CLINICAL SCIENCES

Spontaneous Resolution of Retinal Detachment

Occurring After Macular Hole Surgery
Levent Akduman, MD; Lucian V. Del Priore, MD, PhD; Henry J. Kaplan, MD

Objective: To document the spontaneous resolution
of retinal detachment developing after macular hole
surgery.
Methods: We identified all patients who developed a
postoperative retinal detachment after undergoing macu-
lar hole surgery at Washington University School of Medi-
cine, St Louis, Mo; the surgery was performed by one of
us (L.V.D.P. or H.J.K.) between 1991 and 1996.
Results: Six of 73 eyes developed a postoperative reti-
nal detachment; the retinal detachment was inferior in
all cases. Two eyes that had inferior retinal breaks un-
derwent further surgery to repair the retinal detach-
ment. Retinal breaks could not be identified in the other
4 eyes; the retinal detachment resolved without further
surgery in all 4 of these eyes.
Conclusion: The recognition that retinal detachment oc-
curring after macular hole surgery can resolve without
additional surgery may result in the avoidance of fur-
ther surgical intervention in some eyes.
Arch Ophthalmol. 1998;116:465-467

From the Departments of
Ophthalmology and Visual
Sciences (Drs Akduman,
Del Priore, and Kaplan) and
Biochemistry and Molecular
Biophysics (Dr Del Priore),
Washington University School
of Medicine, St Louis, Mo. None
of the authors has a proprietary
interest in any of the materials
mentioned in this article.
P
ARS PLANA vitrectomy, peel-
ing of the posterior hyaloid,
and intravitreal gas tampon-
ade has become the pre-
ferred management for stage
2, 3, or 4 idiopathic macular holes.1-4 Com-
plications of macular hole surgery include
a high risk of peripheral retinal breaks and
rhegmatogenous retinal detachment, mot-
tling of the retinal pigment epithelium, and
visual field loss after surgery.5-8 The devel-
opment of a retinal detachment after
surgery is considered an indication for
further surgery, as retinal detachments fol-
lowing other types of vitreous surgery are
rhegmatogenous. To our knowledge, there
have been no case reports of spontaneous
resolution of retinal detachment that oc-
curred in the early postoperative period af-
ter macular hole surgery. We describe 4 pa-
tients who developed retinal detachment
after macular hole surgery that either re-
solved spontaneously (1 eye) or after the ad-
ministration of periocular (2 eyes) or oral
(1 eye) corticosteroids. Patients were main-
tained in strict facedown positioning for 7
(patients 1 and 2) or 14 (patients 3 and 4)
days. These cases were derived from a to-
tal of 6 cases of retinal detachment (2 rheg-
matogenous detachments requiring sur-
gery and 4 detachments resolving without
surgery) occurring among 73 patients who
underwent macular hole surgery at Wash-
ington University School of Medicine, St
Louis, Mo, between 1991 and 1996.
REPORT OF CASES
CASE 1
In 1991, a 71-year-old white woman with a
4-week history of visual loss in the right eye
had a best-corrected visual acuity of 20/40
OD and 20/25 OS. Her intraocular pressure
was 14 mm Hg OD and 12 mm Hg OS. The
slit-lampexaminationrevealedbilateralmild
nuclear sclerosis. The results of the fundus
examination revealed a stage 3 (Gass9 clas-
sification) macular hole in her right eye. She
underwent pars plana vitrectomy with peel-
ing of the posterior hyaloid from the pos-
terior pole to the equator with a soft-tip sili-
cone catheter under active suction, as
previously described,1 and pneumatic tam-
ponade with 30% sulfur hexafluoride.
Ten days after the surgery, the patient
developed a bullous inferior retinal detach-
ment with shifting subretinal fluid extend-
ing from the 4-o’clock position to the
9-o’clock position without involvement of
themacula.Thevitreouscavitywasfilled50%
with gas when the retinal detachment was
identified. No peripheral retinal tears were
seen with careful scleral depression. The pa-
tientreceivedtopical1%prednisoloneacetate
4timesdailyandwasmonitoredatleasttwice
per week. The retinal detachment resolved
without any further medical or surgical in-
tervention 3 weeks later. There was no gas
bubble in the vitreous cavity then. The retina
remainedattached,andthemacularholewas

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closed 3 months after surgery. The patient’s final visual acu-
ity was 20/30 OD.
CASE 2
In 1991, a 72-year-old white man complained of an 8-month
history of distorted and blurred vision in his left eye. His best-
corrected visual acuity was 20/50 OD and 20/300 OS. His
intraocular pressure was 14 mm Hg OU. Mild nuclear scle-
rosis was present bilaterally. The results of the fundus ex-
amination revealed a stage 3 macular hole in his left eye, with
asurroundingneurosensorydetachment.Heunderwentpars
plana vitrectomy, peeling of the posterior hyaloid from the
posterior pole to the equator with a soft-tip silicone catheter
under active suction, and intravitreal tamponade with air.
Two weeks after the surgery, he developed a bullous
inferior retinal detachment extending from the 5-o’clock po-
sition to the 7-o’clock position, without involvement of the
macula. There was no gas in the vitreous cavity then, and
no peripheral retinal breaks were seen with careful scleral
depression. The patient received topical 1% prednisolone
acetate 4 times daily and a single sub-Tenon injection of 40
mg of triamcinolone acetonide; the patient was monitored
twice per week. The retinal detachment resolved within 3
weeks. His final visual acuity was 20/200 OS.
CASE 3
A 72-year-old white woman complained of decreased visual
acuityandablackspotinhercentralvisionforapproximately
6 months in the left eye. The results of her ocular examina-
tion revealed a best-corrected visual acuity of 20/25 OD and
20/80 OS. Her intraocular pressure was 21 mm Hg OD and
22 mm Hg OS. She had mild nuclear sclerosis bilaterally. The
results of the fundus examination revealed a stage 3 macu-
lar hole in her left eye. She underwent a pars plana vitrec-
tomy; peeling of the posterior hyaloid from the posterior pole
to the equator with a soft-tip silicone catheter under active
suction; fluid-air exchange; and application of autologous
plasma and thrombin to the macular hole, followed by pneu-
matic tamponade with 20% perfluoropropane.
One week after the surgery, she developed a bullous
inferior retinal detachment with shifting subretinal fluid ex-
tending from the 5-o’clock position to the 7-o’clock posi-
tion. Sixty percent of the vitreous cavity was filled with gas
then. No peripheral retinal breaks were seen with careful
scleral depression. The patient received topical 1% predniso-
lone acetate 4 times daily and a single sub-Tenon injection
of 40 mg of triamcinolone acetonide; the patient was moni-
toredatleasttwiceperweek.Theretinaldetachmentresolved
within 2 weeks. The macular hole remained closed 3 months
after surgery, with no signs of a recurrent retinal detachment.
The patient’s final visual acuity was 20/80 OS.
CASE 4
A 69-year-old white woman complained of seeing a black
spot in her central vision for 2 years in the right eye and for
6 months in the left eye. Her ocular history was notable for
laser iridotomies for glaucoma in both eyes 7 years previ-
ously and cataract extraction with implantation of a poste-
rior chamber intraocular lens in both eyes 5 years previously.
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Theresultsoftheocularexaminationrevealedabest-corrected
visual acuity of 20/200 OD and 20/60 OS. Her intraocular
pressure was 19 mm Hg OU. There were patent peripheral
iridotomies superiorly and well-centered posterior cham-
ber intraocular lenses in both eyes. The results of the fun-
dus examination revealed a stage 4 macular hole with a rim
of subretinal fluid in her right eye and a stage 3 macular hole
in her left eye. She underwent pars plana vitrectomy in the
left eye with peeling of the posterior hyaloid from the pos-
terior pole to the equator with a soft-tip silicone catheter un-
der active suction; fluid-air exchange; and application of au-
tologous serum to the macular hole, followed by pneumatic
tamponade with 17% perfluoropropane.
One day after the surgery, the patient had a bullous
inferior retinal detachment with shifting subretinal fluid
extending from the 4-o’clock position to the 7-o’clock po-
sition, without involvement of the macula. Eighty-five per-
cent of the vitreous cavity was filled with gas then. There
were no peripheral retinal breaks seen with careful scleral
depression. She was given 80 mg of prednisone per day, and
the prednisone was tapered within 2 weeks. She was moni-
tored twice per week, and the retinal detachment resolved
within 2 weeks. The macular hole was closed 3 months af-
ter surgery, and the retina remained reattached with no in-
travitreal gas 9 months after surgery. Her final visual acu-
ity was 20/40 OS.
COMMENT
Senile macular hole is an idiopathic condition that typi-
cally affects women more frequently than men in the sixth
or seventh decade of life. Although the pathogenesis of
macular hole is not completely understood, tangential trac-
tion from the prefoveal cortical vitreous may play a role in
macular hole formation.9-12 In 1991, Kelly and Wendel1
reported the use of pars plana vitrectomy, peeling of the
cortical vitreous, and intravitreal gas tamponade for the
treatment of idiopathic macular hole. Since this initial re-
port, this group and other workers2-4,13-16 have reported
macular hole closure rates in the range of 90%. The use of
transforming growth factor b2, thrombin, autologous se-
rum, or other adjuvants may improve the success rate and
the visual prognosis in patients with macular holes.2-4,13-16
The formation of iatrogenic retinal tears with or with-
out postoperative retinal detachment is a possible compli-
cation of macular hole surgery.8 The incidence of retinal de-
tachment and peripheral retinal breaks after pars plana
vitrectomy for macular hole may be as high as 14%.8 Sur-
geons often assume that a retinal detachment that devel-
ops after vitreous surgery is rhegmatogenous in nature, as
peripheral retinal breaks and rhegmatogenous retinal de-
tachment are well-recognized complications of vitreous sur-
gery performed for other indications, including macular
pucker and proliferative diabetic retinopathy.17-19 However,
our series demonstrates that postvitrectomy retinal detach-
ments in patients with macular holes may resolve without
further surgery, as 4 of our patients with retinal detachment
had no peripheral retinal tears and had resolution of the reti-
nal detachment without further surgery.
The mechanism of formation and subsequent resolu-
tion of inferior retinal detachments after macular hole sur-
gery is unknown, but there are several hypotheses that may
explain our observations. First, some or all of these patients
had small peripheral breaks that escaped detection because
of the difficulty of examining the periphery in a gas-filled
eye. Although peripheral breaks are usually treated with la-
ser photocoagulation or cryopexy to induce a chorioretinal
scar, it is clear that some retinal holes, including macular
holes themselves, can be closed by intraocular tamponade
without the creation of a chorioretinal adhesion. In fact, the
presence of an intraocular gas bubble may exert traction on
the vitreous base and thereby open a small, occult break that
closes spontaneously as the gas resolves. Second, removal
of the cortical vitreous may increase fluid flow from the vit-
reous cavity through the macular hole. The role of the vit-
reous in restricting posterior fluid flow was reviewed
previously by Pederson.20 In the phakic, nonvitrectomized
eye, there is little fluid flow from the vitreous posteriorly,
but there is substantial fluid flow from the vitreous into the
subretinal space in experimental animals in the presence of
a retinal hole and detachment.20 The injection of fluorescein
isothiocyanate–dextran or India ink into the vitreous cav-
ity of primates or rabbits with a rhegmatogenous retinal de-
tachment leads to rapid subretinal accumulation of this
tracer.21 Experimental evidence suggests that a normal vit-
reous offers some resistance to fluid flow. Intravitreal hy-
aluronidase liquifies vitreous and accelerates clearance of
tritiatedwaterfromthevitreouscavity.22 Inaddition,thestate
of vitreous over retinal holes is important in determining the
exchange rate of fluid through the hole in patients with a
retinal detachment. After scleral buckling surgery, fluid re-
sorption may begin before the break actually settles on the
scleral buckle, because the vitreous occludes the retinal
hole.23,24 Localized neurosensory detachments created in
primates and rabbits will resolve spontaneously unless the
vitreous overlying the retinal hole is removed carefully.24,25
Thus, cortical vitreous acts as a barrier to posterior fluid flow
preoperatively in the eye with a macular hole and that re-
moval of the cortical vitreous increases fluid flow from the
vitreous through the macular hole, especially if the patient
is not strictly compliant with facedown positioning. Third,
theretinaldetachmentsthatweobservedmayhavebeenexu-
dative. This is supported by the fact that patients 1, 3, and
4 had shifting subretinal fluid (patient 2 was not checked).
However, shifting of the subretinal fluid may not be a reli-
able sign of exudation in a gas-filled eye because the large
intravitreal gas bubble will push against the inferior retinal
detachment when the patient is supine and, thus, push the
subretinal fluid posteriorly. None of the eyes had excessive
postoperative intraocular inflammation.
Regardless of the mechanism of retinal detachment
formation, some retinal detachments that develop after
macular hole surgery may resolve without further surgi-
cal intervention. Retinal detachments occurring after macu-
lar hole surgery can be observed, or they can be treated with
oral or sub-Tenon corticosteroids if no retinal tears can be
identified by careful examination of the peripheral retina.
Because the macula will receive tamponade for many weeks
after surgery, patients who develop an inferior retinal de-
tachment postoperatively without an identifiable periph-
eral retinal tear can be observed, as long as the patients re-
main in the proper facedown position. Strict facedown
positioning should be emphasized to tamponade the macu-
lar hole and to prevent the retinal detachment from spread-
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ing into the macula. Patients with postoperative retinal de-
tachments should be monitored at least twice per week, and
further surgical intervention can be considered if the macula
is threatened or the retinal detachment does not resolve
spontaneously.
Accepted for publication January 5, 1998.
This study was supported by an unrestricted grant from
Research to Prevent Blindness, New York, NY (Depart-
ment of Ophthalmology and Visual Sciences, Washington
University School of Medicine, St Louis) and core grant EY
02687 from the National Institutes of Health, Bethesda, Md.
Presented at the American Academy of Ophthalmol-
ogy Meeting, Chicago, Ill, October 29, 1996.
Reprints: Henry J. Kaplan, MD, Department of Oph-
thalmology and Visual Sciences, Washington University
School of Medicine, 660 S Euclid Ave, Box 8096, St Louis,
MO 63110-1096 (e-mail: kaplan@am.seer.wustl.edu).
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