between light perception and 1.0, with 30% (16/53) of patients with 0.4 or better. Retinal reattachment was achieved in 64% of cases (34/53) with one and in 92% (49/53) with one or more operations. Final visual acuity was between light perception and 1.0, with 41% (22/53) of patients with 0.4 or better. Cataract formation occurred in 86% (37/43) of all patients with a clear lens preoperatively. Macular pucker was noted in 11% (6/53) and postoperative proliferative vitreoretinopathy causing redetachment in 6% (3/53). With primary vitrectomy, a high final anatomical success rate with few intraoperative complications can be achieved in more complicated forms of rhegmatogenous retinal detachment. The major drawback of the procedure is the high incidence of post-operative cataract formation.

Cobalt-60 Treatment of Choroidal Hemangiomas

We investigated the therapeutic possibilities of gamma brachytherapy to improve the final functional results of eyes with choroidal hemangiomas, which are benign vascular tumors that can induce progressive impairment of visual acuity. We treated 41 patients with choroidal hemangioma with cobalt-60 applicators. The lesions consisted of 39 circumscribed hemangiomas and two diffuse hemangiomas in patients with Sturge-Weber syndrome. Before treatment, visual acuity in the affected eye was 20/200 in ten patients, 20/200 to 20/50 in 17 patients, 20/40 to 20/25 in 11 patients, and 20/20 in three patients. All patients were symptomatic. The macula was infiltrated by the tumor in 12 eyes (29.3%). There was retinal detachment in 40 eyes (97.6%), cystoid edema in ten eyes (24.4%), subretinal fibrosis in eight eyes (19.5%), and areolar atrophy in two eyes (4.9%). After treatment, the retina was reattached in all eyes, and the tumor progressively transformed into a flat scar. The postirradiation macular lesions that we identified were pigment migrations in the macular region, subretinal fibrosis, and an areolar atrophic scar. We correlated the functional results at two, five, and ten years after treatment with the initial visual acuity, and with pre-existing and posttreatment macular lesions. Our results suggest that radiotherapy is a valuable therapeutic modality for choroidal hemangiomas, particularly in hemangiomas that involve the macula, and for tumors associated with bullous retinal detachment.

Vitrectomy techniques in late-stage Coats'-like exudative retinal detachment.

Retinal telangiectasia is the hallmark of Coats' disease. In the late stages, leakage from these abnormal vessels can result in a total, bullous exudative retinal detachment with cholesterol-laden subretinal fluid. Secondary angle-closure glaucoma may result in a blind and painful eye which may require enucleation or evisceration. Surgical reattachment of the retina and destruction of the retinal telangiectasia may preserve these eyes. We have found that vitrectomy, internal drainage of subretinal fluid and cholesterol, direct treatment of the retinal telangiectasia with intraocular diathermy and intravitreal gas or silicone oil injection are effective surgical techniques for salvaging these severely damaged eyes.

Bilateral Bullous Exudative Retinal Detachment Complicating Idiopathic Central Serous Chorioretinopathy during Systemic Corticosteroid Therapy

To present evidence that systemic corticosteroid therapy may cause bilateral bullous serofibrinous exudative retinal detachment in some patients with idiopathic central serous chorioretinopathy. Idiopathic central serous chorioretinopathy usually causes mild, transient loss of central vision, usually in otherwise healthy men with a type A personality. A few patients have permanent visual loss because of chronic and recurrent retinal detachment. The clinical findings in these patients may lead to incorrect diagnoses and use of corticosteroid therapy. The clinical and photographic records of three patients in whom bilateral bullous serofibrinous exudative retinal detachment associated with idiopathic central serous chorioretinopathy developed after treatment with systemic corticosteroids were reviewed. Systemic corticosteroid treatment was instituted (1) as a prophylaxis to prevent exacerbation of the disease while undergoing surgery in the fellow eye, and (2) as the result of misdiagnoses of multifocal choroiditis and retinal vasculitis (Eales disease). Two of the patients had a history of chronic recurrent retinal detachments before institution of corticosteroid treatment. In one of these patients, bilateral chronic inferior retinal detachment developed, causing peripheral retinal vascular nonperfusion, retinal neovascularization, and vitreous hemorrhage. All three patients had severe permanent visual loss in one or both eyes. The findings in these patients provide further evidence that systemic corticosteroid treatment may cause severe exacerbation of retinal detachment and lasting visual loss in some patients with idiopathic central serous retinopathy. Recognition of the atypical presentations of this disorder is important to avoid incorrect diagnoses and treatment.

Experimental transient exudative retinal detachment in the rat.

To establish a new model of exudative retinal detachment in the rat. Photothrombosis was produced in a single retinal vein using direct treatment with a dye laser operating in the yellow wavelength (577 nm). Control eyes received identical laser applications, but treatment was placed alongside the vessel and photothrombosis was not produced. Eyes were examined at intervals during the subsequent week with ophthalmoscopy, photography, fluorescein angiography, and light microscopy. In 13 (41%) of 32 eyes with photothrombosis, bullous retinal detachments developed 1 day after laser treatment, and continued occlusion of the vein was confirmed with fluorescein angiography. Detachments persisted for 2 to 4 days and spontaneously resolved; resolution coincided with restored venous patency at 5 to 7 days. None of the 20 control eyes developed bullous detachments (P < .005). Laser photothrombosis in the rat offers a simple and accessible model of transient exudative retinal detachment without the need for exogenous chromophores.

Pneumatic retinopexy with drainage of subretinal fluid

Thirty bullous retinal detachments were treated with pneumatic retinopexy and drainage of subretinal fluid. Patient selection criteria were similar to pneumatic retinopexy. All the eyes were reattached after the first operation. In three (10%) eyes new breaks with retinal detachment developed within two months after the initial operation and were treated with scleral buckling. One of these three eyes developed proliferative vitreoretinopathy grade D3 two months after scleral buckling. Twenty-nine (96.7%) out of thirty eyes were eventually reattached. The follow-up period was at least nine months. Visual acuity was maintained or improved in 29 (96.7%) eyes. Complications developing due to subretinal fluid like extension of detachment, persistence of subretinal fluid, subretinal gas, reopened retinal breaks were not encountered. By applying cryotherapy to a reattached retina after drainage of subretinal fluid, retinal pigment epithelial dispersion is decreased and the so-called steamroller technique is avoided. Drainage of subretinal fluid did not prevent a good success rate and did not result in additional complications.

Management of Traumatic Hemorrhagic Retinal Detachment with Pars Plana Vitrectomy

Traumatic hemorrhagic retinal detachment may prevent successful visual rehabilitation of eyes with severe posterior segment injury. We managed 19 consecutive cases of traumatic hemorrhagic retinal detachment with pars plana vitrectomy, scleral buckling, and fluid-gas exchange, with or without internal drainage of subretinal hemorrhage. We based our approach on the amount of subretinal hemorrhage present and the location of associated retinal breaks. Internal drainage of subretinal hemorrhage was performed in 16 eyes to allow adequate retinopexy to hemorrhagically elevated retinal breaks (9 eyes), to remove massive subretinal hemorrhage (4 eyes), and to allow intraoperative reattachment when the retina exhibited bullous retinal detachment (3 eyes). Overall, with a minimum of 6 months of follow-up, anatomic reattachment was achieved in 13 (68%) of 19 eyes, and functional success (visual acuity 5/200 or better) was achieved in 6 (32%) of 19 eyes. Anatomic failure resulted from proliferative vitreoretinopathy (4 eyes) and globe atrophy (2 eyes). Drainage of subretinal blood appeared to be beneficial for hemorrhagically elevated retinal tears to allow adequate retinopexy and may help to accomplish long-term anatomic attachment in eyes with massive subretinal hemorrhage or bullous retinal detachment.