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Editor,—Vitreomacular traction syndrome may result in macular pucker, retinal blood vessel avulsion, retinal hole formation, cystoid macular oedema, or traction retinal detachment.1-6 Of these complications, traction retinal detachment is relatively uncommon and has not been well described. We report a case with an unusual convex macular detachment complicated by retinal pigment epithelial disorders caused by vitreomacular traction.
An 83 year old Japanese man was referred to our clinic for treatment of a retinal detachment in the right eye. The duration of retinal detachment was unknown, but he had been aware of decreasing vision in the right eye for more than 9 months. His medical history was unremarkable except for a cataract extraction and intraocular lens implantation in the left eye.
Ocular examination revealed his corrected visual acuities to be 20/200 in the right eye and 20/20 in the left. Intraocular pressure was 7 mm Hg in both eyes. Slit lamp examination disclosed a cortical cataract in the right eye and an intraocular lens in the left eye. Indirect ophthalmoscopy and slit lamp biomicroscopic examination of the right eye with a 90D lens and contact lens disclosed an unusual convex retinal detachment of the macula extending towards the disc in an arch-like configuration (Fig 1A). The posterior hyaloid was adherent to the detached posterior retina and separated from the attached retina. Ophthalmoscopic examination of the left eye revealed a tiny depigmented area in the macula. Scanning laser ophthalmoscopy (SLO) using an argon laser showed apparent radial traction striae of the posterior hyaloid surrounding the macula (Fig 1B). The vitreomacular traction produced by posterior hyaloid was clearly observed during eye movements.
Vitrectomy was performed and abnormal vitreoretinal anatomical features were confirmed intraoperatively. There was marked syneresis of the vitreous cortex but Weiss’s ring was not detected. The posterior vitreous face was detached in all but the macula and optic disc (Fig1C). After core vitrectomy, the detached posterior hyaloid was removed to release the anteroposterior traction on the macula. The thickened posterior hyaloid was markedly adherent to the detached macula and it was necessary to use a microhooked needle to peel it off. Cataract extraction and intraocular lens implantation were simultaneously performed.
There were no remarkable changes in either visual acuity or the retinal detachment at 3 months postoperatively. Fluorescein angiography, performed to rule out subretinal neovascularisation, showed stainings and mild leakages through the retinal pigment epithelium beneath the detached retina and mild leakage at the disc (Fig 2). There were faint leakages from the retinal vessels as well. Four months after surgery, visual acuity began to improve. By 11 months after surgery, vision had been restored to 20/40 and the retinal detachment had disappeared.
Vitreomacular traction syndrome has recently been described as a distinct clinical entity, which develops secondary to persistent anterior to posterior traction on the macula via a directly observable persistent vitreomacular attachment.2 It may cause a variety of abnormalities in macular appearance and function. Typically, the zone of vitreous attachment includes premacular tissues that result in a clinical appearance similar to that of idiopathic macular pucker. Although rare, traction retinal detachment can occur as a complication of vitreomacular traction syndrome.1 2 4We confirmed the diagnosis of vitreomacular traction syndrome in this case through preoperative fundus examinations including SLO and intraoperative observation. The attached posterior hyaloid was thickened and markedly adherent to the macula, thus necessitating membrane peeling. Strong vitreoretinal adhesion throughout the macula and peripapillary retina, in a “sheet-like” configuration, seemed to cause the broad based macular detachment.4
The convex or dome-like detachment in the present case was unusual, in contrast with the commonly seen concave traction detachment. Melberg and colleagues4 described the clinical characteristics of nine cases of vitreomacular traction syndrome with macular detachment. A similar unusual detachment was described in their series as a case report. They performed fluorescein angiography in their series which demonstrated mild intraretinal hyperfluorescence in all eyes, but there was no mention of retinal pigment epithelial changes. We observed mild leakage and staining at the retinal pigment epithelium beneath the detached retina. This retinal pigment epithelial degeneration may be secondary to vitreous traction. Long standing traction forces from the posterior hyaloid to the macula may have created a static pressure which resulted in leakage through the retinal pigment epithelium to produce the unusual concave retinal detachment seen in our case.