Collapse of drusenoid pigment epithelial detachment following macular hole surgery: A case report

Manisha Agarwal; Alankrita Muralidhar; Shalini Singh

doi:10.4103/ijo.IJO_1924_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 419-422

Collapse of drusenoid pigment epithelial detachment following macular hole surgery: A case report

Manisha Agarwal, Alankrita Muralidhar, Shalini Singh
Vitreoretina Services, Dr. Shroff Charity Eye Hospital, New Delhi, India

Date of Submission	04-Aug-2022
Date of Acceptance	07-Dec-2022
Date of Web Publication	28-Apr-2023

Correspondence Address:
Shalini Singh
Vitreo-Retina and Uvea Services, Dr. Shroff's Charity Eye Hospital, 5027, Kedarnath Lane, Daryaganj - 110 002, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1924_22

Abstract

The effect of vitrectomy on the course of dry age-related macular degeneration (AMD) in eyes with full-thickness macular holes (FTMHs) is not well understood and has been variably reported in existing studies. The phenomenon of disappearance of confluent soft drusen (drusenoid pigment epithelial detachment [PED]) after macular hole surgery is, however, a rarely reported occurrence. We report a case of a 61-year-old female patient with a large full-thickness macular hole of minimum diameter 586 μm with an underlying drusenoid PED, who underwent a pars plana vitrectomy with inverted internal limiting membrane flap and 20% sulfur hexafluoride gas injection. The macular hole was successfully closed along with collapse of the underlying drusenoid PED during the postoperative follow-up period.

Keywords: Drusenoid pigment epithelial detachment, inverted ILM flap, macular hole, soft drusen

How to cite this article:
Agarwal M, Muralidhar A, Singh S. Collapse of drusenoid pigment epithelial detachment following macular hole surgery: A case report. Indian J Ophthalmol Case Rep 2023;3:419-22

How to cite this URL:
Agarwal M, Muralidhar A, Singh S. Collapse of drusenoid pigment epithelial detachment following macular hole surgery: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 2];3:419-22. Available from: https://www.ijoreports.in/text.asp?2023/3/2/419/374914

The prevalence of full-thickness macular holes (FTMHs) in eyes with dry age-related macular degeneration (AMD) has been previously reported to be 1%.^[1] The effect of vitrectomy on the course of dry AMD in such eyes is not well understood and has been variably reported in existing studies. The phenomenon of disappearance of confluent soft drusen (drusenoid pigment epithelial detachment [PED]) after macular hole surgery is, however, a rarely reported occurrence. We describe the case of a 61-year-old female with a large full-thickness macular hole with a drusenoid PED, which was noted to resolve post macular hole surgery.

Case Report

A 61-year-old female presented to the outpatient department with complaints of blurred vision from the right eye for 1 month. She gave no history of ocular trauma or any previous ocular intervention (medical or surgical). Best corrected visual acuity (BCVA) was 6/36, N-24 in the right and 6/9, N-6 in the left eye. Slit-lamp examination of both eyes revealed an early cortical cataract in both eyes. Intraocular pressure was recorded as 12 mm of mercury in both eyes. Dilated fundus examination revealed Age Related Eye Disease Studies (AREDS) category three (intermediate AMD) in both eyes with a full-thickness macular hole in the right eye [Figure 1]a. Spectral domain-optical coherence tomography (SD-OCT) of the right eye confirmed a primary full-thickness large (minimum diameter 586 μm) macular hole with underlying drusenoid PED with no vitreomacular traction [Figure 3]a. SD-OCT of the left eye showed a normal foveal contour with drusen. After providing a written informed consent, the patient underwent right eye pars plana vitrectomy with inverted internal limiting membrane (ILM) flap technique with 20% sulfur hexafluoride (SF6) gas injection for FTMH. After construction of sclerotomy ports, posterior vitreous detachment (PVD) was induced and vitrectomy completed. ILM was stained with brilliant blue dye and peeled around the macular hole, leaving one end attached to the hole [Figure 2]a. The attached ILM was then folded into the hole and excess ILM was trimmed [Figure 2]b. At the end of the procedure, 20% SF6 gas was injected and patient was asked to maintain a prone position for 5 days. At 2 weeks post-op visit, the SD-OCT showed V-shaped closure of the macular hole with persistent drusenoid PED. At 3 weeks post-op visit, the drusenoid PED had collapsed [Figure 1]b, [Figure 3]b and [Figure 3]c. The BCVA at the 3-week postoperative visit for the right eye was 6/60, N-18. Cataract progression was noted in the right eye at this visit, for which phacoemulsification with intraocular lens implantation was performed. The BCVA at the 3 months follow-up visit was 6/18, N-12.

Figure 1: Pre- and postoperative color fundus photographs: (a) full-thickness macular hole with AREDS category 3 drusen; (b) soft drusen (AREDS category three) at the posterior pole

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Figure 2: Intraoperative photographs: (a) stained ILM peeled around the macular hole with ends attached to the hole edge; (b) ILM flap inverted and pushed into the hole. ILM = internal limiting membrane

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Figure 3: Spectral domain-OCT of the patient during pre- and postoperative visits: (a) preoperative OCT showing a full-thickness macular hole (minimum diameter 586 μm) with underlying drusenoid PED; (b) postoperative second week: “V”-shaped closure of macular hole seen, but drusenoid PED persists; (c) postoperative third week: drusenoid PED resolved with closure of the hole. OCT = optical coherence tomography, PED = pigment epithelial detachment

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Discussion

On reviewing the literature, we found seven similar cases which reported disappearance of soft confluent drusen following macular hole surgery [Table 1]. Of these, two cases reported by Michelewska and Nawrocki^[2] used the same surgical technique as described above. This case report thus adds to the existing literature. The clinical course of dry AMD following vitrectomy has been variably reported, with some studies finding no change in the size of drusen on follow-up and others finding progression to choroidal neovascular membrane (CNVM).^[3],[4] The occurrence of both outcomes in the same eye following vitrectomy was reported by Lee et al.,^[5] in which disappearance of drusen was followed by formation of CNVM. The resorption of drusen following vitrectomy has been attributed to the phagocytosis of drusen by macrophages, which is thought to be accelerated by the surgery. The step of peeling the ILM has been previously proposed to further enhance this effect.^[2],[6] In addition to this, the increase in oxygenation following vitrectomy has also been postulated to prevent progression of AMD.^[7] Michelewska and Nawrocki^[2] found the rate of macular hole closure following inverted ILM flap technique to be lesser in eyes with dry AMD than in eyes with idiopathic macular holes and similar to that in large holes. The visual outcome in the previously documented cases with resolution of drusen, as shown in [Table 1], has been good over the long term, except in the case reported by Lee et al.^[5] where the patient developed a CNVM on follow-up. The visual acuity improved by two lines in our case at the last follow-up visit (3 months). However, further follow-up is warranted to determine the final visual outcome.

Table 1: Review of literature on drusenoid PED disappearance after macular hole surgery^{[2],[5],[6],[8],[9]}

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Conclusion

In conclusion, inverted ILM flap technique is a safe technique to perform in large full-thickness macular hole cases with coexisting AMD and can occasionally lead to regression of dry AMD. The visual outcomes following the procedure have been noted to be satisfactory in previous studies. Long-term follow-up is, however, recommended due to the occasional chances of developing a CNVM.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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