Progressive atrophy of retinal pigment epithelium after trypan-blue-assisted ILM peeling for macular hole surgery
A 68-year-old phakic Caucasian female presented with decreased central vision in the left eye for the past 18 months secondary to a large macular hole. She denied any prior history of trauma, high myopia, or any other ocular problems. Her presenting visual acuity was 20/200. A full-thickness stage-3 macular hole measuring 680μ in diameter on color photographs (OIS WinStation™ software, Ophthalmic Imaging Systems, Sacramento, CA) was diagnosed. []. An intravenous fluorescein angiogram showed mild hyperfluorescence at the base [], but no obvious atrophy of the retinal pigment epithelium was observed on clinical photographs. The right eye was 20/20, with normal appearing macula. A 20-g pars plana vitrectomy was performed using Accurus machine (Alcon, Fort Worth, TX) under local anesthesia. Halogen illumination at 100% intensity built into the Accurus was used for endoillumination. Posterior vitreous detachment was created by suction with the cutter nasal to the nerve and was confirmed by a visible Weiss ring in the vitreous cavity. After completion of vitrectomy, fluid air exchange was performed and 0.2 ml 0.06% TB (VisionBlue™, DORC Netherlands) was injected over the macular area. The sclerotomy sites were plugged and the microscope light was turned off during the staining period. After waiting for 2 min, air fluid exchange was performed. Process was repeated and TB was left for another 2 min because of poor staining of the ILM. Microforceps were used to remove the ILM completely for about 2 disk diameters around the hole. No subretinal TB was observed beyond the macular hole. Endoilluminator was kept as far away from the macular hole as possible during the ILM peel. Fluid air exchange was performed with a silicone-tipped cannula. Air pressure was set at 35 mm Hg during all fluid air exchanges. No attempt was made to drain through or near the macular hole at any time. Fourteen percent C3F8–air mixture was used for tamponade followed by face-down position for 2 weeks.\nA ring-shaped area of hypopigmentation corresponding to the edge of the macular hole was noted one month after surgery []. Seven months after surgery, atrophy of the RPE involved the entire base and edge of the macular hole []. Spectral domain optical coherence tomography (OCT) showed closed macular hole, defect in inner segment/outer segment junction, and increased transmission of light consistent with RPE atrophy []. Two years after surgery, area of RPE atrophy had increased in intensity and also showed slight enlargement in size to 790μ in diameter [], and spectral domain OCT demonstrated closed macular hole, defect in IS/OS junction, further attenuation of outer retinal layers, and increased transmission of light []. Her visual acuity was 20/200 3 months after surgery, but declined to counting fingers 2 years postoperatively with no improvement with refraction. She developed moderate nuclear sclerosis, which was not believed to be responsible for such a profound loss of vision. The right eye has remained 20/20 without any RPE atrophy, or changes of age-related macular degeneration. She denied history of chloroquine or hydroxychloroquine intake.