Subretinal fluid after retinal reattachment

[sjsjin]

I had successful cataract removal and IOL implantation in both eyes in July, 2009. On December 4 in the middle of a business trip, I awoke to find my left eye full of new floaters. I managed to locate a retinal specialist who could see me that day, and he said he was "very confident" that all I had suffered was a PVD, that he found no evidence at all of a tear or detachment.

However, I did suffer a major detachment in my left eye while in the air on my trip home late on December 10. By the time I arrived at the retina specialist the next morning, it had progressed to the macula. The choice was surgery in 3 days at a facility far away, or in 6 days at one much closer to home. The doctor told me the delay would not affect the outcome, so I opted to wait 6 days. Two days before the surgery, I woke up and surprisingly found that nearly all of my vision had returned, though it was very warped and distorted. I could only see the "gray curtain" in a very thin area next to my nose.

PPV, laser repair, and pneumatic retinopexy were completed on December 17. At post-op exam the next day, he said that all went well, the retina was flat and beautiful.

I noted many more black floaters the next week, went in for a check on January 6, he found no issues, and rescheduled next follow up in 3 weeks. While my VA in the affected eye was 20/50, I told the nurse that the characters were very jagged and distorted, and all of them were much narrower than they should be when I looked directly at them, while the characters at the ends of the line were stretched much wider. Doctor didn't think it was an issue.

On January 15, I noted a dark spot in the periphery close to where the original tear started. Got in ASAP, he confirmed another tear, immediately treated it with the laser, and the exam the next week confirmed it was a success.

On January 29, the bubble was down to 5% and he cleared me for return to work, though I continued to complain of significant distortions and very poor depth perception, which he said could not have been caused by the retina surgery, to go back and see my regular ophthalmologist.

I noted more flashing and flickering in the affected eye a couple of nights ago, plus a large new floater that extends across almost the entire field of vision, so I returned to the office. My VA in the affected eye had actually improved to 20/25 (when the floater wasn't interfering) but the characters, while sharp enough to read, were still very warped, jagged, and narrow. I have the choice of reading clearly with my right eye only, slowly reading distorted text with my left eye only, and not being able to read at all with both eyes open.

I "expressed quite strongly" my exasperation regarding the lack of attention to my complaints to the doctor, who then ordered an OCT and regular visible light photos of my retina. The photos looked fine, but when he then looked at the OCT, he said "Oh, gee, we do have an explanation for this now!"

He pointed out several "pockets of subretinal fluid" (he didn't use the term "cystoid macular edema") and one is directly under the fovea. The fovea doesn't show the typical concave shape on OCT, it actually bows out slightly from the adjoining surface. He said "Wow, right in the center, that must be incredibly annoying!" His advice was to let this resolve itself, but it might take 3 months or longer.

I have been off work since suffering the detachment because my office is 55 miles from home, and if I am not in the office, I am generally traveling on business, mostly driving to places with which I'm not very familiar, often at night. Impossible with my vision in this condition! My short-term disability has run out, and because my VA is so "good", it seems I will not be approved for a continuation.

The doctor agrees that I have severe floaters in my other eye, which has him concerned that I am likely to suffer a detachment in that eye, too. The floaters are so bad that if I occlude just the central distorted image from my left eye while driving and attempt to rely on the right eye for all central vision, those floaters often occlude the entire center of the image from my right eye. It's worse than when I had the cataracts and vision in my right eye was not correctable to 20/200...at least the much clearer image from my strongly dominant left eye predominated.

I printed out an Ambler Grid yesterday. My metamorphopsia is such that not only are 100% of the grid lines wavy and jagged at 14 inches, the entire sheet of paper is warped. About 30% of the lines seem to disappear in a dark beige blur, the rest are relatively sharply focused.

More reading on the web over the past couple of days has me worried that simply waiting for the fluid to diffuse back out and the distortions to go away might result in permanent damage to the fovea. He suggested no NSAID drops or other intervention to possibly speed up the process. With the potential for detachment in my right eye as it is, I don't want lose any more function in my left if at all possible.

I also read that subretinal fluid or CME is experienced by possibly 45% of patients after successful retina reattachment. If that is so, why was it so hard for me to get him to order an OCT to confirm that was the source of my problems?

Thanks!

[Ray T Oyakawa, MD]

Yes.

Dr. O.

[sjsjin]

Thanks, Doctor.

I wondered why they did only the visible light photos and not the fluorescein angiogram, because that's what was done in January '08 to confirm that all of my problems at the time were due to the cataracts.

I am extremely fair skinned, and the doctor how examined me in NC when the floaters appeared said that because I had "blonde fundus", he would use a contact lens and do a much more thorough slit lamp examination to find small tears. Several other eye doctors who have examined me over the years have commented on how little pigmentation they see.

Does that make finding tears a lot more difficult?

Thanks again!

[Ray T Oyakawa, MD]

You should also get a flourescein angiogram to determine where the fluid is coming from.  Residual subretinal fluid is not a good sign and usually means that a tear is not completely closed.  CME will give a certain pattern on flourescein angiogram.

Dr. O.