Abstract
Introduction
Tractional retinal detachment (TRD) can be caused by proliferative diabetic retinopathy (PDR), proliferative sickle cell retinopathy, proliferative vitreoretinopathy, Von Hippel-Lindau disease, exudative vitreoretinopathy, or Coats disease.1,2 These diseases are usually associated with inflammation, retinal neovascularization, or both, leading to glial cell proliferation and accompanying fibrosis through an anomalous wound-healing process. 2
Surgical treatment is typically indicated for TRD to prevent further vision loss. Treatment consists of a pars plana vitrectomy (PPV) to alleviate tractional elements, including removal of epiretinal membranes (ERMs) and/or subretinal membranes. 3 Although literature exists regarding nonsurgical spontaneous reattachment of all types of RDs, it has been more commonly reported in relation to rhegmatogenous RD (RRD), with spontaneous TRD reattachment being a rare phenomenon. 4
In this case series, we report the clinical examination and optical coherence tomography (OCT) features in 4 cases of spontaneous retinal reattachment after diagnosis of a macula-off TRD.
Methods
The clinical course and OCT features of patients with spontaneous reattachment of macula-off TRDs were evaluated. The series comprised 4 eyes of 4 patients with a history of macula-off TRD secondary to DR (n = 3) or sickle cell retinopathy (n = 1).
Results
Case 1
A 63-year-old woman with a history of sickle cell trait presented to our clinic reporting blurred vision in the right eye. The patient was functionally monocular as a result of a history of neovascular glaucoma, resulting in severe vision loss in the fellow eye. The visual acuity (VA) was 20/60 OD and light perception OS. A posterior segment examination showed evidence of an ERM and vitreomacular traction with peripheral sea-fan neovascularization temporally and preretinal hemorrhage at the 9 o’clock position along with a partial posterior vitreous detachment (PVD).
Given the monocular status, the patient was observed every 6 months until 18 months later, when she was noted to have developed a macula-off TRD with decreased VA to 20/200 (Figure 1, A and C). There was a mild ERM with severe vitreomacular traction elevating the macula. Surgical intervention was discussed; however, the patient was reluctant to proceed. Subsequent visits did not show a significant change in vision or the status of the TRD. However, 10 months after the initial TRD diagnosis, the VA improved to 20/60. The examination and imaging showed spontaneous improvement in the TRD, despite the vitreomacular traction persisting (Figure 1, B and D). The macula remained attached as of the last visit approximately 11 months after the spontaneous reattachment.
Optical coherence tomography (OCT) shows spontaneous resolution of the tractional retinal detachment (TRD) resulting from proliferative sickle cell retinopathy, with widefield fundus imaging showing spontaneous resolution of the TRD. (A) Baseline OCT presentation. (B) OCT shows spontaneous reattachment. (C) Baseline fundus presentation. (D) Fundus image shows spontaneous reattachment.
Case 2
A 33-year-old man with diabetes was referred for blurred vision in the left eye for 1 month. He had a history of panretinal photocoagulation (PRP) for PDR in the left eye. His glycosolated hemoglobin (HbA1c) was 7.3%. The VA was 20/30 OD and 20/70 OS. An examination of the left retina showed a macula-off TRD (Figure 2A) with neovascularization overlying the optic disc and along the superotemporal and inferotemporal vascular arcades with a flat peripheral retina. Additional PRP was promptly performed, and the need for early surgical intervention to repair the TRD was discussed with the patient.
Optical coherence tomography (OCT) shows spontaneous resolution of the tractional retinal detachment in a patient with diabetes. In the near-infrared image on the left, the neovascular tissue is apparent over the disc and along the arcades in a wolf-jaw configuration, appearing as a dark curvilinear opacity that is obscuring the disc and vessels. (A) Baseline presentation. (B) Spontaneous reattachment is seen.
One month after receiving 2 sessions of PRP, the patient returned with a dramatic improvement in the TRD and a VA of 20/40 without evidence of further posterior vitreous separation (Figure 2B). Four months later, the VA decreased to 20/200 as a result of a recurrence of superotemporal and inferotemporal traction, causing a macula-off TRD and increased subretinal fluid (SRF) without apparent changes in posterior vitreous separation. The patient had surgical repair with a PPV and membrane peeling. One year later, the VA had improved to 20/80 and the retina remained successfully attached.
Case 3
A 47-year-old man was referred to our clinic with a 3-week history of blurry vision in the left eye. The VA was 20/40 OD and 20/80 OS. An examination of the retina showed an active vitreous hemorrhage (VH) in the left eye caused by PDR and fibrotic tissue overlying part of the macula and along the superotemporal arcade (Figure 3A). The HbA1c was 8%. The patient received an aflibercept injection (Regeneron) in the left eye. Six weeks later, the VA was 20/70 and an examination showed improvement in the VH but development of a fovea-involving TRD (Figure 3C).
Widefield fundus imaging shows spontaneous resolution of the tractional retinal detachment (TRD) in a patient with diabetes. Optical coherence tomography (OCT) shows spontaneous resolution of the TRD. (A) Baseline OCT presentation. (B) OCT shows spontaneous reattachment. (C) Initial fundus presentation. (D) Fundus image shows spontaneous reattachment.
Surgical intervention was recommended for TRD repair. However, the patient canceled the surgery and was lost to follow-up for 2 months. On his return, the VA had improved to 20/50. On examination, the TRD had settled centrally and OCT showed only trace SRF (Figure 3, B and D). The posterior segment examination showed partial PVD and severe PDR. The patient received PRP and did not required surgery through an additional 19 months of follow-up, with OCT showing resolution of the SRF.
Case 4
A 48-year-old woman with diabetes presented with floaters in the right eye. Her HbA1c was 6%. The VA was 20/25 OU. A dilated fundus examination and fluorescein angiography showed PDR in both eyes, and bilateral PRP was performed.
The patient was lost to follow-up for 1 year before returning with an acute decline in vision in the right eye. The VA was hand motions as a result of a VH. B-scan ultrasonography showed no tractional component at the time. The patient received 1 aflibercept injection in the right eye and was lost to follow-up for another year before again presenting with an acute decline in central vision in the same eye. The VA was 20/50, and a fundus examination and OCT confirmed a macula-off TRD extending into the temporal and inferior periphery (Figure 4, A and C). The patient was scheduled for surgery at this visit but did not return for another year.
Optical coherence tomography (OCT) shows spontaneous resolution of the tractional diabetic detachment (TRD) in a patient with diabetes. Widefield fundus imaging shows spontaneous resolution of the TRD. (A) Baseline OCT presentation. (B) OCT shows spontaneous reattachment. (C) Baseline fundus presentation. (D) Fundus image shows spontaneous reattachment.
When the patient returned, the VA had improved to 20/40 OD. A clinical examination showed a localized area of SRF inferiorly with no evidence of posterior vitreous separation. However, OCT showed that the fovea was now attached with a substantial decrease in the SRF (Figure 4, B and D). The macula remained attached as of the last visit, which took place approximately 26 months after the initial spontaneous reattachment.
Conclusions
Spontaneous TRD reattachment has been reported less commonly than spontaneous RRD reattachment. Before the widespread use of vitrectomy, one study reported a 20% rate of spontaneous reattachment of diabetic TRDs that were observed over a mean period of 4.6 years.5 Another study reported spontaneous reattachment in 5 of 15 eyes with diabetic TRDs that were observed for 6 to 14 months. 6 However, these studies preceded the development of OCT. Unlike RRDs that are believed to spontaneously reattach as a result of relief of traction on breaks and/or vitreous fibers or membranes that interrupt the flow of fluid through the retinal breaks,4,7 TRDs are often believed to spontaneously reattach with an alteration in the tractional forces. Despite the understanding that tractional forces must dissipate for reattachment to occur, there is poor consensus on how traction is typically relieved in these patients.
Although PVD is thought to play a significant role in spontaneous reattachments, no complete posterior vitreous separation was documented and tractional membranes remained present in all cases. In this situation, the worsening TRD may have resulted from contraction of fibrovascular membranes that later relaxed. In 2 of the cases, the macula-off TRD occurred soon after an antivascular endothelial growth factor (anti-VEGF) injection or PRP, possibly related to VEGF attenuation. In patients with sickle cell, autoinfarction is a known phenomenon that may be related to spontaneous decreases in VEGF levels, perhaps resulting from more complete cell death in peripheral ischemic areas. 8
Attenuation of VEGF levels has been associated with increases in other cytokines, such as transforming growth factor-β (TGF-β), 9 which may have led to fibrosis and contracture of the fibrovascular proliferation, thereby inducing or exacerbating a TRD. Elevated vitreous concentrations of TGF-β isoforms from patients with PDR are strongly correlated with enhanced contractility of hyalocyte-containing collagen gel matrices. 10 Perhaps in some of these cases, gradual relaxation of the fibrotic membranes occurs as VEGF levels rebound or as a new homeostatic environment develops with an alteration in the cytokine milieu, leading to the spontaneous reattachment.
Alternatively, it is possible there may have been partial release of the tractional membranes over time that permitted the macula to settle back down despite these membranes appearing to still be attached on clinical examination. Unfortunately, without peripheral OCT imaging through the membranes, it is not possible to determine whether such a mechanism might have contributed.
The other possible mechanism would be progressive vitreous liquefaction over time (without posterior vitreous separation), resulting in decreased anteroposterior traction on the fibrovascular membranes. In patients with DR, vitreoschisis may play an additional role in causing temporized relief of anteroposterior tractional forces, although the potential for hemorrhage into this plane may propagate fibroproliferative traction. 11
In Case 2, the TRD seemed to improve initially after PRP before later redetaching and requiring surgical intervention. One hypothesis is related to the finding that PRP has been associated with an acute increase in interleukin-6 (IL-6), an inflammatory cytokine. 12 This could be one reason some patients develop worsening macular edema after PRP. A study by Inoue-Mochita et al 13 found that IL-6 inhibited TGF-β signaling. Although this work was done in human trabecular meshwork cells, it is possible that similar inhibitory pathways exist in the posterior segment as well. The initial inhibition of TGF-β in response to increased IL-6 shortly after PRP may have temporarily led to relaxation of the fibrotic membranes, allowing the TRD in Case 2 to initially reattach. However, IL-6 and VEGF levels later decreased as the post-laser inflammation improved and the effects of the PRP set in. Therefore, it is likely that the TGF-β levels rebounded, leading to worsening traction and the recurrent TRD the patient experienced.
In conclusion, spontaneous reattachment of macula-off TRDs with significant visual gain can occur, albeit rarely. Mechanisms other than PVD development appear to be responsible in these eyes. The reattachments described here represent an uncommon situation in which the patients did not pursue recommended timely surgical intervention, which remains the standard of care for macula-off TRDs. Because of the small number of cases, baseline features that might predict this outcome cannot be identified at this time.
Footnotes
Ethical Approval
This case report was conducted in accordance with the Declaration of Helsinki. The collection and evaluation of all protected patient health information was performed in a US Health Insurance Portability and Accountability Act–compliant manner.
Statement of Informed Consent
Written informed consent to publish potentially identifying information, including permission for all photographs and images included herein, was obtained from the patients.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: J. Arch McNamara Retina Research Fund Grant Support.
