Background: To report a case series in which a modified technique was used to remove retained submacular perfluorocarbon liquid (PFCL) secondary to vitreoretinal surgery for rhegmatogenous retinal detachment. Case presentation: Four patients who had undergone pars plana vitrectomy for rhegmatogenous retinal detachment were further treated with surgical intervention because of retained submacular PFCL. With a three-port pars plana approach, after the internal limiting membrane peeling with indocyanine green staining, a 38-gauge flexible cannula was used to aspirate the submacular perfluorocarbon bubble, followed by fluid-air exchange and air injection into vitreous cavity. Submacular perfluorocarbon liquid was removed successfully and visual acuity had an improvement in all cases. Conclusion: The surgical removal of retained submacular PFCL using a 38-gauge flexible cannula combined with internal limiting membrane peeling and intravitreal air tamponade may provide anatomical and visual satisfactory outcomes. Keywords: Perfluorocarbon liquid, Submacular, Internal limiting membrane peeling Background Case presentation Perfluorocarbon liquid (PFCL) is now in wide and crit- Case 1 ical use in vitreoretinal surgery. The presence of subma- A 71-year-old male, presented with rhegmatogenous cular PFCL is a significant surgery-associated retinal detachment in the right eye, underwent complication and can lead to functional visual loss, cen- 23-gauge vitrectomy, perfluoropropane (C F )gas 3 8 tral scotoma and irreversible retinal structural damage tamponade, as well as phacoemulsification with intra- . Removal of submacular PFCL is generally recom- ocular lens implantation. Three weeks later, when the mended. However, there is no expert consensus or refer- patient visited our clinic for the first time postopera- ence for the standard surgical treatment. Here, we tively, 2 bubbles of submacular PFCL were detected report four cases of surgical removal of retained subma- on optical coherence tomography (OCT) scans cular PFCL bubbles using a 38-gauge flexible cannula (Fig. 1a). The patient was further treated with a combined with internal limiting membrane (ILM) peel- three-port pars plana vitrectomy (PPV). At the time ing and intravitreal air tamponade. of surgery, after the ILM peeling with indocyanine green (ICG) staining, direct aspirations of PFCL were performed using a 38-gauge needle placed on the top * Correspondence: email@example.com; firstname.lastname@example.org 1 of the bubbles. This was followed by fluid-air ex- Department of Ophthalmology, Ruijin Hospital, Affiliated Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China change and air injection into vitreous cavity. One Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lin et al. BMC Ophthalmology (2018) 18:132 Page 2 of 5 flat open macular hole (Fig. 2e). Visual acuity was stable at 20/125 without central scotoma. Case 3 A 42-year-old male complained of impaired vision in the right eye for 5 days and was diagnosed as rhegmatogen- ous retinal detachment. He had received 23-gauge vitreoretinal surgery with the use of PFCL and silicone oil tamponade. The left eye was normal. Visual acuity improved from counting fingers close to face to 20/1000 after 2 weeks. Although retina was well attached, a 300-μm bleb of subfoveal PFCL was noted (Fig. 3a-c). The patient accepted the surgical option after discussing the possible consequences and outcomes for the man- agement of submacular PFCL. Immediately, the patient underwent PPV, ILM peeling, PFCL aspiration and intra- vitreal air tamponade. Two weeks postoperatively, visual acuity had improved to 20/100. Funduscopy and OCT revealed a normal foveal contour without edema or sub- retinal fluid (Fig. 3d-f). Case 4 A 44-year-old female was referred to our institution with Fig. 1 Multimodal imaging of the affected eye. a Preoperative OCT retinal detachment. The patient underwent 23-gauge showing two submacular PFCL bubbles. b Postoperative OCT pars plana vitrectomy, accompanied by intravitreal PFCL showing restoration of the foveal contour injection, retinal laser treatment, and fluid-air exchange, followed by silicone oil tamponade. Prior to the comple- tion of the surgery, submacular PFCL in the juxta foveal location was noticed (Fig. 4a). A 38-gauge needle was month later, visual acuity improved from 20/1000 to inserted into the bubble, and active suction was used to 20/60, and OCT scans showed a relatively remove the PFCL. Intraoperatively, no significant well-preserved macular appearance (Fig. 1b). changes were observed in the macular region beneath the PFCL after its removal. At 1 month postoperatively, Case 2 the patient complained of metamorphopsia. OCT re- A 52-year-old male with visual loss in the left eye was vealed the presence of epiretinal membrane and signifi- referred to our clinic. Fundus examinations suggested cant macular thickening (Fig. 4b), and visual acuity was retinal detachment. The patient underwent 23-gauge 20/100. After a thorough discussion, the patient agreed vitreoretinal surgery, involving PFCL injection, laser to undergo the surgical intervention. After removing the photocoagulation around the retinal tear and peripheral silicon oil, we performed ILM peeling and intravitreal air retinal cryopexy for lattice degeneration. Silicone oil was tamponade. Two months postoperatively, visual acuity injected as an intraocular tamponade after fluid-air ex- had improved to 20/50, and the macular regained a nor- change. Four weeks later, at the time of the first mal appearance without signs of edema (Fig. 4c). follow-up clinic visit, subfoveal PFCL retention was ob- served by funduscopy and OCT (Fig. 2a and b), and vis- Discussion ual acuity of the left eye was limited to 20/1000. The Subretinal PFCL is a relatively rare but serious complica- patient underwent silicone oil removal, PPV, ILM peel- tion secondary to surgical repair of rhegmatogenous ret- ing, PFCL aspiration and air injection. Two weeks post- inal detachment. Temporary exposure to PFCL has been operatively, the patient complained about a central reported to be clinically safe, however, retained PFCL scotoma and visual deformation of the affected eye. has the potential toxic effects on various structures of After careful examinations, the PFCL droplet disap- the retina . Actually, it is optimal to notice the PFCL peared but a full-thickness macular hole was noticed bubbles intraoperatively and remove subretinal PFCL (Fig. 2c and d). Additional vitrectomy with 14% C F in- immediately. However, subretinal retention of PFCL can- 3 8 jection was performed to enhance macular hole closure. not be detected in 0.9 to 11.1% of cases until follow-up Six months after the last surgery, OCT still revealed a visits . Lin et al. BMC Ophthalmology (2018) 18:132 Page 3 of 5 Fig. 2 Multimodal imaging of the affected eye. a Fundus photograph showing a subfoveal PFCL bubble after the first surgery. b OCT showing a small PFCL droplet under the retina after the first surgery. c Postoperative fundus photograph showing a macular hole. d Postoperative OCT shows a full-thickness macular hole. e OCT showing a flat open macular hole During vitreoretinal surgery, especially for macular-off PFCL is challenging and may cause significant damages, retinal detachment or giant retinal tears, unnoticed small prompt intervention appears to be recommended par- droplets could migrate into the subretinal space via ret- ticularly in the submacular location. inal breaks during PFCL injection. The high jet stream In our cases, a modified minimally traumatic tech- of the injection may induce turbulence in the vitreous nique was used for direct aspiration of the retained cavity, causing disruption of the PFCL surface tension, PFCL bubbles. A standard three-port pars plana vitrec- thus increasing the possibility for PFCL bubbles to mi- tomy was performed in all patients. The ILM of the ret- grate towards the subretinal space. If the end of the in- ina was stained with the use of ICG and then peeled to jection needle is not completely submerged into the the vascular arcades. Subsequently, a 38-gauge flexible growing bubble, subretinal PFCL droplets may also cannula was used to carefully aspirate the PFCL drop- occur. Once PFCL was displayed in the subretinal space, lets, with the tip in a substantially perpendicular pos- long-term retention may induce progressive retinal pig- ition. Additional file 1: Video S1 shows the procedure in ment epithelial and photoreceptor damage, resulting in more detail. Postoperatively, the patients achieved both irreversible visual impairment . Visual prognosis of an anatomic success and an improvement in visual acu- residual PFCL depends on the location, size and expos- ity. Despite in one case, the patient developed a macular ure time. Since the removal of the retained subretinal hole which was successfully resolved with another Lin et al. BMC Ophthalmology (2018) 18:132 Page 4 of 5 Fig. 3 Multimodal imaging of the affected eye. a Preoperative fundus photograph showing a small PFCL bubble beneath the fovea. b Preoperative images showing the position of OCT scans. c Preoperative OCT showing a subfoveal PFCL droplet. d Postoperative fundus photograph showing a normal foveal contour. e Postoperative images showing the position of OCT scans. f Postoperative OCT showing a normal foveal contour surgical intervention, this method should be considered limited number of previously published case reports as alternative for the treatment of retained submacular [6–8], follow-up results indicated that early surgical re- PFCL. Further studies with larger patient population and moval generally showed a good prognosis. Second, ILM longer follow-up are warranted to verify and extend our peeling is a technical procedure applied to release tan- findings. Moreover, it is worth noting that, in case 4, dir- gential traction, thus minimizing the risk of an iatro- ect ILM peeling was not attempted at the beginning as genic macular hole. On the other hand, since the inner silicon oil had already been injected into the vitreous retina seemstobemorerigid whentheILM exists, cavity. We observed the development of epiretinal mem- ILM peeling might weaken the force acting to confine brane postoperatively, which could be due to the perifo- PFCL in the subretinal space and increase retinal flexi- veal retinal puncture and a predisposition in young bility. Cillà et al.  also affirmed the significance of patients . More specifically, PFLC aspiration could ILM peeling and further demonstrated that performing make an open break, facilitating the access of retinal pig- the procedure immediately before or shortly after the ment epithelial cells or fibroblast-like cells to the epiret- PFCL aspiration did not seem to influence anatomic re- inal surface and to produce collagen. Further sults. Third, different sizes of cannulas were used for histopathologic studies on epiretinal membrane are PFCL aspiration in previous reports, ranging from needed to better demonstrate this problem. 36-gauge to the smallest 50-gauge [10–13]. It is chal- There are several issues that deserve further discus- lenging to select the most suitable cannula and the sions. First, there is no consensus about the optimal choice will largely depend on the size and location of timing for submacular PFCL removal. But in general, PFCL,aswell asthe technical considerations ofthe sur- earlier removal seems to be more appropriate to im- geons. While aspirating the subretinal PFCL, the tip of prove visual functions and to avoid further retinal dam- the cannula should be placed exactly on the top of the ages. As we all know, the photoreceptor inner segment/ bubble in a substantially perpendicular position, so as outer segment (IS/OS) junction has been found to be to minimize the potential damage to retinal functions. an important prognostic factor for visual acuity. In our Fourth, since the risk of postoperative macular hole current cases, we noticed that the appearance of photo- could not be excluded, all patients were finally treated receptor layers seemed to be defective, thus necessitat- with intravitreal air injection and instructed to maintain ing earlier surgical interventions. If we don’tconsider a face-down position for at least 3 days. Intravitreal gas the time periods when submacular PFCL is detected, tamponade is supposed to be beneficial for macular and the patient is willing to accept the surgical inter- hole closure after elimination of the tangential force. In vention, the procedure is recommended in 2 weeks addition, it provides a template for glial cell prolifera- after the initial surgery. Based on our results and the tion and migration. Lin et al. BMC Ophthalmology (2018) 18:132 Page 5 of 5 Availability of data and materials The datasets and videos used and/or analyzed during the current study available from the corresponding author on reasonable request. Authors’ contributions Conceptualization of the study: ZJL and XS. Data acquisition: ZJL, YWC and SG. Manuscript preparation: ZJL. Revision of manuscript: YSZ and XS. All authors have read and approved the final manuscript. Ethics approval and consent to participate Ethical approval was not required as this manuscript just involved four cases. The study was adhered to the tenets of the Declaration of Helsinki. Written informed consents were obtained from the patients before the surgery. Consent for publication Written informed consents for publication of the clinical details and accompanying images were obtained from the patients. A copy of the written consents is available for review by the Editor of this journal. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Department of Ophthalmology, Ruijin Hospital, Affiliated Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China. Department of Ophthalmology, Ruijin Hospital North, Affiliated Shanghai Jiaotong University School of Medicine, 999 Xiwang Road, Shanghai 201801, China. Received: 12 February 2018 Accepted: 23 May 2018 References 1. 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Published: Jun 4, 2018