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Acute serous detachment with argon laser photocoagulation in retinopathy of prematurity
Acute Serous Detachment with Argon Laser Photocoagulation in Retinopathy of Prematurity C. P. Noonan, FRCSL and D. I. Clark, FRCS
n acute serous macular detachment developed in a neonate immediately after treatment for threshold retinopathy of prematurity (ROP zone II) with argon laser photocoagulation. The serous detachment resolved spontaneously during the next 2 weeks. This complication has not been previously described in an infant after indirect laser treatment, and only one recent report of pigment epithelial detachment in a neonate exists in the literature.1 The recent availability of indirect ophthalmoscopic laser photocoagulation delivery systems has produced results encouraging for their use in ROP. It has been suggested that laser treatment is an effective treatment for stage 3 ROP and that this treatment is potentially less traumatic than cryotherapy. 2 We report a case of acute serous detachment that occurred as a patient received argon laser photocoagulation for threshold ROP.
A
CASE R E P O R T A premature infant with a gestational age of 25 weeks and a birth weight of 720 gm was referred to our unit at 12 weeks of postnatal age for laser treatment of stage 3 ROP. Both eyes were dilated with two drops each of 0.5% cyclopentolate and 2.5 % phenylephrine per eye. Examination of his right eye revealed 5 contiguous clock hours of stage 3+ ROP temporally and 2 isolated clock hours of stage 3 ROP nasally, zone II. The infant was placed under general anesthesia and treated with the H G M Spectrum Compac Argon Laser (HGM, Salt Lake City) (green). He was paralyzed with pancuronium, ventilated on an air/oxygen mixture, and given 15 ~tg/kg fentanyl for analgesia. Scatter laser burns were placed anterior to the ridge throughout the 360 degrees ofavascular retina in the right eye. A 28 D lens was used, producing a spot about 600 ~tm in diameter. Power used to achieve a dull grey or white reaction was 0.16 W,
t~rom the Department of Ophthabnology, Walton Hospital, Liverpool, England. Reprint requests: Mr. D. I. Clark, Department of Ophthahnology, 14~altonHospital, Rice Lane, Liverpool L9 1AE, United Kingdo~n. J AAPOS 1997;1:183-4. Copyright© 1997 by the American Associationfor PediatricOphthalmologyand Strabismns. 1091-8Y31/97 5Y.O0 + 0 7~/1/83848
Journal of AAPOS
FI6.1. Serous detachment noted immediately after treatment.
with a pulse duration of 0.1 seconds. On examination at completion of treatment, a discrete, dome-shaped elevation was noted in the right eye (Figure 1). The left eye remained unchanged (360-degree stage II). On follow-up examination 2 weeks later, the lesion had resolved and the ROP had regressed in the right eye.
DISCUSSION To date several complications have been reported after indirect laser treatment for ROP. Complications in the anterior segment include lens opacities, corneal haze, and burns of the iris and tunica vasculosa lenfis; those in the posterior segment include vitreous and choroidal hemorrhages. 3-6A serous detachment at the macula has not been previously reported in a neonate after laser treatment for ROP, although we are aware that it is a potential complication after panretinal photocoaguladon in adults with proliferative diabetic retinopathy. 7Phenylephrine has recently been implicated in the development of bilateral pigment epithelial detachments during a ROP screening examination. ~The authors of that report speculated that the 2.5% phenylephrine was locally absorbed, causing
September 1997 183
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changes at the level of the choriocapillaris that secondarily affected the retinal pigment epithelium. Because we did not do an angiogram, we cannot say definitively whether this serous detachment was a central serous retinopathy or a pigment epithelial detachment. Various mechanisms have been suggested to explain exudative retinal detachments. Serous detachments can occur in hypertension, toxemia of pregnancy, and central serous retinopathy. In patients with central serous retinopathy, a primary dysfunction of the retinal pigment epithelium, which is thought to be induced by changes in the choriocapillaris, has been proposed. Experimental work by Marmor and Yao 8 suggested that three factors are necessary for serous detachments: (1) a source of pressure fluid, (2) a defect in the blood retinal barrier, and (3) a surrounding area of impaired fluid transport. Phenylephrine was used in both eyes to aid dilation of the pupils. There were no visible changes in the macular area of the left, untreated eye after the dilating drops. We postulate that the phenylephrine sensitized the right eye in our patient, with local absorption inducing changes in the choriocapillaris leading to an element of hypoperfusion, thereby affecting the pigment epithelium (impaired fluid transfer). T h e laser treatment induced an inflammatory
Journal of AAPOS Volume 1 Number 3 September 1997 reaction that led to stasis and vasodilation (source of fluid pressure) and increased permeability (defect in the blood retinal barrier). The combination of these three factors led to the formation of a serous detachment. References
1. Berman DH, Deutsch JA. Bilateral spontaneous pigment epithelial detachmentsin a premature neonate. Arch Ophthalmol 1994;112:161-2. 2. McNamara JA, Tasman W, Brown, GC, Federman, JL. Laser photocoagulation for state 3+ retinopathy of prematurity. Ophthalmology1991;98:576-80. 3. PogrebniakAE, BollingJP,StewartMW. Argoninducedcataractin an infant with retinopathy of prematurity. Am J Ophthalmol 1994;117:261-2. 4. IrvineWD, SmiddyWE,NicholsonDH. Cornealand irisburnswith laser indirectophthalmoscope.AmJ Ophthalmol 1990;110:311-4. 5. Rubinfeld RS, Pilkerton AR, Zimmerman LE. A corneal complication of indirect ophthalmic laser deliverysystems.Am J Ophthalmol 1990;110:206-8. 6. PreslanMW. Lasertherapyfor retinopathyof prematurity.J Pediatr Ophthalmol Strabismus 1993;30:80-3. 7. BresnickGH. Evaluationand treatment of diabetic retinopathy.J Cont Ed Ophthalmol 1979;41:15-35. 8. Marmor MF, Yao X-Y. Conditionsnecessaryfor the formationof serous detachment: experimental evidence from the cat. Arch Ophthalmol 1994;112:830-8.
n acute serous macular detachment developed in a neonate immediately after treatment for threshold retinopathy of prematurity (ROP zone II) with argon laser photocoagulation. The serous detachment resolved spontaneously during the next 2 weeks. This complication has not been previously described in an infant after indirect laser treatment, and only one recent report of pigment epithelial detachment in a neonate exists in the literature.1 The recent availability of indirect ophthalmoscopic laser photocoagulation delivery systems has produced results encouraging for their use in ROP. It has been suggested that laser treatment is an effective treatment for stage 3 ROP and that this treatment is potentially less traumatic than cryotherapy. 2 We report a case of acute serous detachment that occurred as a patient received argon laser photocoagulation for threshold ROP.
A
CASE R E P O R T A premature infant with a gestational age of 25 weeks and a birth weight of 720 gm was referred to our unit at 12 weeks of postnatal age for laser treatment of stage 3 ROP. Both eyes were dilated with two drops each of 0.5% cyclopentolate and 2.5 % phenylephrine per eye. Examination of his right eye revealed 5 contiguous clock hours of stage 3+ ROP temporally and 2 isolated clock hours of stage 3 ROP nasally, zone II. The infant was placed under general anesthesia and treated with the H G M Spectrum Compac Argon Laser (HGM, Salt Lake City) (green). He was paralyzed with pancuronium, ventilated on an air/oxygen mixture, and given 15 ~tg/kg fentanyl for analgesia. Scatter laser burns were placed anterior to the ridge throughout the 360 degrees ofavascular retina in the right eye. A 28 D lens was used, producing a spot about 600 ~tm in diameter. Power used to achieve a dull grey or white reaction was 0.16 W,
t~rom the Department of Ophthabnology, Walton Hospital, Liverpool, England. Reprint requests: Mr. D. I. Clark, Department of Ophthahnology, 14~altonHospital, Rice Lane, Liverpool L9 1AE, United Kingdo~n. J AAPOS 1997;1:183-4. Copyright© 1997 by the American Associationfor PediatricOphthalmologyand Strabismns. 1091-8Y31/97 5Y.O0 + 0 7~/1/83848
Journal of AAPOS
FI6.1. Serous detachment noted immediately after treatment.
with a pulse duration of 0.1 seconds. On examination at completion of treatment, a discrete, dome-shaped elevation was noted in the right eye (Figure 1). The left eye remained unchanged (360-degree stage II). On follow-up examination 2 weeks later, the lesion had resolved and the ROP had regressed in the right eye.
DISCUSSION To date several complications have been reported after indirect laser treatment for ROP. Complications in the anterior segment include lens opacities, corneal haze, and burns of the iris and tunica vasculosa lenfis; those in the posterior segment include vitreous and choroidal hemorrhages. 3-6A serous detachment at the macula has not been previously reported in a neonate after laser treatment for ROP, although we are aware that it is a potential complication after panretinal photocoaguladon in adults with proliferative diabetic retinopathy. 7Phenylephrine has recently been implicated in the development of bilateral pigment epithelial detachments during a ROP screening examination. ~The authors of that report speculated that the 2.5% phenylephrine was locally absorbed, causing
September 1997 183
184
Noonanand Clark
changes at the level of the choriocapillaris that secondarily affected the retinal pigment epithelium. Because we did not do an angiogram, we cannot say definitively whether this serous detachment was a central serous retinopathy or a pigment epithelial detachment. Various mechanisms have been suggested to explain exudative retinal detachments. Serous detachments can occur in hypertension, toxemia of pregnancy, and central serous retinopathy. In patients with central serous retinopathy, a primary dysfunction of the retinal pigment epithelium, which is thought to be induced by changes in the choriocapillaris, has been proposed. Experimental work by Marmor and Yao 8 suggested that three factors are necessary for serous detachments: (1) a source of pressure fluid, (2) a defect in the blood retinal barrier, and (3) a surrounding area of impaired fluid transport. Phenylephrine was used in both eyes to aid dilation of the pupils. There were no visible changes in the macular area of the left, untreated eye after the dilating drops. We postulate that the phenylephrine sensitized the right eye in our patient, with local absorption inducing changes in the choriocapillaris leading to an element of hypoperfusion, thereby affecting the pigment epithelium (impaired fluid transfer). T h e laser treatment induced an inflammatory
Journal of AAPOS Volume 1 Number 3 September 1997 reaction that led to stasis and vasodilation (source of fluid pressure) and increased permeability (defect in the blood retinal barrier). The combination of these three factors led to the formation of a serous detachment. References
1. Berman DH, Deutsch JA. Bilateral spontaneous pigment epithelial detachmentsin a premature neonate. Arch Ophthalmol 1994;112:161-2. 2. McNamara JA, Tasman W, Brown, GC, Federman, JL. Laser photocoagulation for state 3+ retinopathy of prematurity. Ophthalmology1991;98:576-80. 3. PogrebniakAE, BollingJP,StewartMW. Argoninducedcataractin an infant with retinopathy of prematurity. Am J Ophthalmol 1994;117:261-2. 4. IrvineWD, SmiddyWE,NicholsonDH. Cornealand irisburnswith laser indirectophthalmoscope.AmJ Ophthalmol 1990;110:311-4. 5. Rubinfeld RS, Pilkerton AR, Zimmerman LE. A corneal complication of indirect ophthalmic laser deliverysystems.Am J Ophthalmol 1990;110:206-8. 6. PreslanMW. Lasertherapyfor retinopathyof prematurity.J Pediatr Ophthalmol Strabismus 1993;30:80-3. 7. BresnickGH. Evaluationand treatment of diabetic retinopathy.J Cont Ed Ophthalmol 1979;41:15-35. 8. Marmor MF, Yao X-Y. Conditionsnecessaryfor the formationof serous detachment: experimental evidence from the cat. Arch Ophthalmol 1994;112:830-8.