Sir,

Posterior retinal folds have been rarely reported after the use of intravitreal gas combined with scleral buckling.1, 2 We report a case where a symptomatic retinal fold developed after scleral buckling and intravitreal gas injection and spontaneously regressed a year later.

Case report

A 43-year-old woman, presented with a superotemporal bullous retinal detachment (RD) sparing the macula, with a U-tear at 1 o'clock hours. Best-corrected visual acuity (BCVA) was 20/20. The patient underwent uncomplicated scleral buckling (SB) procedure during which preplacement of scleral sutures, drainage of subretinal fluid (SRF), and placement and tightening of a circumferential solid (276) silicone tire extending from 12 to 3 h were carried out; additionally, as the eye was still hypotonous, 1 ml of air was injected intravitreally. In the first postoperative day, the retina was attached; however, a retinal fold extending from the area of the buckle towards the posterior pole, involving the superior arcade and distorting the macular area (Figure 1a and b) was noted. The patient complained for disturbing metamorphopsia and VA could not improve more than 20/80. After a discussion on underlining benefits and risks of possible treatment options, the patient denied further surgery.

Figure 1
figure 1

The first postoperative day; although the retina is flat, a retinal fold is formed extending from the indentation of the buckle (a) towards the posterior pole and the nasal side of the optic disc (b).

Six months later, BCVA was 20/30 and the retinal fold less was prominent (Figure 2). Twelve months postoperatively, as the indentation of the buckle had completely flatten (Figure 3a), the retinal fold regressed (Figure 3b) and BCVA was 20/20.

Figure 2
figure 2

Six months after surgery, the retinal fold has partially ‘ironed out’ corresponding with an improvement in the visual acuity.

Figure 3
figure 3

An year after surgery, as the indentation of the buckle has diminished in height (a), the retinal fold has completely flatten (b), and visual acuity has restored to 20/20.

Comment

Posterior retinal folds have been rarely reported after the use of intravitreal gas combined with SB.1, 2 A circumferential SB occupies a substantial part of the intraocular volume and thereby makes retinal tissue relatively redundant. Retinal folds have been considered to form by the combined action of gravity and intravitreal gas bubble to the redundant retina, which is pushed posteriorly.3 If the SRF is then absorbed, an arcuate retinal fold could remain, and if the macula is involved, vision could be impaired.1, 2, 3, 4 Surgical treatment of symptomatic retinal folds with vitrectomy, induction of an RD with injection of saline subretinally, and relocation of the retina with gas5 or with perfluorohexy-loctane(F6H8)6 have been reported in the literature.

In our patient, the retinal fold did not involve the fovea; however, it distorted the macular (Figure 1) area causing metamorphopsia and decreased VA. As the indentation of the buckle diminished in height within the next months, the retina gradually unfolded and VA was completely restored.

Our case illustrates the rare but possible occurrence of arcuate retinal folds, which could compromise the results of successful retinal reattachment surgery. We postulate that in our case, the formation of the retinal fold might have been prevented if the air was injected after the drainage of SRF and a gentler buckle was placed when the retina was more or less completely reattached. It could be also postulated that in cases where permanent indentation is not necessary, the removal of the circumferential buckle might be an option for the treatment of symptomatic arcuate retinal folds, as in our patient, the retinal fold regressed when the buckle indentation diminished in height.