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Tunisie Medicale

Métamorphopsie après une vitrectomie Pars Plana pour


décollement de rétine rhégmatogène

Journal : La Tunisie Médicale


Manuscript ID : TUNISMED-2021-440-8859
Type : ARTICLES ORIGINAUX
Date de soumission : 05/07/2021
Auteurs : zgolli hsouna :IHROT- service A
/ université el manar/faculté de
medecine de tunis,
mabrouk Sonya :IHROT- service
A / université el manar/faculté de
medecine de tunis,
cherni ines :IHROT- service A /
université el manar/faculté de
medecine de tunis,
zeghal imene :IHROT- service A
/ université el manar/faculté de
medecine de tunis,
fekih olfa :IHROT- service A /
université el manar/faculté de
medecine de tunis,
nacef leila :IHROT- service A /
université el manar/faculté de
medecine de tunis,

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Mot clés décollement de rétine


rhegmatogène, vitrectomie,
métamorphopsie, image
multimodale

L’auteur correspondant confirme aux noms des co auteurs que :

- Tous les auteurs ont contribué à la préparation du manuscrit et sont au courant de


son contenu.
- Ce manuscrit n’a pas été publié ou en cours de soumission dans un autre journal.
- Il n’y a aucun conflit d’intérêt pour chaque auteur avec le contenu du manuscrit.
- En cas d’acceptation pour publication, les auteurs doivent transférer le copyright du
manuscrit au journal.

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Tunisie Medicale

Lettre de motivation

Dear Editor ;

We are honored to submit our article entitled « Metamorphopsia After Pars


Plana Vitrectomy For Rhegmatogenous Retinal Detachment ».

Our article has not been submitted elsewhere.

Metamorphopsia is a serious complaint of patients succefully treated for


rhegmatogenous retinal detachment. Multimodal imaging proves macular
slide secondary to vitrectomy.

We hope that our work meets the objectives of your journal and will be
accepted.

Sincerely.

Dr. Sonya Mabrouk

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Tunisie Medicale

Résumé

Objectif : Estimer la prévalence de la métamorphopsie chez les patients


opérés pour un décollement de rétine rhegmatogène (DRR) avec macula
décollée et déterminer les étiologies par imagerie multimodale.

Patients et méthodes : Etude prospective, incluant 50 yeux vitrectomisés


pour un décollement de rétine rhégogène avec décollement de la macula et
utilisant un tamponnement standard à l'huile de silicone (SO). Les patients
qui ont eu une chirurgie réussie avec une réapplication anatomique durable
de la rétine après le retrait du SO ont été inclus. Les patients ont été
examinés le jour 1, le jour 7, le mois 1 et le mois 3 après la chirurgie. La
meilleure acuité visuelle corrigée, la grille d'Amsler, la biomicroscopie du
fond d'œil, la tomographie par cohérence optique dans le domaine spectral et
l'auto-fluorescence du fond d'œil (FAF) ont été réalisées chez tous les
patients après la chirurgie.

Résultats : Nous avons identifié la métamorphopsie comme une déficience


visuelle postopératoire chez 27 patients (54%). Des anomalies structurelles,
telles qu'une membrane épirétinienne, un œdème maculaire cystoïde et une
perturbation fovéale de la couche ellipsoïde ont été observées à la
tomographie. Les plis rétiniens maculaires et le déplacement maculaire ont
été diagnostiqués sur le FAF. Parmi les 5 anomalies tomographiques, seuls
les plis rétiniens maculaires et le déplacement maculaire étaient
significativement corrélés à la survenue d'une métamorphopsie
postopératoire (p=0,03 et <0,001 respectivement).

Conclusion : La métamorphopsie est une plainte fréquente après une


vitrectomie pour RRD. La rotation et les plis maculaires seraient les
principales causes après une réapplication complète et durable de la rétine.

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6
7 Abstract:
8
9
10 Purpose: To estimate the prevalence of metamorphopsia in patients operated for
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12 rhegmatogenous retinal detachment (RRD) with detached macula and determine
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14 etiologies by multimodal imaging.
15
16 Patients and Methods: Retrospective study, included 50 eyes; vitrectomized
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18 for RRD with detached macula and using standard silicone oil (SO) tamponade.
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20 Patients who had successful surgery with durable anatomic reapplication of the
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22 retina after SO removal were included. Patients were examined on day 1, day 7,1
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24 month, and 3 months after surgery. Best corrected visual acuity, Amsler grid,
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26 fundus biomicroscopy, Spectral Domain Optical Coherence Tomography and
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28 fundus auto-fluorescence (FAF) were performed in all patients after surgery.
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30
Results: We identified metamorphopsia as post-operative visual impairments in
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32
27 patients (54%). Structural abnormalities, such as epiretinal membrane, cystoid
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34 macular edema, and foveal disruption of the ellipsoid layer were observed on
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36 tomography. Macular retinal folds and macular displacement were diagnosed on
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38 the FAF. Of the 5 tomographic anomalies, only the macular retinal folds and
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40 macular displacement were significantly correlated with the occurrence of
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42 postoperative metamorphopsia (p=0.03 and <0.001 respectively).
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44
45 Conclusion: Metamorphopsia is a common complaint after vitrectomy for RRD.
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47 Macular rotation and folds would be the main causes after complete and durable
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49 reapplication of the retina.
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51 Keywords: Rhegmatogenous retinal detachment, Metamorphopsia, Vitrectomy,
52
53 Multimodal imaging.
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15 Résumé:
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Objectif : Estimer la prévalence de la métamorphopsie chez les patients opérés
18
19 pour un décollement de rétine rhegmatogène (DRR) avec macula décollée et
20
21 déterminer les étiologies par imagerie multimodale.
22
23
24 Patients et méthodes : Etude prospective, incluant 50 yeux vitrectomisés pour un
25
26 décollement de rétine rhégogène avec décollement de la macula et utilisant un
27
28 tamponnement standard à l'huile de silicone (SO). Les patients qui ont eu une
29
30 chirurgie réussie avec une réapplication anatomique durable de la rétine après le
31
32 retrait du SO ont été inclus. Les patients ont été examinés le jour 1, le jour 7, le
33
34 mois 1 et le mois 3 après la chirurgie. La meilleure acuité visuelle corrigée, la
35
36 grille d'Amsler, la biomicroscopie du fond d'œil, la tomographie par cohérence
37
optique dans le domaine spectral et l'auto-fluorescence du fond d'œil (FAF) ont
38
39
été réalisées chez tous les patients après la chirurgie.
40
41
42 Résultats : Nous avons identifié la métamorphopsie comme une déficience
43
44 visuelle postopératoire chez 27 patients (54%). Des anomalies structurelles,
45
46 telles qu'une membrane épirétinienne, un œdème maculaire cystoïde et une
47
48 perturbation fovéale de la couche ellipsoïde ont été observées à la tomographie.
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50 Les plis rétiniens maculaires et le déplacement maculaire ont été diagnostiqués
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52 sur le FAF. Parmi les 5 anomalies tomographiques, seuls les plis rétiniens
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54 maculaires et le déplacement maculaire étaient significativement corrélés à la
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3
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5 survenue d'une métamorphopsie postopératoire (p=0,03 et <0,001
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7
respectivement).
8
9 Conclusion : La métamorphopsie est une plainte fréquente après une vitrectomie
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11 pour RRD. La rotation et les plis maculaires seraient les principales causes après
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13 une réapplication complète et durable de la rétine.
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15
16 Mots clés: décollement de rétine rhegmatogène, vitrectomie, métamorphopsie,
17
image multimodale
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24
25 Introduction:
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28 Pars plana vitrectomy is currently considered as the most effective technique for
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30 the treatment of rhegmatogenous retinal detachment (RRD). The rate of
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32 anatomical success and reapplication of the retina nowadays exceeds 90% (1).
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34 However, anatomical reapplication of the retina does not always mean a good
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36 recovery of visual function, especially in the case of RRD with detached macula.
37
Metamorphopsia is one of the most frequent post-operative complaint. In fact,
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39
Amemeya and al.(2) showed that in almost 30% of cases, patients complained of
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postoperative metamorphopsia. In studies that included only macula-off cases,
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the incidence of metamorphopsia was much higher, ranging from 66.7% to 88.6
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45 (3-5). The exact physiopathology of such metamorphopsia remains poorly
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47 understood, but it is considered to be an objective sign of retinal distortion and
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49 macular displacement [6]. Today, multimodal imaging offers, thanks to different
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51 sectioning and scanning techniques, a more in-depth analysis of the retina and
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53 macula. Optical Coherence Spectral Domain Tomography (OCT-SD) provides a
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5 diagnosis of microstructural changes in the neuroretina that may explain
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7
metamorphopsia.
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9 This study aims to estimate the prevalence of metamorphopsia in patients
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11 operated for RRD with detached macula. We also discussed the
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13 physiopathogenesis of metamorphopsia after successful vitreoretinal surgery,
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15 based on multimodal imaging findings.
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17
Patients and Method:
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20 This study was carried out under the principles of the Declaration of Helsinki and
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22 was approved by the Ethics Committee of the Hedi Raies Institute of
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24 Ophthalmology. All participants provided written informed consent before
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26 enrollment and the ethical aspects of the study were approved by the Ethics
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28 Committee of the Hedi Raies Institute of Ophthalmology.
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30
It is a transversal retrospective study, including 50 eyes of 50 patients who
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32
underwent pars plana vitrectomy with standard silicone oil tamponade for the
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34 treatment of RRD with detached macula.
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37 Patients treated for RRD with detached macula in our department from July 2019
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39 to January 2020 were included. Inclusion criteria were a macula off RRD;
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41 successful surgery with total and durable reapplication of the retina after silicone
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43 oil removal; minimal postoperative follow-up of 6 months. Non-inclusion criteria
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45 were giant tear’s RRD, traumatic RRD, RRD with severe proliferative
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47 vitreoretinopathy (PVR) (stage> C3); patients with diabetes or other systemic
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49 pathologies that may affect the retinal microstructures and patients with a
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51 history of chronic maculopathies (dystrophies or degenerations). Exclusion
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criteria were patients lost to follow-up or incomplete files.
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5 All patients received, preoperatively, a complete ophtalmological exam including
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best corrected visual acuity using the Snellen visual acuity chart and fundus
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exam. Postoperatively, all patients were examined on day 7, 1 month, 3 months
9
10
and 6 months after surgery. At 3 month after surgery, we measured the
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12
best-corrected visual acuity (BCVA) and checked for the presence or absence of
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14 metamorphopsia using the Amsler grid. A Spectral Domain Optical Coherence
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16 Tomography (OCT SD) (Heidelberg© Spectralis©) with B scan centered on the
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18 fovea and fundus autofluorescence were performed. Microstructural changes and
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20 postoperative abnormalities such as epiretinal membrane, cystoid macular
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22 edema, macular hole and subretinal fluid were documented. Autofluorescence
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24 Lines of increased autofluorescence parallel to retinal vessels were interpreted as
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26 evidence of retinal displacement.
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29 Collected data included demographic data, pre and postoperative visual acuity,
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31 preoperative vitreoretinal proliferation stage.
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33 We used SPSS software version 20.0 Microsoft Corporation, for statistical
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35 analysis. Qualitative results were expressed in frequencies and percentages.
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37 Quantitative data were expressed as mean ± standard deviation (SD). To
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39 compare categorical findings, we used the Chi-square test (χ2) or the exact
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41 Fisher test. All tests were considered significant for a value of p<0.05.
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43
Surgical technique:
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46 All patients underwent a 23-gauge pars plana vitrectomy (PPV). A complete
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48 central and peripheral vitrectomy was performed with posterior mechanical
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50 vitreous detachment (Figure 1). After stabilization of the posterior pole by
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52 perfluorocarbon Liquid (PFCL), retinectomy of the tear edges was performed.
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54 Then, we proceeded to laser retinopexy and/or cryopexy and PFCL-silicone oil
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56 exchange for all patients (figure 2). We performed, on the other hand, a
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5 dissection of epiretinal membranes and vitréo-retinal proliferation under PFCL.
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7
(figure 3).
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9 Results:
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12 A total of 50 eyes of 50 patients were included in our study. The average age was
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14 40 ± 15 years. A male predominance was recorded (32 males out of 18 females),
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16 19 patients were pseudophakic (38%).
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18 Metamorphopsia was clinically assessed (interrogation and Amsler grid) in 27
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20 patients (54% of cases). Autofluorescence imaging objectified retinal
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22 displacement in 16/27 patients (59.25%) (Figure 4).
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25 Clinically, the rate of postoperative metamorphopsia was significantly dependent
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27
on the period between initial symptomatology and surgical management
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(p<0.01), the number of detached retinal quadrants (p=0.02) as well as the
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30
stage of proliferative vitreoretinopathy (p=0.042).
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33 The SD-OCT identified epimacular membrane (figure 5a), macular folds (figure
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35 5b), cystoid macular edema (figure 5c), and ellipsoid layer distortion (figure 5d),
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37 in respectively 6/27, 15/27, 5/27 and 1/27 of patients. Table 1 summarizes the
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39 correlation between multimodal imaging results (tomographic and
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41 autofluorescence) and metamorphopsia. Only macular displacement (p<0.01)
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43 and retinal folds (p=0.03) were significantly correlated with postoperative
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45 metamorphopsia. The mean final BCVA, at 6 months, was 0.39 LogMAR (4/10 on
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47 the Snellen scale). It was not correlated with the presence of metamorphopsia
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49 (p=1). However, the final visual acuity was statistically correlated to the presence
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51 of epiretinal membrane (p<0.001) and disruption of the ellipsoid line (p=0.048).
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5 Table 1: correlation between multimodal imaging and metamorphopsia
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7 METAMORPHOPSIA P
8 Multimodal imaging
(27/50) value
9 With without
10 YES 15 2
11 Macular folds 0.03
No 12 21
12
YES 6 22
13 Epiretinal membrane 0.98
14 No 21 1
15 YES 5 19
Cystoid macular edema 0.17
16 No 22 4
17 Discontinuity of the
YES 1 20 0.13
18 ellipsoid zone
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Discussion:
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31
32 Our study showed that after successful RRD surgery, metamorphopsia is a
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34 common functional disorder diagnosed in 54% of participants treated for RRD and
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36 associated with macular displacement in 59% of cases. Retinal folds were the
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38 tomographic abnormalities most likely to cause metamorphopsia (p<0.01).
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40 According to the literature, the prevalence of metamorphopsia after macula-Off
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42 RRD surgery, all techniques included (pars plana vitrectomy/scleral buckling
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44 surgery), ranged from 66.7 to 88.6%.
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46 This wide variation in the prevalence of postoperative metamorphopsia in the
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48 literature [6) is mainly due to the size of the study population; average age; type
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50 of surgery and tamponade; the ability of the surgeon; follow-up and the methods
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52 used to diagnose metamorphopsia.
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55 Delay of metamorphopsia after surgery varied from 6 months to 33 months
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57 according to the literature[6]. Rossetti and al [5] in a study with long-term
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5 postoperative follow-up showed that the importance of metamorphopsia
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7
decreased with time and a complete disappearance was objectively observed in
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3% of patients after 6 years of observation.
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11 The exact physiopathology of postoperative metamorphopsia still not fully
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13 clarified. Several hypotheses were discussed in literature. Two studies concluded
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15 that there was no significant correlation between postoperative RRD tomographic
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17 abnormalities and metamorphopsia (4,5).
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19
On the other hand, many studies had confirmed the highly positive relationship
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21
between tomographic disruptions of the external limiting membrane following
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23
RRD surgery, and the development of metamorphopsia (6,7,8). According to our
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25 results, the presence of epimacular membrane, residual sub-retinal fluid, cystoid
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27 macular edema, and ellipsoid zone disruptions are not significantly correlated
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29 with postoperative metamorphopsia.
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32 Furthermore, we have identified macular displacement and folds as being
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34 significantly associated with postoperative metamorphopsia. The diagnosis can
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36 easily be made using auto-fluorescence. This is in line with various studies that
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38 have shown that this imaging technique can diagnose infraclinical macular
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40 displacement after pars plana vitrectomy for RRD (6,3,9-11).
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42 Finally, through our study, we demonstrated that the postoperative
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44 metamorphopsia did not influence the final corrected visual acuity, unlike Zhou
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46 and al. (6) and Van Put and al. (4) who reported that metamorphopsia was
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48 associated with distortions of the retinal layers with poor final visual acuity.
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51 Our study despite being prospective one has some limitations, such as limited
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sample size (50 eyes) and a short follow-up time (6 months). Larger and more
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expanded prospective studies maybe even more conclusive.
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5 Conclusion: Postoperative metamorphopsia would be basically related to a
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7
major macular displacement, which can be responsible of retinal distortions and
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metamorphopsia. Thus, the main interest would be to find out how to reduce the
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10
macular slide during the pars plana vitrectomy.
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12
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18 Conflicts of interest: There is no conflict of interest regarding the publication of
19 this article.
20
21 Findings: none.
22 Acknowledgments: none.
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24 Availability of Data and Material: The data supporting the findings of this
25 study are available from the corresponding author on request.
26
27 .
28
29
30
31
32 References:
33 1. Kobashi H, Takano M, Yanagita T, et al. Scleral buckling and pars plana
34 vitrectomy for rhegmatogenous retinal detachment: an analysis of 542
35 eyes. Curr Eye Res 2014;39:204–11.
36
37 2. Amemiya T, Iida Y, Yoshida H. Subjective and Objective Ocular
38 Disturbances in Reattached Retina after Surgery for Retinal Detachment,
39 with Special Reference to Visual Acuity and Metamorphopsia.
40 Ophthalmologica. 1983;186:25–30.
41
42 3. Lee E, Williamson TH, Hysi P, Shunmugam M, Dogramaci M, Wong R, et al.
43 Macular displacement following rhegmatogenous retinal detachment
44 repair. Br J Ophthalmol. 2013;97(10):1297–302.
45
4. Van de Put MA, Vehof J, Hooymans JM, et al. Postoperative metamorphopsia
46
in macula-off rhegmatogenous retinal detachment: associations with visual
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48
function, vision related quality of life, and optical coherence tomography
49 findings. PLoS ONE. 2015;10:e0120543.
50 5. Rossetti A, Doro D, Manfre A, et al. Long-term follow-up with optical
51 coherence tomography and microperimetry in eyes with metamorphopsia
52 after macula-off retinal detachment repair. Eye (Lond).2010;24:1808–13.
53
54 6. Ch Zhou, Q Lin,F Chen. Prevalence and predictors of metamorphopsia after
55 successful rhegmatogenous retinal detachment surgery: a cross-sectional,
56 comparative study. Br J Ophthalmol.2017;101:725–729.
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5 7. Wang Y, Li S-Y, ZhuMet al.Metamorphopsia after successful retinal
6 detachment surgery: an optical coherence tomography study. Acta
7 Ophthalmol Scand. 2015. 83:168–171.
8 8. Dell’omo R, Cifariello F, Dell’omo E et al. Influence of retinal vessel
9
printings on metamorphopsia and retinal architectural abnormalities in
10
eyes with idiopathic macular epiretinal membrane. Invest Ophthalmol Vis
11
Sci. 2013. 54:7803–7811.
12
13 9. Shiragami C, Fukuda K, Yamaji H et al. A method to decrease the
14 frequency of unintentional slippage after vitrectomy for rhegmatogenous
15 retinal detachment. Retina. 2015. 35:758–763.
16
17 10.Nitta E, Shiraga F, Shiragami C et al. Displacement of the retina and its
18 recovery after vitrectomy in idiopathic epiretinal membrane. Am J
19 Ophthalmol. 2013. 155:1014–1020.
20
21
11.Codenotti M, Fogliato G, Iuliano L et al. Influence of intraocular tamponade
22 on unintentional retinal displacement after vitrectomy for rhegmatogenous
23 retinal detachment. Retina.2013. 33:349–355.
24 12.M Schawkat ; C Valmaggia ; C Lang ; H PN Scholl ; J Guber. Multimodal
25 imaging for detecting metamorphopsia after successful retinal detachment
26
repair. Graefes Arch Clin Exp Ophthalmol. 2020 Jan;258(1):57-61
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28 13.Okamoto F, Sugiura Y, Okamoto Y et al. Metamorphopsia and optical
29 coherence tomography findings after rhegmatogenous retinal detachment
30 surgery. Am J Ophthalmol. 2014. 157:214–220.
31
32 14.Van de Put MAJ, Hooymans JMM, Los LI. The incidence of rhegmatogenous
33 retinal detachment in the Netherlands. Ophthalmology. 2013.120:616–622.
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36 Figures caption:
37
38 Figure 1: Vitrectomy under perfluorocarbon liquid (PFCL): (a, b):
39 peripheric vitrectomy with indentation under PFCL, (c): Endolaser retinopexy, (d):
40 silicon oil tamponade.
41
42
43 Figure 2: Perfluorocarbon liquid (PFCL) reapplication of central retina:
44 (a): bullous total rhegmatogenous retinal detachment with detached macula, (b):
45 reapplication of the macula using PFCL.
46
47
48
Figure 3: Proliferative membrane dissection under perfluorocarbon
49
50
liquid (PFCL) in rhegmatogenous retinal detachment: (a, b, c): central
51 epiretinal proliferative membrane dissection under PFCL, (d): complete central
52 membranectomy.
53 Figure 4: Auto-fluorescence image: The macular postoperative displacement:
54 Red arrows pointing to hyperfluorescent lines indicate the preoperative position
55
of the retinal vessels.
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5 Figure 5: Tomographic anomalies: (a): epimacular membrane, (b): retinal
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FIGURE 2
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