Introduction/Background
Posterior retinal folds represent a rare yet potentially severe complication following
retinal detachment surgery. Although these have a considerable impact on visual outcomes,
they are still underreported in the literature, with an incidence as low as 2.8% or
as single case reports [1]. As the practice of primary vitrectomy for retinal detachment repair continues to
gain popularity [2], there is an increasing concern about the incidence of this complication [1]. Retinal folds can result in photoreceptor dysfunction, visual field defects, and
metamorphopsia, which have a significant impact on patientsʼ quality of life [3], [4], [5], [6]. This case report presents a unique example of spontaneous regression of a paracentral
posterior retinal fold following primary vitrectomy for rhegmatogenous
retinal detachment in a pseudophakic eye. This contributes to the limited body of
evidence on the natural history and management of this complication.
History and Signs
A 47-year-old male patient with a history of high myopia in the left eye (− 13.75 D
sphere with an axial length of 28.4 mm) presented with a superior bullous retinal
detachment in his left eye, 13 days after undergoing uneventful phacoemulsification
with posterior chamber intraocular lens (IOL) implantation following the diagnosis
of advanced cataract. The patient reported a sudden onset of an inferior visual field
defect. Fundoscopy revealed a superior bullous macula-on retinal detachment. Optical
coherence tomography (OCT) confirmed the macular attachment and the absence of subretinal
fluid in the foveal region ([Fig. 1]).
Fig. 1 a Optical coherence tomography (OCT) of the macula of the left eye, prior to primary
vitrectomy, with a superonasal bullous retinal detachment and macula-on. b Same OCT section as a, 4 days after primary vitrectomy with a paracentral posterior retinal fold involving
the temporal macula. c The same OCT section as a, 39 days after vitrectomy. The fold is already spontaneously regressing, and the
macular contour is recognizable, with an intact ellipsoidal zone. d Same OCT section as a, 88 days after vitrectomy. The macular fold has completely regressed spontaneously.
The patient underwent an uneventful 23-gauge pars plana vitrectomy (PPV) under general
anesthesia. The surgical procedure included fluid-air exchange, perfluorocarbon liquid
(PFCL) insertion, subretinal fluid drainage, endolaser photocoagulation, and cryotherapy
to seal the retinal breaks. The surgery concluded with the implementation of a 20%
sulfur hexafluoride (SF6) gas tamponade. The patient was advised to maintain the prone
position following the procedure. During the early post-vitrectomy period (4 days
postoperatively), as the gas began to absorb, a posterior retinal fold became evident
on OCT, extending in the paracentral region ([Fig. 1]). The patientʼs visual acuity was 20/250.
Therapy and Outcome
Given the recent reports of spontaneous improvement in some cases of post-vitrectomy
retinal folds, a conservative “watch-and-wait” approach was adopted [7], [8]. The patient was closely monitored with five follow-up visits in the first 3 months,
including visual acuity testing, fundus examination, and OCT imaging.
Over the course of approximately 3 months, a gradual and spontaneous regression of
the retinal folds was observed. Serial OCT scans demonstrated a progressive flattening
of the folds and restoration of the normal retinal contour seen 39 days post-vitrectomy
([Fig. 1]). Concurrently, the patient reported subjective improvement in visual acuity, with
an objective improvement to 20/50, and a concomitant reduction in metamorphopsia.
At 88 days post-vitrectomy, the retinal fold had completely resolved on both clinical
examination and OCT imaging ([Fig. 1]). The patientʼs BCVA had improved to 20/20, with no residual metamorphopsia.
Discussion
This case demonstrates the potential for spontaneous resolution of posterior retinal
folds following vitrectomy for retinal detachment, even in the presence of multiple
risk factors for fold formation. The formation of posterior retinal fold risk factors
has been linked with multiple risk factors in the literature, including the use of
intraocular gas tamponade, recent onset of detachment, and a superior bullous configuration
of the detachment. Other contributing factors include large circumferential buckles,
external drainage of subretinal fluid, incomplete internal drainage during vitrectomy,
and detachment involving the fovea, which creates conditions that facilitate the formation
of folds through mechanical and fluid dynamics [1], [8], [9], [10], [11].
In our case, the posterior paracentral retinal folds most likely resulted from a combination
of factors, such as the gas tamponade, the presence of residual subretinal fluid,
and possible retinal slippage during fluid-air exchange [1], [9], [11]. The gradual resolution of the fold over a 3-month period indicates that the elasticity
of the retina and the potential intrinsic reparative processes of the eye can, in
certain cases, overcome the structural alterations induced by fold formation [1], [12]. It is important to note that the type of retinal fold can influence management
decisions [13]. While partial-thickness or outer retinal folds can often be managed conservatively,
as seen in our case, full-thickness retinal folds more frequently require surgical
intervention, depending on the clinical course and
progression [14].
The current literature lacks standardized treatment recommendations for post-vitrectomy
posterior retinal folds. While some case reports recommend prompt surgical intervention,
particularly in cases of substantial retinal slippage, others advocate a more conservative
approach [5], [12]. Our case study lends support to the latter strategy, demonstrating that a “wait-and-see”
approach can lead to excellent visual outcomes without the need for additional surgical
intervention.
In conclusion, this case report underscores the importance of considering conservative
management in cases of post-vitrectomy posterior retinal folds due to their potentially
benign prognosis, even when multiple risk factors are present. Further research is
needed to better understand the natural history of this complication and to develop
evidence-based guidelines for its management. Careful patient selection, regular monitoring,
and shared decision-making remain crucial in determining the optimal approach for
each individual case.
