Sir,

Subretinal bands usually occur in younger patients with long-term retinal detachment.1 After a scleral buckle procedure, a major subretinal band may prevent the fovea reattachment. It may be necessary to perform vitrectomy and retinotomy with removal or cutting of a band.2 We described two young patients with persistent fovea detachment after scleral buckling for long-term retinal detachment. Delayed development of a major subretinal band, which uplift the macula, was disrupted with neodymium:yttrium–aluminium–garnet (Nd:YAG) laser. Subretinal laser membranotomy allowed the retina to reattach gradually. Optical coherence tomography (OCT) disclosed macula reattachment after 4 and 12 months, respectively.

Case reports

Case 1

A 12-year-old boy with a 9-month history of blurred vision in his right eye presented with a long-term total retinal detachment and the best-corrected visual acuity of 20/400. After a scleral buckle procedure, inferior subretinal fluid persisted with the occurrence of a major taut subretinal band (Figure 1a) preventing macula reattachment for 4 months. Nd:YAG laser (Lightmed, USA) subretinal membranotomy was performed with a wavelength of 1064 nm, a pulse width of 4 ns, and a focal plan of up to 250 μm anteriorly. After mounting the Golmann contact lens (Haag-Streit, UK), the laser was applied to the thinner part of a band far from the macula. The end point of treatment was disruption of a band with total six pulses of 5.0 μJ/pulse. Preretinal and subretinal haemorrhage (Figure 1b) was found immediately after the procedure and resolved spontaneously within 2 months. A disrupted subretinal band (arrow) pulled apart gradually, allowing the retina to reattach (Figure 1c). Twelve months after the laser treatment, the best-corrected visual acuity improved to 20/100. OCT images disclosed macula attachment (Figure 1d). During the post-laser 18-month follow-up, no complications such as late detachment or choroidal neovascularization were encountered and the vision remained at 20/100.

Figure 1
figure 1

Fundus colour photographs and OCT in case 1. (a) A major fibrotic subretinal band after scleral bucking 4 months. (b) Nd:YAG laser subretinal membranotomy with the occurrence of haemorrhage. (c) Disrupted ends of a subretinal band (arrow) pull apart inferiorly. (d) OCT shows macula reattached after subretinal membranotomy 12 months.

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Case 2

A 23-year-old girl with a 6-month history of blurred vision in her left eye presented with a long-term inferior retinal detachment and the best-corrected visual acuity of counting finger at 20 cm. Three months after a scleral buckle procedure, the best-corrected visual acuity improved to 20/600. However, shallow detachment persisted with nasal (arrow) and temporal (arrowhead) subretinal bands extending in parallel across the macula (Figure 1a). OCT images disclosed a temporal band (arrowhead) embedded within the retina, along with a nasal band (arrow) creating a ‘clothesline’ effect (Figure 2b). Nd:YAG laser subretinal membranotomy with the same procedure as described in case 1 was targeted on the thinner part of a nasal band away from the macula. A subretinal band snapped immediately with faint subretinal haemorrhage (Figure 2c), which resolved within 1 month. A disrupted nasal band pulled apart inferiorly, allowing the retina to reattach 4 months later (Figure 2d). The best-corrected visual acuity improved to 20/400. OCT showed marked subfoveal fluid decrease with residual traction by the temporal fibrotic intraretinal band (arrowhead; Figure 2e). During the postlaser 8-month follow-up, the best-corrected visual acuity remained at 20/400 and no late complications were noted.

Figure 2
figure 2

Fundus colour photographs and OCT in case 2. (a) A fibrotic nasal (arrow) and a temporal (arrowhead) subretinal band uplift the macula after scleral bucking 3 months. (b) OCT shows a temporal intraretinal band (arrowhead), and a nasal subretinal band (arrow) elevating the macula. (c) Nd:YAG laser subretinal membranotomy targeting on a nasal band with faint haemorrhage. (d) Disrupted ends of a subretinal band pull apart gradually. (e) OCT shows marked subfoveal fluid decrease with a temporal intraretinal band (arrowhead) after subretinal membranotomy 4 months.

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Comment

Nd:YAG laser produces photodisruption, and it can be applied in disorders of posterior segment including subhyaloid haemorrhage,3 diabetic tractional retinal detachment, preretinal macular fibrosis, and vitreoretinal traction from horseshoe tears.4 In patients with retinal detachment after scleral buckling, the subfoveal fluid may persist for several months, and late subretinal proliferative vitreoretinopathy can occur.5 Significant ‘clothesline’ effects exerted by a major subretinal band result in macula detachment for at least 3 months in our two patients. We successfully perform Nd:YAG laser subretinal membranotomy to break a subretinal band that exerts significant traction and prevents macula reattachment. In these nonvitrectomized eyes of young patients, intact posterior hyaloid with no significant degenerated vitreous decreases the potential risk of detachment from a laser-induced new retinal break. However, the application of laser is limited by the location of the subretinal band. As in case 2, although the temporal band played a more significant role of macula elevation, the extrafoveal nasal band was chosen to prevent creating a new perifoveal break because a temporal band embedded within the retina.

In conclusion, Nd: YAG subretinal membranotomy is a safe and effective procedure. It can successfully disrupt a subretinal band to reattach the retina, and prevent the need for vitreoretinal surgery. For young patients with subretinal bands after a scleral buckle procedure, anatomic and visual outcomes of the subretinal membranotomy are encouraging.