Description

A 24-year-old man, presented with a right eye oculus dexter (OD) chronic macular off rhegmatogenous retinal detachment (RRD) (figure 1A), underwent a 23-guage pars plana vitrectomy followed by perfluorocarbon liquid (PFCL) injection, endolaser retinopexy, fluid–air exchange along with silicone–oil endotamponade and was advised strict prone position during his postoperative period. There was a presence of horizontal subretinal band passing through macula (proliferative vitreoretinopathy) prior to surgery, which was attempted to remove with forceps by creating peripheral access retinotomy using intravitreal diathermy. However, the band got severed at the middle and retracted back making it difficult to regain surgical access. There was no documentation of subretinal PFCL bubble at the conclusion of the surgery. The best-corrected visual acuity at first week postoperatively was 20/250 in OD with an intraocular pressure of 12 mm Hg. Dilated fundus evaluation revealed an attached retina with pre-existing whitish subretinal band under silicon oil along with three subretinal well-defined dome-shaped refractile golden yellow-coloured bubbles, the larger one sitting subfoveally (figure 1B,C) suggestive of a retained PFCL bubble. Swept source optical coherence tomography horizontal scan passing through fovea showed a dome-shaped hyporeflective space at the fovea with subtle underlying retinal pigment epithelium (RPE) hyperreflectivity (figure 1D). Patient is planned for pars plana silicone oil removal, PFCL aspiration using 38 g needle, internal limiting membrane peeling along with gas endotamponade.

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Figure 1

(A) Colour fundus photograph of right eye shows a subtotal rhegmatogenous retinal detachment with a horizontally oriented subretinal band bifurcating the macula; (B) colour fundus photograph taken at postoperative 1 week reveals an attached retina with severed and retracted whitish subretinal band under silicon oil along with three subretinal well defined dome shaped refractile golden yellow-coloured bubbles, the larger one sitting sub-foveally suggestive of a retained PFCL, features being more prominent in red-free imaging (C); (D) swept source optical coherence tomography horizontal scan passing through fovea shows a dome-shaped hyporeflective space at the fovea with subtle underlying RPE and choroid hyperreflectivity. PFCL, perfluorocarbon liquid.

Retained subretinal PFCL is a relatively rare but dreadful complication seen in almost 11% of cases of RRD requiring PFCL intraoperatively,1 the two most common risk factors are being large peripheral retinotomies extending more than 120° and inadequate saline rinse at the conclusion of fluid–air exchange.2 One possible cause of retained subfoveal PFCL in our case could be secondary to the persistent subretinal band, which could have aided entry of an undetected PFCL droplet into the subretinal space and migration into the macula, by acting as a conduit or ‘tenting up’ the retina in the macula. Retained subfoveal PFCL can lead to acute vision loss secondary to an inflammatory reaction involving macrophages with intracellular vacuoles containing PFCL and mechanical compression of the retina, mandating immediate surgical intervention.3 The visual outcomes of retained PFCL bubble depend on its anatomic location with regards to macula, size and duration.4 Clinical differentiation of subretinal PFCL from residual subretinal fluid may pose a problem in the early postoperative period.

The optical coherence tomographic features of a retained subretinal PFCL include an omega-shaped configuration, acute angle between the retinal pigment epithelium and the neurosensory retina, compressed overlying retinal layers and an RPE hyper-reflective band along with a hyper-reflective shadow at the choroid.5 Some of the mimickers of subfoveal PFCL include acute central serous chorioretinopathy along with pigment epithelial detachment, subfoveal hydatid cyst and best macular dystrophy. The typical glittery nature of subretinal PFCL could be secondary to the internal reflectivity of light inside PFCL bubble with posterior wall of PFCL acting as major reflectance for fundus camera-based flash light. Small bubbles of PFCL removal can either be achieved with a small retinotomy adjacent to the PFCL bubble and then a small gauge cannula (39–50 gauges) is used for active aspiration of the bubble.6 Larger bubbles may require a peripheral retinotomy, induction of a localised detachment of the retina and the insertion of a flute needle under the retina.7 8 In our case, the patient probably had subretinal PFCL migration through the large peripheral retinotomy made for removing subretinal bands that ultimately shifting to a subfoveal location over the course of time. In conclusion, retained subfoveal PFCL causes outer retinal atrophy and photoreceptor loss; thus, warranting an immediate surgical intervention to remove the bubble. Surgical removal leads to retinal morphologic restoration and functional improvement.