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Metamorphopsia and Optical Coherence Tomography Findings After Rhegmatogenous Retinal Detachment Surgery
Metamorphopsia and Optical Coherence Tomography Findings After Rhegmatogenous Retinal Detachment Surgery FUMIKI OKAMOTO, YOSHIMI SUGIURA, YOSHIFUMI OKAMOTO, TAKAHIRO HIRAOKA, AND TETSURO OSHIKA PURPOSE:
To investigate the relationship between metamorphopsia and macular morphologic changes after successful repair of rhegmatogenous retinal detachment (RD). DESIGN: Prospective, interventional, consecutive study. METHODS: The study included 129 eyes of 129 patients who had undergone successful retinal reattachment surgery. The severity of metamorphopsia was recorded using M-CHARTS and foveal microstructure was assessed with spectral-domain optical coherence tomography (OCT) at 6-12 months postoperatively. RESULTS: The mean metamorphopsia score was 0.30 ± 0.46, and 50 of 129 patients (39%) had metamorphopsia. Metamorphopsia was more severe in eyes with maculaoff rhegmatogenous RD than those with macula-on (P < .001). Eighteen of 50 eyes with metamorphopsia exhibited abnormal structures in the macular region (epiretinal membrane, disruption of the photoreceptor inner and outer segment junction, cystoid macular edema, macular hole, or subretinal fluid), whereas the other 32 eyes showed no morphologic changes with OCT. In these 32 eyes, the horizontal metamorphopsia score (0.86 ± 0.50) was significantly higher than the vertical metamorphopsia score (0.62 ± 0.39, P < .05). Nine of 69 eyes with preoperative macula-on rhegmatogenous RD developed postoperative metamorphopsia. Of the 9 eyes, 6 showed abnormal macular structures and the other 3 had normal-appearing OCT. The macula briefly detached during vitrectomy in these 3 cases. CONCLUSIONS: In eyes that remained macula-on throughout surgery and had normal-appearing OCT, metamorphopsia did not develop. In some cases, the reason for metamorphopsia was anatomically obvious. In other cases that were preoperative and intraoperative maculaoff, postoperative retinal vertical displacement could cause predominantly horizontal metamorphopsia. (Am J Ophthalmol 2014;157:214–220. Ó 2014 by Elsevier Inc. All rights reserved.) Accepted for publication Aug 6, 2013. From the Department of Ophthalmology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan. Inquiries to Fumiki Okamoto, Department of Ophthalmology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575 Japan; e-mail: [email protected]
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HE EFFECTIVENESS OF RHEGMATOGENOUS RETINAL
detachment (RD) surgery has generally been assessed by the rates of retinal reattachment and the postoperative visual acuity.1–6 Even after successful retinal reattachment and improvement of visual acuity, however, the postoperative quality of vision may be unsatisfactory in some cases. Metamorphopsia is one of the most common postoperative symptoms in patients with RD, with 22%-33% of patients complaining of metamorphopsia by questionnaire.7,8 Wang and associates investigated 46 patients with macula-off rhegmatogenous RD undergoing scleral buckling surgery and found that 67% of them had metamorphopsia on the Amsler grid at 2 months postoperatively.9 Recent advancement in optical coherence tomography (OCT) technologies has provided critical insights into the various retinal conditions.10,11 The development of spectral-domain OCT enhances the resolution with which the intraretinal architectural morphology, such as the ganglion cell layer (GCL), inner nuclear layer (INL), outer plexiform layer (OPL), outer nuclear layer (ONL), photoreceptor inner and outer segment junction (IS/OS), and external limiting membrane (ELM), can be clearly seen.12,13 Studies using OCT revealed that the visual acuity in RD patients deteriorated because of disruption of the IS/OS,14–16 disruption of the ELM,17 disruption of the cone outer segment tips, and thickening of the outer retina.18 Few studies, however, have investigated the relation between metamorphopsia and OCT findings.19–21 Using the Amsler grid in patients with epiretinal membrane (ERM), Watanabe and associates reported that the INL was thicker in patients with broad metamorphopsia than in those without metamorphopsia.19 It has also been reported that the severity of metamorphopsia, quantified by M-CHARTS, was strongly associated with the thickness of the INL in patients with ERM.20 Rossetti and associates examined 7 patients who complained of long-standing metamorphopsia after successful repair of macula-off rhegmatogenous RD and found that all eyes had normal findings on spectral-domain OCT.21 There is, however, no report quantifying metamorphopsia in rhegmatogenous RD patients and evaluating the relationship between metamorphopsia and detailed OCT findings.
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0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2013.08.007
The purpose of the present study was to quantify the severity of metamorphopsia after successful repair of rhegmatogenous RD and to investigate the relationship between metamorphopsia and morphologic changes in the macular region assessed with spectral-domain OCT.
METHODS WE ANALYZED 129 PATIENTS AFTER SUCCESSFUL SURGERY
for unilateral rhegmatogenous RD undertaken at University of Tsukuba Hospital from October 1, 2010 to April 26, 2012. Their ages averaged 52.3 6 11.0 years (mean 6 SD), and there were 84 male and 45 female patients. We conducted this prospective, interventional, consecutive study in accordance with the Declaration of Helsinki, and received approval from the institutional review committees of University of Tsukuba Hospital. Prior to inclusion in the study, all patients provided informed consent after the nature of the study was explained to them. Exclusion criteria included patients with a previous history of vitreoretinal surgery and ophthalmic disorders except myopia of less than -6 diopters and severe cataract of more than grade 3 nuclear sclerosis or cortical opacity. Eyes with complicated vitreoretinal disease, such as proliferative vitreoretinopathy and RD resulting from giant retinal tears, macular hole, or ocular trauma, were excluded. Patients with logarithm of minimal angle of resolution best-corrected visual acuity (logMAR BCVA) of >0.7 were also excluded because of possible incorrect measurement of the severity of metamorphopsia.22 Visual acuity, metamorphopsia, and OCT images were obtained at 6-12 months postoperatively. BCVA measured with the Landolt chart was expressed as logMAR. The severity of metamorphopsia was quantified with MCHARTS (Inami Co, Tokyo, Japan). M-CHARTS consists of 19 dotted lines with dot intervals ranging from 0.2-2.0 degrees of visual angle. If the straight line is substituted with a dotted line and the dot interval is changed from fine to coarse, the distortion of the line decreases with the increasing dot interval, until the dotted line appears straight.22,23 At first, vertical straight lines (0 degrees) were shown to the patient. If the patient recognized a straight line as straight, the metamorphopsia score was 0. If the patient recognized a straight line as irregular or curved, then subsequent pages of M-CHARTS, in which the dot intervals of the dotted line change from fine to coarse, were shown one after another. When the patient recognized a dotted line as being straight, the visual angle that separated the dots was considered to represent his or her metamorphopsia score for vertical lines (Figure 1). Then the M-CHARTS was rotated 90 degrees and the same test was performed with horizontal lines. The examinations were repeated 3 times, and their mean values were used for data analyses. VOL. 157, NO. 1
FIGURE 1. Method of determining the metamorphopsia scores with M-CHARTS. The minimum angle of the dots in the line that appeared straight was taken to be the metamorphopsia score. In this case, metamorphopsia for the vertical line was determined as 2.0.
Each examination was performed at 30 cm with the refraction of the eye exactly corrected for this distance. The presence of metamorphopsia was defined as the mean _0.2, metamorphopsia score (metamorphopsia score) > because the metamorphopsia scores were 0 in all normal subjects.22 Retinal images were obtained with spectral-domain OCT (Cirrus high-definition OCT; Carl Zeiss, Dublin, California, USA). We performed the 5-line raster scans in a horizontal and vertical manner for each eye using Cirrus analysis software version 3.0. Scans with signal strength of more than 7/10 were considered to be appropriate, and a representative image was selected. Diagnosis of a disrupted IS/OS was made based on loss and irregularity of the hyperreflexive line corresponding to the IS/OS junction. We also assessed the degree of the ELM disruption in a similar fashion. Two graders (Y.S., T.H.) assessed the status of the IS/OS and the ELM lines. Both graders were masked to the clinical findings of the patients, including their visual acuity and metamorphopsia score results. Clinical data were collected, including age, sex, surgical procedures, the number of retinal tears, circumferential dimension of retinal tears, area of retinal detachment, and macular status (on/off) (Table 1). We evaluated whether RD existed at the macula region using spectraldomain OCT in all eyes preoperatively. All surgeries were performed at our clinic by 2 experienced vitreoretinal surgeons (F.O., Y.O.). In eyes with cataract of grade 2 nuclear sclerosis or cortical opacity, the crystalline lens was removed by phacoemulsification and an acrylic foldable intraocular lens was implanted in the
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TABLE 1. Demographic and Clinical Data of Patients With Rhegmatogenous Retinal Detachment Number of eyes Age (y) Sex (male/female) Surgical procedures (scleral buckling/ vitrectomy) Number of retinal tears Circumferential dimension of retinal tears (degrees) Area of retinal detachment (degrees) Macular status (on/off) Preoperative visual acuity (logMAR) Postoperative visual acuity (logMAR) Postoperative metamorphopsia score (Mscore) Horizontal M-score Vertical M-score Mean M-score
129 55.3 6 11.0 84/45 31/98 2.0 6 1.5 17.9 6 16.6 126 6 73 69/60 0.56 6 0.80 0.05 6 0.18
0.30 6 0.50 0.31 6 0.49 0.30 6 0.46
FIGURE 2. Histogram of the mean metamorphopsia score in all patients after retinal detachment surgery. The metamorphopsia score ranged from 0.0-2.0. Fifty patients demonstrated mean metamorphopsia score of 0.2 or more.
Values are presented as n or as mean 6 standard deviation.
capsular bag, followed by vitrectomy. The surgical technique comprised a 23- or 25-gauge pars plana vitrectomy that released vitreous traction around the breaks, internal drainage of the subretinal fluid, a total gas-fluid exchange with 20% sulfur hexafluoride (SF6), and laser photocoagulation. When scleral buckling was performed, cryopexy and an exoplant (segmental silicone sponges in combination with an encircling silicone band) were used to support the retinal breaks. Subretinal fluid drainage and SF6 gas injection were performed when required. In both treatment groups, patients injected with gas were instructed to maintain a face-down position during the first postoperative week. The mean and standard deviations were calculated for metamorphopsia score and other parameters. The Student t test was performed to compare age, the number of retinal tears, circumferential dimension of retinal tears, and area of retinal detachment between patients with and without metamorphopsia. Differences in sex, surgical procedures, and macula status between patients with and without metamorphopsia were analyzed by the Fisher exact probability test. A logistic regression analysis was performed to determine parameters significantly relevant to the presence of metamorphopsia. Wilcoxon signed rank test was used to compare horizontal and vertical metamorphopsia scores. All tests of associations were considered statistically significant if P < .05. We carried out the analyses using StatView (version 5.0; SAS Inc, Cary, North Carolina, USA).
RESULTS THE MEAN METAMORPHOPSIA SCORE OF ALL PATIENTS WAS
0.30 6 0.46, while horizontal and vertical metamorphopsia 216
TABLE 2. Logistic Regression Analysis of the Presence or Absence of Metamorphopsia Score and Independent Variables in Patients With Rhegmatogenous Retinal Detachment
Age (y) Surgical procedures (scleral buckling/vitrectomy) Number of retinal tears Circumferential dimension of retinal tears (degrees) Area of retinal detachment (degrees) Macular status (on/off)
b
SE
P Value
0.00 0.00
0.03 0.66
.79 .98
0.08 0.00
0.17 0.02
.85 .67
0.00 0.35
0.01 0.62
.89 <.0001a
b ¼ partial correlation coefficient; SE ¼ standard error. a Significant at P < .05.
scores were 0.30 6 0.50 and 0.31 6 0.49, respectively. There was no significant difference between horizontal and vertical metamorphopsia scores (P ¼ .81). The mean metamorphopsia score ranged from 0.0-2.0 (Figure 2). Fifty of 129 patients (39%) had metamorphopsia (metamor_0.2). Forty-one of 60 eyes with macula-off phopsia score > rhegmatogenous RD (68%) and 9 of 69 eyes with macula-on rhegmatogenous RD (13%) had metamorphopsia. Patients with macula-off rhegmatogenous RD showed a significantly higher incident of metamorphopsia than those with macula-on rhegmatogenous RD (P < .0001). Patients with metamorphopsia had a larger area of retinal detachment (P < .0001) than those without metamorphopsia. Age (P ¼ .16), sex (P ¼ .71), surgical procedures (P ¼ .39), the number of retinal tears (P ¼ .33), and
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FIGURE 3. A breakdown of 50 eyes having metamorphopsia after retinal detachment surgery and representative images of spectraldomain optical coherence tomography.
circumferential dimension of retinal tears (P ¼ .50) showed no association with either the presence or absence of metamorphopsia. In logistic regression analysis, postoperative metamorphopsia score was significantly associated with macula-off rhegmatogenous RD (P < .0001), whereas other parameters were not relevant (Table 2). Figure 3 shows OCT findings in eyes with metamorphopsia. Of the 50 eyes, 6 eyes had ERM, 5 eyes had disruption of IS/OS, 3 eyes had cystoid macular edema (CME), and 2 eyes had macular hole (MH) and 2 eyes with persistent subretinal fluid (SRF), while the other 32 eyes exhibited no abnormal morphologic change. In these 32 eyes, the horizontal metamorphopsia score (0.86 6 0.50) was significantly higher than the vertical metamorphopsia score (0.62 6 0.39, P < .05) (Figure 4). Nine of the 69 eyes with macula-on rhegmatogenous RD developed postoperative metamorphopsia. Of the 9 eyes, 4 eyes had ERM, 1 eye had MH and 1 eye had SRF, and the other 3 eyes were without any abnormal morphologic change. Our operation video confirmed that the macula detached briefly during vitrectomy in these 3 patients.
DISCUSSION AS SHOWN IN THE ABOVE RESULTS, LESS THAN HALF OF
patients exhibited metamorphopsia after rhegmatogenous RD surgery at 6-12 months into follow-up. Among macula-off rhegmatogenous RD patients, 68% developed postoperative metamorphopsia, whereas the incidence was 13% among macula-on rhegmatogenous RD patients. Postoperative metamorphopsia score was associated with macula-off rhegmatogenous RD. These results are consistent with the findings of previous reports. Wright and associates7 and Amemiya and associates8 investigated the incidence of metamorphopsia in patients after scleral buckling surgery by questionnaire and found that 22% and 33% of patients, respectively, complained of metamorphopsia. Wang and associates conducted qualitative analysis of metamorphopsia following macula-off rhegmatogenous VOL. 157, NO. 1
RD surgery using the Amsler grid and found that 67% of patients had metamorphopsia.9 As this report focused only on scleral buckling surgery and the observation period was short (2-month follow-up), the incidence proved to be high, with the cause of metamorphopsia considered mainly to be postoperative persistent subretinal fluid. In addition, this study used the Amsler grid, which has been widely adopted to detect and evaluate metamorphopsia in patients with macular diseases.24,25 With the Amsler grid, however, it is difficult to quantify the severity of metamorphopsia because the patients have to self-describe the degree of image distortion. In contrast, M-CHARTS is an instrument that can easily and quantitatively evaluate the degree of metamorphopsia associated with macular diseases, with the patients only needing to answer whether the line is distorted or not.20,22,23 Our present study was the first to quantify the severity of metamorphopsia using MCHARTS in rhegmatogenous RD patients. As shown in the results of OCT images, 6 eyes had ERM, 5 eyes disruption of IS/OS, 3 eyes CME, and 2 eyes MH and 2 eyes persistent SRF, among 50 metamorphopsic eyes. The reported ERM incidence using OCT after repair of primary rhegmatogenous RD ranged between 9.0% and 23%.16,17,26–28 In our study, 15 of 129 eyes (11.6%) developed ERM, of which 6 had metamorphopsia. Metamorphopsia is one of the most common symptoms of patients with ERM, with 80%-85% complained of moderate to severe distortion.29,30 Studies using the 25-item National Eye Institute Visual Function Questionnaire demonstrated that the severity of metamorphopsia strongly influenced vision-related quality of life in patients with ERM.31,32 In the literature, studies using OCT detected persistent SRF in 47% and 52.3% of eyes 1 month after rhegmatogenous RD surgery.33,34 At 6 months postoperatively, 8% of eyes after vitrectomy and 43% of eyes after scleral buckling still had SRF.35,36 In most cases, SRF gradually disappeared within 1 year after surgery, but disrupted IS/OS was slow to be recovered.17,34 In our study, only 2 SRF and 5 disrupted IS/OS cases were noticed, probably because our patients were examined at least 6-12 months after surgery.
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FIGURE 4. Horizontal vs vertical metamorphopsia scores in 32 metamorphopsic patients who showed normal optical coherence tomography findings after successful repair of retinal detachment.
CME and MH are also well-known postoperative complications responsible for secondary visual impairment, with a prevalence of 4%-11% for CME16,17,26 and 0.85%1.1% for MH.37–39 In our study, 3 cases of CME (2.3%) and 2 cases of MH (1.6%) were detected, and these results were similar to those of previous reports. Thirty-two of the 50 metamorphopsic eyes (64%) exhibited normal-appearing OCT findings without any disruption of IS/OS, ELM, or abnormal macular contour. In these 32 eyes, the horizontal metamorphopsia score was significantly higher than the vertical metamorphopsia score. A previous paper indicated that poor visual acuity, color vision defects, or persistent metamorphopsia could persist over time, suggesting the existence of a microstructural macular damage that a standard fundus biomicroscopy could not detect.40 Rossetti and associates reported that long-standing metamorphopsia could occur after successful macula-off rhegmatogenous RD repair even without detectable photoreceptor disruption in spectral-domain OCT examination.21 Such persistent metamorphopsia appears to be arising from retinal vertical displacement by rhegmatogenous RD surgery. Shiragami and associates clarified that the extent of RD and macular status were significantly associated with postoperative inferior displacement of the retina using fundus autofluorescence.41 They suggested that a large-extent macula-off rhegmatogenous RD could cause retinal translocation even after successful surgery, resulting in dislocation of the macula from its original location. 218
Arimura and associates23 investigated the relationship between the degree of retinal contraction and metamorphopsia using M-CHARTS in patients with ERM, and found that the vertical metamorphopsia score correlated with the degree of horizontal contraction and the horizontal metamorphopsia score correlated with the degree of vertical contraction. In our study, the horizontal metamorphopsia score was higher than the vertical metamorphopsia score in 32 metamorphopsic patients who showed normal macular structures. We do not consider that these results were affected by a possible fatigue effect arising from the order of the directions of M-CHARTS tests. The reason was that both the horizontal and vertical metamorphopsia scores were similar in all eyes (mean value 0.30 and 0.31, respectively). In consideration of the previous reports, our results suggested that postoperative retinal vertical displacement could cause predominantly horizontal metamorphopsia. In addition, retinal microcirculation in the macular area was disturbed in patients with RD.42 Previous study of RD patients using multifocal electroretinography revealed that a decrease in retinal response densities was recorded in the reattached retina as well as in the detached retina.43 In view of these findings, it was possible that a slight foveal dysfunction that could not be detected by OCT caused metamorphopsia. Nine of 69 eyes with preoperative macula-on rhegmatogenous RD developed metamorphopsia. Of the 9 eyes, 6 revealed an abnormal macular structure while other 3 showed normal findings on OCT. The macula briefly detached during vitrectomy in these 3 cases. Of those, the retina detached near the macula preoperatively, and macular detachment occurred during core vitrectomy in 2 cases. In the remaining 1 case, the macula detached during fluid-air exchange because of movement of subretinal fluid attributable to air pressure from the anterior to posterior segment of the eye. It was shown that metamorphopsia could occur postoperatively if the macula detached even briefly during vitrectomy. The limitations of this study include a short-term followup, an extensive range of the last follow-up examination, and the resolution of OCT. We evaluated the patients at 6-12 months postoperatively. Previous studies reported that visual acuity in patients with rhegmatogenous RD improved more at 1-5 years postoperatively than at 6 months postoperatively.3,44 In addition, metamorphopsia could continue to improve over a long course of observation in patients with macula-off rhegmatogenous RD.21 Our OCT measurements were based on only 5 horizontal B-scan cross sections, and imaging inaccuracy might exist in the photoreceptor layer after RD. Future studies on metamorphopsia with a long-term follow-up and improved OCT technologies will be needed. In conclusion, after successful rhegmatogenous RD repair, 39% of patients developed metamorphopsia at 612 months postoperatively. OCT imaging found, however,
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that more than half of the metamorphopsic patients had normal macula structures. Our results suggested that retinal vertical displacement after surgery might mainly induce
horizontal metamorphopsia. Preoperative and intraoperative macula-on RD did not appear to have resulted in metamorphopsia postoperatively.
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST and none were reported. The authors indicate no funding support. Author contributions: Involved in design of study (F.O., Y.S.); conduct of study (F.O.); data collection (F.O., Y.O.); management, analysis, and interpretation of data (F.O., Y.O., T.H.); writing of article and literature search (F.O., Y.O., T.H.); revision of article (T.O., T.H.); and final approval of article (F.O., Y.S., Y.O., T.H., T.O.).
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35. Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG. Optical coherence tomography analysis of the macula after vitrectomy surgery for retinal detachment. Ophthalmology 2006;113(7):1179–1183. 36. Benson SE, Schlottmann PG, Bunce C, Xing W, Charteris DG. Optical coherence tomography analysis of the macula after scleral buckle surgery for retinal detachment. Ophthalmology 2007;114(1):108–112. 37. Garcia-Arumi J, Boixadera A, Martinez-Castillo V, Zapata MA, Fonollosa A, Corcostegui B. Macular holes after rhegmatogenous retinal detachment repair: surgical management and functional outcome. Retina 2011;31(9):1777–1782. 38. Fabian ID, Moisseiev E, Moisseiev J, Moroz I, Barak A, Alhalel A. Macular hole after vitrectomy for primary rhegmatogenous retinal detachment. Retina 2012;32(3):511–519. 39. Benzerroug M, Genevois O, Siahmed K, Nasser Z, Muraine M, Brasseur G. Results of surgery on macular holes that develop after rhegmatogenous retinal detachment. Br J Ophthalmol 2008;92(2):217–219. 40. Nork TM, Millecchia LL, Strickland BD, Linberg JV, Chao GM. Selective loss of blue cones and rods in human retinal detachment. Arch Ophthalmol 1995;113(8): 1066–1073. 41. Shiragami C, Shiraga F, Yamaji H, et al. Unintentional displacement of the retina after standard vitrectomy for rhegmatogenous retinal detachment. Ophthalmology 2010;117(1): 86–92. 42. Eshita T, Shinoda K, Kimura I, et al. Retinal blood flow in the macular area before and after scleral buckling procedures for rhegmatogenous retinal detachment without macular involvement. Jpn J Ophthalmol 2004;48(4):358–363. 43. Ozgu¨r S, Esgin H. Macular function of successfully repaired macula-off retinal detachments. Retina 2007;27(3):358–364. 44. Chang SD, Kim IT. Long-term visual recovery after scleral buckling procedure of rhegmatogenous retinal detachment involving the macula. Korean J Ophthalmol 2000;14(1): 20–26.
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Biosketch Fumiki Okamoto graduated from Tsukuba University School of Medicine, Ibaraki, Japan in 1994. He completed his ophthalmology residency and fellowship at University of Tsukuba Hospital. Dr Okamoto is currently the Assistant Professor in University of Tsukuba, Department of Ophthalmology. He specializes in vitreoretinal surgery.
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To investigate the relationship between metamorphopsia and macular morphologic changes after successful repair of rhegmatogenous retinal detachment (RD). DESIGN: Prospective, interventional, consecutive study. METHODS: The study included 129 eyes of 129 patients who had undergone successful retinal reattachment surgery. The severity of metamorphopsia was recorded using M-CHARTS and foveal microstructure was assessed with spectral-domain optical coherence tomography (OCT) at 6-12 months postoperatively. RESULTS: The mean metamorphopsia score was 0.30 ± 0.46, and 50 of 129 patients (39%) had metamorphopsia. Metamorphopsia was more severe in eyes with maculaoff rhegmatogenous RD than those with macula-on (P < .001). Eighteen of 50 eyes with metamorphopsia exhibited abnormal structures in the macular region (epiretinal membrane, disruption of the photoreceptor inner and outer segment junction, cystoid macular edema, macular hole, or subretinal fluid), whereas the other 32 eyes showed no morphologic changes with OCT. In these 32 eyes, the horizontal metamorphopsia score (0.86 ± 0.50) was significantly higher than the vertical metamorphopsia score (0.62 ± 0.39, P < .05). Nine of 69 eyes with preoperative macula-on rhegmatogenous RD developed postoperative metamorphopsia. Of the 9 eyes, 6 showed abnormal macular structures and the other 3 had normal-appearing OCT. The macula briefly detached during vitrectomy in these 3 cases. CONCLUSIONS: In eyes that remained macula-on throughout surgery and had normal-appearing OCT, metamorphopsia did not develop. In some cases, the reason for metamorphopsia was anatomically obvious. In other cases that were preoperative and intraoperative maculaoff, postoperative retinal vertical displacement could cause predominantly horizontal metamorphopsia. (Am J Ophthalmol 2014;157:214–220. Ó 2014 by Elsevier Inc. All rights reserved.) Accepted for publication Aug 6, 2013. From the Department of Ophthalmology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan. Inquiries to Fumiki Okamoto, Department of Ophthalmology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575 Japan; e-mail: [email protected]
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T
HE EFFECTIVENESS OF RHEGMATOGENOUS RETINAL
detachment (RD) surgery has generally been assessed by the rates of retinal reattachment and the postoperative visual acuity.1–6 Even after successful retinal reattachment and improvement of visual acuity, however, the postoperative quality of vision may be unsatisfactory in some cases. Metamorphopsia is one of the most common postoperative symptoms in patients with RD, with 22%-33% of patients complaining of metamorphopsia by questionnaire.7,8 Wang and associates investigated 46 patients with macula-off rhegmatogenous RD undergoing scleral buckling surgery and found that 67% of them had metamorphopsia on the Amsler grid at 2 months postoperatively.9 Recent advancement in optical coherence tomography (OCT) technologies has provided critical insights into the various retinal conditions.10,11 The development of spectral-domain OCT enhances the resolution with which the intraretinal architectural morphology, such as the ganglion cell layer (GCL), inner nuclear layer (INL), outer plexiform layer (OPL), outer nuclear layer (ONL), photoreceptor inner and outer segment junction (IS/OS), and external limiting membrane (ELM), can be clearly seen.12,13 Studies using OCT revealed that the visual acuity in RD patients deteriorated because of disruption of the IS/OS,14–16 disruption of the ELM,17 disruption of the cone outer segment tips, and thickening of the outer retina.18 Few studies, however, have investigated the relation between metamorphopsia and OCT findings.19–21 Using the Amsler grid in patients with epiretinal membrane (ERM), Watanabe and associates reported that the INL was thicker in patients with broad metamorphopsia than in those without metamorphopsia.19 It has also been reported that the severity of metamorphopsia, quantified by M-CHARTS, was strongly associated with the thickness of the INL in patients with ERM.20 Rossetti and associates examined 7 patients who complained of long-standing metamorphopsia after successful repair of macula-off rhegmatogenous RD and found that all eyes had normal findings on spectral-domain OCT.21 There is, however, no report quantifying metamorphopsia in rhegmatogenous RD patients and evaluating the relationship between metamorphopsia and detailed OCT findings.
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0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2013.08.007
The purpose of the present study was to quantify the severity of metamorphopsia after successful repair of rhegmatogenous RD and to investigate the relationship between metamorphopsia and morphologic changes in the macular region assessed with spectral-domain OCT.
METHODS WE ANALYZED 129 PATIENTS AFTER SUCCESSFUL SURGERY
for unilateral rhegmatogenous RD undertaken at University of Tsukuba Hospital from October 1, 2010 to April 26, 2012. Their ages averaged 52.3 6 11.0 years (mean 6 SD), and there were 84 male and 45 female patients. We conducted this prospective, interventional, consecutive study in accordance with the Declaration of Helsinki, and received approval from the institutional review committees of University of Tsukuba Hospital. Prior to inclusion in the study, all patients provided informed consent after the nature of the study was explained to them. Exclusion criteria included patients with a previous history of vitreoretinal surgery and ophthalmic disorders except myopia of less than -6 diopters and severe cataract of more than grade 3 nuclear sclerosis or cortical opacity. Eyes with complicated vitreoretinal disease, such as proliferative vitreoretinopathy and RD resulting from giant retinal tears, macular hole, or ocular trauma, were excluded. Patients with logarithm of minimal angle of resolution best-corrected visual acuity (logMAR BCVA) of >0.7 were also excluded because of possible incorrect measurement of the severity of metamorphopsia.22 Visual acuity, metamorphopsia, and OCT images were obtained at 6-12 months postoperatively. BCVA measured with the Landolt chart was expressed as logMAR. The severity of metamorphopsia was quantified with MCHARTS (Inami Co, Tokyo, Japan). M-CHARTS consists of 19 dotted lines with dot intervals ranging from 0.2-2.0 degrees of visual angle. If the straight line is substituted with a dotted line and the dot interval is changed from fine to coarse, the distortion of the line decreases with the increasing dot interval, until the dotted line appears straight.22,23 At first, vertical straight lines (0 degrees) were shown to the patient. If the patient recognized a straight line as straight, the metamorphopsia score was 0. If the patient recognized a straight line as irregular or curved, then subsequent pages of M-CHARTS, in which the dot intervals of the dotted line change from fine to coarse, were shown one after another. When the patient recognized a dotted line as being straight, the visual angle that separated the dots was considered to represent his or her metamorphopsia score for vertical lines (Figure 1). Then the M-CHARTS was rotated 90 degrees and the same test was performed with horizontal lines. The examinations were repeated 3 times, and their mean values were used for data analyses. VOL. 157, NO. 1
FIGURE 1. Method of determining the metamorphopsia scores with M-CHARTS. The minimum angle of the dots in the line that appeared straight was taken to be the metamorphopsia score. In this case, metamorphopsia for the vertical line was determined as 2.0.
Each examination was performed at 30 cm with the refraction of the eye exactly corrected for this distance. The presence of metamorphopsia was defined as the mean _0.2, metamorphopsia score (metamorphopsia score) > because the metamorphopsia scores were 0 in all normal subjects.22 Retinal images were obtained with spectral-domain OCT (Cirrus high-definition OCT; Carl Zeiss, Dublin, California, USA). We performed the 5-line raster scans in a horizontal and vertical manner for each eye using Cirrus analysis software version 3.0. Scans with signal strength of more than 7/10 were considered to be appropriate, and a representative image was selected. Diagnosis of a disrupted IS/OS was made based on loss and irregularity of the hyperreflexive line corresponding to the IS/OS junction. We also assessed the degree of the ELM disruption in a similar fashion. Two graders (Y.S., T.H.) assessed the status of the IS/OS and the ELM lines. Both graders were masked to the clinical findings of the patients, including their visual acuity and metamorphopsia score results. Clinical data were collected, including age, sex, surgical procedures, the number of retinal tears, circumferential dimension of retinal tears, area of retinal detachment, and macular status (on/off) (Table 1). We evaluated whether RD existed at the macula region using spectraldomain OCT in all eyes preoperatively. All surgeries were performed at our clinic by 2 experienced vitreoretinal surgeons (F.O., Y.O.). In eyes with cataract of grade 2 nuclear sclerosis or cortical opacity, the crystalline lens was removed by phacoemulsification and an acrylic foldable intraocular lens was implanted in the
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TABLE 1. Demographic and Clinical Data of Patients With Rhegmatogenous Retinal Detachment Number of eyes Age (y) Sex (male/female) Surgical procedures (scleral buckling/ vitrectomy) Number of retinal tears Circumferential dimension of retinal tears (degrees) Area of retinal detachment (degrees) Macular status (on/off) Preoperative visual acuity (logMAR) Postoperative visual acuity (logMAR) Postoperative metamorphopsia score (Mscore) Horizontal M-score Vertical M-score Mean M-score
129 55.3 6 11.0 84/45 31/98 2.0 6 1.5 17.9 6 16.6 126 6 73 69/60 0.56 6 0.80 0.05 6 0.18
0.30 6 0.50 0.31 6 0.49 0.30 6 0.46
FIGURE 2. Histogram of the mean metamorphopsia score in all patients after retinal detachment surgery. The metamorphopsia score ranged from 0.0-2.0. Fifty patients demonstrated mean metamorphopsia score of 0.2 or more.
Values are presented as n or as mean 6 standard deviation.
capsular bag, followed by vitrectomy. The surgical technique comprised a 23- or 25-gauge pars plana vitrectomy that released vitreous traction around the breaks, internal drainage of the subretinal fluid, a total gas-fluid exchange with 20% sulfur hexafluoride (SF6), and laser photocoagulation. When scleral buckling was performed, cryopexy and an exoplant (segmental silicone sponges in combination with an encircling silicone band) were used to support the retinal breaks. Subretinal fluid drainage and SF6 gas injection were performed when required. In both treatment groups, patients injected with gas were instructed to maintain a face-down position during the first postoperative week. The mean and standard deviations were calculated for metamorphopsia score and other parameters. The Student t test was performed to compare age, the number of retinal tears, circumferential dimension of retinal tears, and area of retinal detachment between patients with and without metamorphopsia. Differences in sex, surgical procedures, and macula status between patients with and without metamorphopsia were analyzed by the Fisher exact probability test. A logistic regression analysis was performed to determine parameters significantly relevant to the presence of metamorphopsia. Wilcoxon signed rank test was used to compare horizontal and vertical metamorphopsia scores. All tests of associations were considered statistically significant if P < .05. We carried out the analyses using StatView (version 5.0; SAS Inc, Cary, North Carolina, USA).
RESULTS THE MEAN METAMORPHOPSIA SCORE OF ALL PATIENTS WAS
0.30 6 0.46, while horizontal and vertical metamorphopsia 216
TABLE 2. Logistic Regression Analysis of the Presence or Absence of Metamorphopsia Score and Independent Variables in Patients With Rhegmatogenous Retinal Detachment
Age (y) Surgical procedures (scleral buckling/vitrectomy) Number of retinal tears Circumferential dimension of retinal tears (degrees) Area of retinal detachment (degrees) Macular status (on/off)
b
SE
P Value
0.00 0.00
0.03 0.66
.79 .98
0.08 0.00
0.17 0.02
.85 .67
0.00 0.35
0.01 0.62
.89 <.0001a
b ¼ partial correlation coefficient; SE ¼ standard error. a Significant at P < .05.
scores were 0.30 6 0.50 and 0.31 6 0.49, respectively. There was no significant difference between horizontal and vertical metamorphopsia scores (P ¼ .81). The mean metamorphopsia score ranged from 0.0-2.0 (Figure 2). Fifty of 129 patients (39%) had metamorphopsia (metamor_0.2). Forty-one of 60 eyes with macula-off phopsia score > rhegmatogenous RD (68%) and 9 of 69 eyes with macula-on rhegmatogenous RD (13%) had metamorphopsia. Patients with macula-off rhegmatogenous RD showed a significantly higher incident of metamorphopsia than those with macula-on rhegmatogenous RD (P < .0001). Patients with metamorphopsia had a larger area of retinal detachment (P < .0001) than those without metamorphopsia. Age (P ¼ .16), sex (P ¼ .71), surgical procedures (P ¼ .39), the number of retinal tears (P ¼ .33), and
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FIGURE 3. A breakdown of 50 eyes having metamorphopsia after retinal detachment surgery and representative images of spectraldomain optical coherence tomography.
circumferential dimension of retinal tears (P ¼ .50) showed no association with either the presence or absence of metamorphopsia. In logistic regression analysis, postoperative metamorphopsia score was significantly associated with macula-off rhegmatogenous RD (P < .0001), whereas other parameters were not relevant (Table 2). Figure 3 shows OCT findings in eyes with metamorphopsia. Of the 50 eyes, 6 eyes had ERM, 5 eyes had disruption of IS/OS, 3 eyes had cystoid macular edema (CME), and 2 eyes had macular hole (MH) and 2 eyes with persistent subretinal fluid (SRF), while the other 32 eyes exhibited no abnormal morphologic change. In these 32 eyes, the horizontal metamorphopsia score (0.86 6 0.50) was significantly higher than the vertical metamorphopsia score (0.62 6 0.39, P < .05) (Figure 4). Nine of the 69 eyes with macula-on rhegmatogenous RD developed postoperative metamorphopsia. Of the 9 eyes, 4 eyes had ERM, 1 eye had MH and 1 eye had SRF, and the other 3 eyes were without any abnormal morphologic change. Our operation video confirmed that the macula detached briefly during vitrectomy in these 3 patients.
DISCUSSION AS SHOWN IN THE ABOVE RESULTS, LESS THAN HALF OF
patients exhibited metamorphopsia after rhegmatogenous RD surgery at 6-12 months into follow-up. Among macula-off rhegmatogenous RD patients, 68% developed postoperative metamorphopsia, whereas the incidence was 13% among macula-on rhegmatogenous RD patients. Postoperative metamorphopsia score was associated with macula-off rhegmatogenous RD. These results are consistent with the findings of previous reports. Wright and associates7 and Amemiya and associates8 investigated the incidence of metamorphopsia in patients after scleral buckling surgery by questionnaire and found that 22% and 33% of patients, respectively, complained of metamorphopsia. Wang and associates conducted qualitative analysis of metamorphopsia following macula-off rhegmatogenous VOL. 157, NO. 1
RD surgery using the Amsler grid and found that 67% of patients had metamorphopsia.9 As this report focused only on scleral buckling surgery and the observation period was short (2-month follow-up), the incidence proved to be high, with the cause of metamorphopsia considered mainly to be postoperative persistent subretinal fluid. In addition, this study used the Amsler grid, which has been widely adopted to detect and evaluate metamorphopsia in patients with macular diseases.24,25 With the Amsler grid, however, it is difficult to quantify the severity of metamorphopsia because the patients have to self-describe the degree of image distortion. In contrast, M-CHARTS is an instrument that can easily and quantitatively evaluate the degree of metamorphopsia associated with macular diseases, with the patients only needing to answer whether the line is distorted or not.20,22,23 Our present study was the first to quantify the severity of metamorphopsia using MCHARTS in rhegmatogenous RD patients. As shown in the results of OCT images, 6 eyes had ERM, 5 eyes disruption of IS/OS, 3 eyes CME, and 2 eyes MH and 2 eyes persistent SRF, among 50 metamorphopsic eyes. The reported ERM incidence using OCT after repair of primary rhegmatogenous RD ranged between 9.0% and 23%.16,17,26–28 In our study, 15 of 129 eyes (11.6%) developed ERM, of which 6 had metamorphopsia. Metamorphopsia is one of the most common symptoms of patients with ERM, with 80%-85% complained of moderate to severe distortion.29,30 Studies using the 25-item National Eye Institute Visual Function Questionnaire demonstrated that the severity of metamorphopsia strongly influenced vision-related quality of life in patients with ERM.31,32 In the literature, studies using OCT detected persistent SRF in 47% and 52.3% of eyes 1 month after rhegmatogenous RD surgery.33,34 At 6 months postoperatively, 8% of eyes after vitrectomy and 43% of eyes after scleral buckling still had SRF.35,36 In most cases, SRF gradually disappeared within 1 year after surgery, but disrupted IS/OS was slow to be recovered.17,34 In our study, only 2 SRF and 5 disrupted IS/OS cases were noticed, probably because our patients were examined at least 6-12 months after surgery.
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FIGURE 4. Horizontal vs vertical metamorphopsia scores in 32 metamorphopsic patients who showed normal optical coherence tomography findings after successful repair of retinal detachment.
CME and MH are also well-known postoperative complications responsible for secondary visual impairment, with a prevalence of 4%-11% for CME16,17,26 and 0.85%1.1% for MH.37–39 In our study, 3 cases of CME (2.3%) and 2 cases of MH (1.6%) were detected, and these results were similar to those of previous reports. Thirty-two of the 50 metamorphopsic eyes (64%) exhibited normal-appearing OCT findings without any disruption of IS/OS, ELM, or abnormal macular contour. In these 32 eyes, the horizontal metamorphopsia score was significantly higher than the vertical metamorphopsia score. A previous paper indicated that poor visual acuity, color vision defects, or persistent metamorphopsia could persist over time, suggesting the existence of a microstructural macular damage that a standard fundus biomicroscopy could not detect.40 Rossetti and associates reported that long-standing metamorphopsia could occur after successful macula-off rhegmatogenous RD repair even without detectable photoreceptor disruption in spectral-domain OCT examination.21 Such persistent metamorphopsia appears to be arising from retinal vertical displacement by rhegmatogenous RD surgery. Shiragami and associates clarified that the extent of RD and macular status were significantly associated with postoperative inferior displacement of the retina using fundus autofluorescence.41 They suggested that a large-extent macula-off rhegmatogenous RD could cause retinal translocation even after successful surgery, resulting in dislocation of the macula from its original location. 218
Arimura and associates23 investigated the relationship between the degree of retinal contraction and metamorphopsia using M-CHARTS in patients with ERM, and found that the vertical metamorphopsia score correlated with the degree of horizontal contraction and the horizontal metamorphopsia score correlated with the degree of vertical contraction. In our study, the horizontal metamorphopsia score was higher than the vertical metamorphopsia score in 32 metamorphopsic patients who showed normal macular structures. We do not consider that these results were affected by a possible fatigue effect arising from the order of the directions of M-CHARTS tests. The reason was that both the horizontal and vertical metamorphopsia scores were similar in all eyes (mean value 0.30 and 0.31, respectively). In consideration of the previous reports, our results suggested that postoperative retinal vertical displacement could cause predominantly horizontal metamorphopsia. In addition, retinal microcirculation in the macular area was disturbed in patients with RD.42 Previous study of RD patients using multifocal electroretinography revealed that a decrease in retinal response densities was recorded in the reattached retina as well as in the detached retina.43 In view of these findings, it was possible that a slight foveal dysfunction that could not be detected by OCT caused metamorphopsia. Nine of 69 eyes with preoperative macula-on rhegmatogenous RD developed metamorphopsia. Of the 9 eyes, 6 revealed an abnormal macular structure while other 3 showed normal findings on OCT. The macula briefly detached during vitrectomy in these 3 cases. Of those, the retina detached near the macula preoperatively, and macular detachment occurred during core vitrectomy in 2 cases. In the remaining 1 case, the macula detached during fluid-air exchange because of movement of subretinal fluid attributable to air pressure from the anterior to posterior segment of the eye. It was shown that metamorphopsia could occur postoperatively if the macula detached even briefly during vitrectomy. The limitations of this study include a short-term followup, an extensive range of the last follow-up examination, and the resolution of OCT. We evaluated the patients at 6-12 months postoperatively. Previous studies reported that visual acuity in patients with rhegmatogenous RD improved more at 1-5 years postoperatively than at 6 months postoperatively.3,44 In addition, metamorphopsia could continue to improve over a long course of observation in patients with macula-off rhegmatogenous RD.21 Our OCT measurements were based on only 5 horizontal B-scan cross sections, and imaging inaccuracy might exist in the photoreceptor layer after RD. Future studies on metamorphopsia with a long-term follow-up and improved OCT technologies will be needed. In conclusion, after successful rhegmatogenous RD repair, 39% of patients developed metamorphopsia at 612 months postoperatively. OCT imaging found, however,
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that more than half of the metamorphopsic patients had normal macula structures. Our results suggested that retinal vertical displacement after surgery might mainly induce
horizontal metamorphopsia. Preoperative and intraoperative macula-on RD did not appear to have resulted in metamorphopsia postoperatively.
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST and none were reported. The authors indicate no funding support. Author contributions: Involved in design of study (F.O., Y.S.); conduct of study (F.O.); data collection (F.O., Y.O.); management, analysis, and interpretation of data (F.O., Y.O., T.H.); writing of article and literature search (F.O., Y.O., T.H.); revision of article (T.O., T.H.); and final approval of article (F.O., Y.S., Y.O., T.H., T.O.).
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AMERICAN JOURNAL OF OPHTHALMOLOGY
JANUARY 2014
Biosketch Fumiki Okamoto graduated from Tsukuba University School of Medicine, Ibaraki, Japan in 1994. He completed his ophthalmology residency and fellowship at University of Tsukuba Hospital. Dr Okamoto is currently the Assistant Professor in University of Tsukuba, Department of Ophthalmology. He specializes in vitreoretinal surgery.
VOL. 157, NO. 1
METAMORPHOPSIA AND OCT FINDINGS AFTER RETINAL DETACHMENT SURGERY
220.e1