Purpose
To understand the natural history of macular folds using serial spectral-domain optical coherence tomography (SD-OCT).
Design
Prospective case series.
Method
Serial OCTs were performed using Topcon 3D OCT. The main outcome measures were: patient demographics; preoperative, perioperative, and postoperative details; serial SD-OCTs; and length of follow-up.
Results
Ten patients who underwent standard 3-port pars plana vitrectomy with gas tamponade to repair rhegmatogenous retinal detachment were included in this study. Mean follow-up was 9.9 months (range 5–17 months). Three types of retinal folds were identified: 1) ripple; 2) taco; 3) displacement. Ripple and taco folds were found to resolve spontaneously. Outer retinal hyperreflective lesions resolved first, followed by flattening of the inner retinal layers. Displacement folds also resolved, but left the macula translocated inferiorly, causing binocular diplopia.
Conclusion
Ripple and taco folds could be managed conservatively with good outcomes. However, the optimal treatment of displacement folds requires further research.
Macular fold, or dry arcuate folds, following rhegmatogenous retinal detachment (RD) surgery is a rare complication. Patients with macular folds may complain of metamorphopsia, diplopia, and/or blurred vision. Surgical intervention to flatten the fold in the form of redetachment of the retina and massage has been documented in isolated cases. Other case reports suggest a spontaneous recovery of these folds. By analyzing serial spectral-domain optical coherence tomography (SD-OCT) scans, I attempt to explain the natural history and in vivo appearance of macular folds.
Method
I prospectively followed 15 eyes from 15 patients who developed macular folds following retinal detachment repair between January 2007 and January 2010. Five patients were excluded because they had subsequent treatment for these retinal folds by redetaching the retina using subretinal saline injection combined with gas or air tamponade. Therefore, only 10 eyes were included in this series to demonstrate the natural history of these folds.
All 10 patients had acute rhegmatogenous RD with no proliferative vitreoretinopathy (PVR). They underwent standard 20-gauge pars plana vitrectomy with no scleral buckling procedure by experienced fellows and consultants at St. Thomas’ Hospital, London, United Kingdom, with intraocular gas tamponade and cryopexy and/or laser retinopexy. The patients’ age, gender, laterality, position of RD, macula status and other ocular comorbidities were recorded. Operation details including type of anesthetic, gas tamponade, and postoperative posture instructions were also recorded. Serial SD-OCT images using the Topcon 3D OCT 1000 (Tokyo, Japan) were obtained to monitor progression of folds.
Results
Patient demographics are listed in Table 1 . Operation details are listed in Table 2 .
| Patient | Age (Years) | Sex | Eye | Macula Involvement | Preoperative VA | Postoperative VA | Fold Type | Follow-up (Months) |
|---|---|---|---|---|---|---|---|---|
| 1 | 46 | M | Right | Off | PL | 20/30 | R | 10 |
| 2 | 50 | F | Right | Split | 20/30 | 20/30 | R | 5 |
| 3 | 50 | M | Right | On | 20/30 | 20/30 | R | 5 |
| 4 | 56 | F | Right | Off | PL | 20/30 | R | 17 |
| 5 | 53 | M | Left | Split | 20/80 | 20/30 | R | 6 |
| 6 | 75 | M | Left | Off | CF | 20/40 | R | 12 |
| 7 | 40 | M | Left | Off | CF | 20/40 | R | 6 |
| 8 | 55 | F | Left | Off | HM | 20/30 | D | 15 |
| 9 | 38 | M | Left | Off | 20/200 | 20/40 | T | 9 |
| 10 | 64 | M | Right | On | 20/30 | 20/20 | T | 14 |
| Patient | Retinotomy | Posture (Recommended for 1 Week) | Tamponade | Anesthetic |
|---|---|---|---|---|
| 1 | Y | Left cheek down | SF6 | LA |
| 2 | Y | Right cheek down | SF6 | LA |
| 3 | N | None | SF6 | LA |
| 4 | N | Supine 2 hrs; sit-up day, left cheek down night | SF6 | LA |
| 5 | N | Sit-up day; left cheek down night | SF6 | GA |
| 6 | N | Sit-up day; left cheek down night | SF6 | GA |
| 7 | N | Sit-up day; left cheek down | C3F8 | LA |
| 8 | N | Sit-up day | SF6 | GA |
| 9 | N | Sit-up day | SF6 | LA |
| 10 | N | Prone 8 hrs; sit-up thereafter | SF6 | LA |
There were 3 patterns of retinal folds that could be distinguished by both color fundus photography and OCT imaging. The first pattern, designated as a “ripple,” was seen as a subtle undulation of the retina radially from the optic disc. On OCT imaging, the inner retina gently undulated while the outer retina showed numerous distinct hyperreflective lesions. These outer retinal lesions had corresponding inner segment/outer segment (IS/OS) defects, which spanned beyond these lesions ( Figure 1 ) . During the follow-up period, these lesions disappeared, leaving an intact IS/OS layer. However, the flattening of the inner retinal undulations was delayed ( Figure 1 ). In some cases of ripple there were only outer retinal lesions seen, with very little, if any, inner retinal disruption ( Figure 2 ) . Eventually, these ripples disappear, leaving limited evidence of a fold (Patients 1–7). The majority of patients did reasonably well, attaining good visual acuity without symptomatic metamorphopsia or diplopia.
The second pattern, described as a “taco,” was characterized by a single, broad fold, usually in the posterior pole, with a central white line running along the fold ( Figure 3 ) . The taco on OCT scanning showed a large undulation of the inner retina with a corresponding large outer retinal hyperreflective lesion similar to a ripple, but much larger and almost appearing to lift the inner retina ( Figure 4 ) . In some cases, the outer retinal lesion formed an annular configuration, possibly signifying the formation of a photoreceptor rosette ( Figure 5 ) . There were usually surrounding lesions of ripple folds present on either side of the main taco fold. Like the ripple folds, the outer retinal lesions disappeared first, followed by the delayed flattening of the inner retina ( Figure 4 ). These folds all resolved without the need for treatment.
