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Iatrogenic macular hole during liquid perfluorocarbon injection in retinal detachment surgery
Agujero macular iatrógeno durante la inyección de perfluorocarbono líquido en una cirugía de desprendimiento de retina
N. Ruiz del Rio
, F. Garcí Ibor, D. Hernandez Perez, A.M. Duch Samper
Corresponding author
Departamento de Cirugía, Facultad de Medicina, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
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Agujero macular completo y burbuja de perfluorocarbono subretiniana. B) Funduscopia en el postoperatorio, con presencia de gas en la cavidad vítrea. C) Imagen de OCT del agujero macular completo con edema perilesional. D) Imagen de OCT un mes después de la cirugía de DR con el agujero macular completo de mayor diámetro y aumento del edema perilesional.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Ruiz del Río, F. García Ibor, D. Hernández Perez, A.M. Duch Samper" "autores" => array:4 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Ruiz del Río" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "García Ibor" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Hernández Perez" ] 3 => array:2 [ "nombre" => "A.M." 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(A) Macular OCT of the left eye: shows hard exudates and microaneurysmal lesion marked with red arrow. (B) Angio-OCT and en face: hyperreflective spot in deep plexus. (C) FAG: microaneurysm in posterior pole, marked with red arrow, with minimal paramacular exudative component at late times, with no signs of peripheral ischemia. (D) Colour fundus photograph of the left eye.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Sotomayor-Toribio, F. López-Herrero, J.L. Sánchez-Vicente, B. González-Jáuregui, C. Rodríguez-Fernández, J. Suárez-Pérez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Sotomayor-Toribio" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "López-Herrero" ] 2 => array:2 [ "nombre" => "J.L." "apellidos" => "Sánchez-Vicente" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "González-Jáuregui" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Rodríguez-Fernández" ] 5 => array:2 [ "nombre" => "J." 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Asensio-Sánchez" "autores" => array:1 [ 0 => array:2 [ "nombre" => "V.M." "apellidos" => "Asensio-Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669123000850" "doi" => "10.1016/j.oftal.2023.04.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669123000850?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579423000828?idApp=UINPBA00004N" "url" => "/21735794/0000009800000007/v1_202307031243/S2173579423000828/v1_202307031243/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Iatrogenic macular hole during liquid perfluorocarbon injection in retinal detachment surgery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "413" "paginaFinal" => "416" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "N. Ruiz del Rio, F. Garcí Ibor, D. Hernandez Perez, A.M. Duch Samper" "autores" => array:4 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Ruiz del Rio" "email" => array:1 [ 0 => "Noe_ruiz@gva.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Garcí Ibor" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Hernandez Perez" ] 3 => array:2 [ "nombre" => "A.M." "apellidos" => "Duch Samper" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Cirugía, Facultad de Medicina, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Agujero macular iatrógeno durante la inyección de perfluorocarbono líquido en una cirugía de desprendimiento de retina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1262 "Ancho" => 1340 "Tamanyo" => 159608 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Macular OCT after ILM peel and reverse flap surgery. Hyper-reflective material can be seen above the ILM and occupation of the macular hole defect with homogeneous hyper-reflective material with disruption of the outer retinal layers. (B) OCT 6 months after macular hole repair surgery, there is a recovery of the ultrastructure of the foveal area.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Perfluorocarbon liquids (PFCLs) are chemical compounds that do not occur in nature. They are formed from hydrocarbon molecules in which hydrogen atoms are replaced by fluorine atoms. These compounds are produced by methods such as electrochemical fluorination, oligomerisation and telomerisation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">PFCLs have been used in vitreoretinal surgery as buffers for short-, medium- and long-term use. Some indications for use are: repositioning and stabilisation of a detached retina, facilitating the drainage of subretinal fluid in retinal detachment, protecting the macular area in surgery for lens dislocation or intraocular lens dislocation in the vitreous cavity, easing the drainage of suprachoroidal hemorrhages, protecting the macula if potentially toxic substances are used during surgery1. In addition, it has also been described to facilitate the placement of the inner limiting membrane inverted flap in cases of macular hole.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> PFCLs are a useful and safe tool in vitreoretinal surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand, some side effects derived from their use in vitreoretinal surgery have been described, including corneal toxicity with endothelial decompensation in cases of migration to the anterior chamber, retinal inflammatory reaction similar to a foreign body reaction when they are used as postoperative buffers and remain in the vitreous cavity for more than a week, a reversible alteration when they are removed.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Cases of acute retinal toxicity have also been reported with the use of intraoperative PFCLs, especially perflorooctane (PFO). Recently, numerous cases have been reported from Europe, the Middle East and South America linking intraoperative PFO and subsequent amaurosis. In these cases, toxicity has been associated with the acidity of the intravitreal medium after PFO injection. In these cases, ISO guidelines (ISO 16672:2020) have been developed in 2019 recommending direct cytotoxicity tests on live cells as well as chemical analyses to measure the quality and safety of the fluids.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Emphasising the need to control the quality of the products, both purity and safety.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">Male, 73, with a history of simple myopia, decreased visual acuity in the right eye with myodesopsia and photopsia of 48<span class="elsevierStyleHsp" style=""></span>h' evolution. Visual acuity (VA) was 20/30 in the RE and 20/20 in the LE. Intraocular pressure (IOP) is normal. Funduscopy showed a superotemporal retinal detachment with a horseshoe tear and preservation of the macular area in the RE (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). Optical coherence tomography (OCT) confirmed the integrity of the macular area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A 23G-gauge vitrectomy is indicated and injection of liquid perfluorocarbon is used to facilitate the outflow of subretinal fluid through the superior tear. An intraocular pressure of 15<span class="elsevierStyleHsp" style=""></span>mmHg was programmed during the fluid injection. For manual injection, a 10<span class="elsevierStyleHsp" style=""></span>ml syringe and a one-way silicone-tipped cannula were used, always injecting into the bubble and in the direction of the papilla, assessing pressure changes through the papillary pulse. During injection, a full-thickness macular hole was ioatrogenically produced and a large bubble of PFCL lodged in the freshly dissected subretinal space (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a). Part of the bubble volume refluxed through the macular hole when releasing the pressure on the plunger of the injection device. The remainder of the subretinal volume of PFCL was removed by aspiration through the newly created hole, thus avoiding a new retinotomy. Removal of the fluid through the peripheral retinal tear was impossible. The retinal detachment was then repaired. The subretinal fluid was drained through the macular hole, liquid-air exchange was performed, the peripheral tear sealed with cryotepexy and the air replaced with SF6 20% gas. Postoperatively, a full-thickness macular hole was evident (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b), with a hole diameter of 180 microns on OCT and cystoid edema at the margins of the hole (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>c). One month after RD the macular hole had not closed and the perilesional edema had increased (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>d). A vitrectomy with peeling of the internal limiting membrane (ILM) and reverse flap of the ILM was indicated. The technique had a good anatomical result with closure of the macular hole, (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>a) OCT showed a homogeneous hyperreflective material disrupting the outer retinal layers in the foveal area. Six months later the structure of the outer retina was restored except for a 350<span class="elsevierStyleHsp" style=""></span>micron segment in the line corresponding to the outer segments of the photoreceptors, VA being 20/30 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>b). Twelve months after surgery the VA was 20/25 and the disruption in the line of the photoreceptor outer segments had reduced to 180 microns (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>c).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Iatrogenic macular holes produced during vitrectomy surgery are a very rare complication. It has been described in relation to the injection of dyne blue in epiretinal membrane surgery.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Increased macular hole diameter during macular hole surgery has also been described and sudden intraocular pressure variations during air exchange using strong suction has been proposed as a pathophysiological process.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The use of perfluorocarbon in vitreoretinal surgery has many advantages, although it is not without complications, the most serious of which, described in recent times, is retinal toxicity.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> So far, no case of macular hole produced during perfluorocarbon injection has been reported.</p><p id="par0040" class="elsevierStylePara elsevierViewall">One hypothesis would be the difference in elasticity and pressure resistance that the inner retinal layers might have in comparison to the pigment epithelium of the retina.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Considering the ultrastructure of the retina, it is the Müller cells that maintain the inner architecture of the retina, from the inner to the outer limiting membrane.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> When tissue dissection occurs, fluid enters the virtual space above the retinal pigment epithelium, which is excluded from the cohesion provided by the Müller cells. The outer limiting membrane is below the cell body of the photoreceptors, and only the outer segments of the photoreceptors would be below. The histological structure of the foveal area is much simpler, and the Müller cells form the foveal cone on the one hand and are included in the retinal structure in an oblique or horizontal arrangement on the other hand.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> is therefore the most vulnerable point for pressure changes that could lead to the formation of a macular hole.</p><p id="par0045" class="elsevierStylePara elsevierViewall">When using the one-way silicone-tipped injection cannula, intraocular pressure control is coarse, assessing the perfusion in the papilla. Although we lower the intraocular pressure automatically, when injecting the PFCL manually there is a pressure balance offset. We use small incisions and trocars, usually valved, which hinder the drainage of intraocular fluid. The two-way injection cannula allows for better maintenance of intraocular pressure by allowing fluid to flow out without resistance as the LCP injection occurs.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1924335" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1659205" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1924336" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:1 [ "identificador" => "abst0015" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Caso clínico" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1659206" "titulo" => "Palabra clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1659205" "palabras" => array:3 [ 0 => "Complete macular hole" 1 => "Iatrogenic macular hole" 2 => "Perfluorocarbon liquid" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To describe a macular hole development during intravitreal injection of perfluorocarbon liquid used to repair a regmatogenous retinal detachment.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical case</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A 73-year-old man presented with superotemporal regmatogenous retinal detachment. During surgery, along the perflorocarbon liquid injection, a full thickness macular developed and perfluorocarbon was accumulated in subretinal space. Perfluorocarbon liquid was then extracted through the macular hole. Postoperatively, ocular coherence tomography confirmed the existence of a full-thickness macular hole. One month later, this macular hole was successfully treated with the use of an Inverted internal limiting membrane flap.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Intravitreous liquid PFC injection is a resource to aid in subretineal fluid exit. A number of complications, both intra and postoperative, have been associated with the use of PFC. This is the first reported case of a complete macular hole secondary to PFC injection.</p></span>" "secciones" => array:2 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Reportar la formación de agujero macular durante la inyección intravítrea de perfluorocarbono líquido en la cirugía programada de desprendimiento de retina.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Caso clínico</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Varón de 73 años con desprendimiento de retina regmatógeno superotemporal. Durante la inyección de perfluorocarbono líquido se produce un agujero macular de espesor completo con acumulación del perfluorocarbono en el espacio subretiniano. El líquido se extrajo a través del agujero macular. La tomografía de coherencia ocular confirmó un agujero macular de espesor total en el examen postoperatorio. Un mes después se repara con técnica de colgajo invertido de membrana limitante interna con resultado funcional satisfactorio.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La inyección de perflurocarbono líquido intravítreo es electiva, facilita el drenaje del fluido subretiniano en los desprendimientos de retina. Algunas complicaciones han sido asociadas a su empleo, intraoperatorias y postoperatorias. Hasta el momento no ha sido reportado ningún caso de agujero macular completo producido durante la inyección intravítrea de perfluorocarbono.</p></span>" "secciones" => array:2 [ 0 => array:1 [ "identificador" => "abst0015" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Caso clínico" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1846 "Ancho" => 1340 "Tamanyo" => 193197 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Retinal detachment of the right eye with tear in the superotemporal horseshoe. B. Optical coherence tomography with preservation of macular anatomy.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2306 "Ancho" => 1340 "Tamanyo" => 279818 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Intraoperative image. Complete macular hole and subretinal perfluorocarbon bubble. (B) Postoperative funduscopy, with presence of gas in the vitreous cavity. (C) OCT image of complete macular hole with perilesional edema. (D) OCT image one month after RD surgery with full macular hole of larger diameter and increased perilesional edema.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1262 "Ancho" => 1340 "Tamanyo" => 159608 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Macular OCT after ILM peel and reverse flap surgery. Hyper-reflective material can be seen above the ILM and occupation of the macular hole defect with homogeneous hyper-reflective material with disruption of the outer retinal layers. 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