OSLI Retina

August 2019

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510 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina ■ T E C H N I Q U E ■ Intraoperative Drainage of a Bullous Serous Pigment Epithelial Detachment Robert A. Sisk, MD, FACS BACKGROUND AND OBJECTIVE: To describe a novel, simple technique for surgically draining a bullous serous pigment epithelial detachment (PED). PATIENTS AND METHODS: Pars plana vitrectomy was performed with confirmed elevation of the hyaloid face. Proportional diathermy allowed stepwise entry into the PED superotemporally through an initially small, needle-point focus while provid- ing control of any potential bleeding. Thick fluid was aspirated with a soft-tipped cannula, fluid-air exchange was performed, and intravitreal bevaci- zumab was injected before removing the cannulas. RESULTS: The PED was successfully completely drained intraoperatively and remained flat at 1 week postoperatively. However, the draining site ultimately closed, and continued exudation from choroidal neovascularization led to recurrent PED and eventual nonhemorrhagic retinal pigment epithelial tear despite aggressive treatment with aflibercept and photodynamic therapy. The early visual acuity benefit may relate to resolution of hy- peropic shift. CONCLUSION: Serous PED can be surgically reduced without hemorrhagic complications, but long-term success depends upon control of the underlying choroidal neovascularization. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:510-513.] INTRODUCTION Pigment epithelial detachment (PED) is a round elevation separating the retinal pigment epithelium (RPE) from Bruch's membrane in conditions like exudative age-related macular degeneration (AMD), polypoidal choroidal vasculopathy, and central se- rous chorioretinopathy. 1 PED associated with cho- roidal neovascularization (CNV) may be poorly re- sponsive to anti-vascular endothelial growth factor (VEGF) intravitreal injections and photodynamic therapy (PDT). 2 Severe forms of PED may lead to RPE tear with associated subretinal hemorrhage (SRH) and risk for severe vision loss despite aggres- sive conventional treatment. 3,4 Case Report A 76-year-old female presented with massive sub- macular hemorrhage associated with RPE tear from wet AMD in her left eye (OS) (Figure 1). She under- went successful displacement of SRH by vitrectomy, subretinal injection (tissue plasminogen activator [tPA], bevacizumab [Avastin; Genentech, South San Francisco, CA], and air), and gas-fluid exchange with 20% sulfur hexafluoride. Unfortunately, despite ana- tomic success and continued monthly anti-VEGF therapy, her vision remained finger counting at 3 feet. Eight months after surgery, her right eye (OD) developed new wet AMD (Figure 2) with gradually enlarging serous PED despite injections of intravitreal bevacizumab and aflibercept (Eylea; Regeneron, Tar- rytown, NY) every 4 weeks, indocyanine green-guid- ed reduced-fluence PDT, and off-label intravitreal dexamethasone implant (Ozurdex; Allergan, Dublin, Ireland) injection. Inspection 2 weeks after aflibercept From Cincinnati Eye Institute, Cincinnati; the Department of Ophthalmology, University of Cincinnati, Cincinnati; and Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center, Cincinnati. Originally submitted August 13, 2018. Revision received November 15, 2018. Accepted for publication January 17, 2019. This technique will be presented at the 51st Annual Retina Society Meeting in San Francisco on September 12, 2018. The author reports no relevant financial disclosures. Address correspondence to Robert A. Sisk, MD, FACS, Cincinnati Eye Institute, 1945 CEI Drive, Cincinnati, OH 45242; email: rsisk@cincinnatieye.com. doi: 10.3928/23258160-20190806-06

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