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Description
A 29-year-old female presented to our retina clinic with sudden-onset, painless diminution of vision in the right eye (OD) from the last 5 days. Her best-corrected visual acuity (BCVA) in OD was 4/60 and 6/6 in the left eye. Fundus examination of OD revealed the presence of subtotal retinal detachment involving the macula with a superior horseshoe tear at the posterior edge of the lattice (figure 1A).
(A) Preoperative wide-field colour fundus photograph showing rhegmatogenous retinal detachment with a superior break (white arrowhead). (B) Postoperative (day 1) wide-field colour fundus photograph showing attachment of the retina with a superior gas bubble.
Standard management options for retinal detachment, viz., scleral buckling (SB) and pars plana vitrectomy (PPV) were discussed with the patient. Though the literature on management options of retinal detachment is limited, studies have shown good outcomes with SB and PPV.1 2 The woman was in her third trimester of pregnancy, and she would have difficulty in lying supine for a prolonged period of time. Supine position is associated with profound hypotension due to aortic and vena caval compression in the second and third trimesters. It is generally advised to maintain a left lateral position to avoid such a complication.3 In order to make surgery possible, some authors suggest rotation of the patient’s hips, abdomen and thighs while maintaining a normal head position every 10 min during surgery.1
As the female was apprehensive to maintain supine or a lateral position on the operative room table for a prolonged time, performing SB or PPV (with either oil or gas tamponade) under local anaesthesia, which are time-consuming surgeries, could have posed difficulties to the surgeon to complete the procedure. Regarding performing retinal surgery under general anaesthesia, use of narcotics, paralysing agents and anaesthetic agents has been shown to have deleterious effects on the fetus.4 Thus, assessing the risk:benefit ratio, surgery under general anaesthesia was avoided. Lastly, PPV usually requires prone positioning for few days in postoperative period, which was not feasible in our case.
Finally, the patient was given a third option of pneumatic retinopexy (PR), to which she agreed. PR is a procedure which can be performed under topical anaesthesia and is not time-consuming.5 After instilling a few drops of proparacaine 0.5%, cryopexy was performed around the break. This was followed by paracentesis and injecting 100% sulfur hexafluoride (0.6 mL) in the vitreous cavity. Finally, a repeat paracentesis was done and the patient was given a heads up position with a slight tilt towards the left. The entire procedure was completed within 10 min without causing any discomfort to the patient.
On postoperative day 1, the retina was attached. BCVA in OD improved to 6/24 and intraocular pressure (IOP) was 16 mm Hg (figure 1B). Associated lattices in the superior quadrant were lasered postoperatively using laser indirect ophthalmoscopy. Four weeks later, the gas completely resolved and the retina remained attached. Her BCVA improved to 6/9 and IOP was 14 mm Hg. Figure 2 highlights the postoperative fundus photo and optical coherence tomography through the macula at the last follow-up visit (3 months).
Postoperative wide-field colour fundus photograph showing the attached retina at the last follow-up visit of 3 months (A). Optical coherence tomography shows the macula to be attached with resolution of the subretinal fluid (B).
This study highlights the role of PR in such special circumstances. SB is an ideal surgical approach in young patients with superior break. The scleral buckle versus primary vitrectomy in retinal detachment (SPR) study demonstrated superior outcomes with SB compared with PPV in phakic eyes.6
The Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) study has shown better functional outcomes with PR than PPV.7 Similarly, a study by Singh and Behera has shown PR to be faster, more economical, less tissue manipulative and equally efficacious compared with SB.8 A recent American Society of Retina Specialist (ASRS) preferences and trends survey also has shown PR to be preferred by most retina specialists in cases with superior breaks.9 SB was definitely an option available, but lack of patient compliance to lie supine even for a short period of time made us perform PR as a primary procedure.
Learning points
This report highlights some important aspects of retinal surgeries in pregnancy. Inadequacy to maintain an adequate positioning for a prolonged period of time during the surgery by the patient is a challenge to the surgeon.
Second, maintaining postoperative prone positioning after pars plana vitrectomy for a pregnant woman is difficult and should always be discussed and considered while deciding the surgical approach.
Lastly, it is important to assess the risk:benefit ratio of performing surgery under general anaesthesia during pregnancy.
When postoperative positioning is possible, pneumatic retinopexy might be considered a safe and effective procedure to treat rhegmatogenous retinal detachment (RRD) due to superior retinal breaks during pregnancy.
Ethics statements
Patient consent for publication
Footnotes
Contributors AM prepared the manuscript and performed the surgical procedure. HM and PS collected the patient images, edited the images and were involved in patient care. RS reviewed and edited the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.