Introduction

Macular edema is a known postoperative complication of retinal detachment surgery (peak incidence: 30–180 days post-op, 10.6%) as well as cataract surgery [1,2]. While retinal folds are rare [3], they can lead to significant visual impairment and prolonged recovery if not promptly identified and treated. This case report highlights the importance of recognizing retinal fold leakage as the cause of persistent macular edema and outlines a successful minimally invasive treatment strategy.

Case Presentation

A 56-year-old Caucasian male underwent pars plana vitrectomy, endolaser photocoagulation, and gas tamponade for a temporal rhegmatogenous retinal detachment (RRD) in his right eye on 10 October 2024 at another institution. On 22 December 2024, he presented with complaints of persisting blurred vision in the operated eye (BSCVA: OD 0.4). (Table 1) Clinical examination revealed a complicated cataract, mild macular edema and a temporal superior retinal fold. On 20 January 2025, cataract surgery was successfully performed. However, on 15 March 2025, the patient returned with complaints of significantly decreased vision in the right eye (BSCVA: OD 0.2). Optical coherence tomography (Cirrus 5000™) revealed a significant macular edema with intra- and subretinal fluid accumulation (Figure 1a, 1b). Intravitreal Faricimab was administered resulting in some improvement in visual acuity. However, two months later, the patient returned with significantly blurred vision in the right eye. Wide-field imaging and peripheral OCT (Silverstone™) showed internal limiting membrane wrinkling and discreet subretinal fluid emanating from the retinal fold and reaching into the macula. Optical coherence tomography confirmed the recurrence of macular edema (CRT 515μ) and thus the retinal fold was identified as the source of leakage. Laser retinopexy was performed around the fold and followed by a second intravitreal injection of Faricimab (Figure 2a, 2b). This combined approach led to the permanent resolution of the macular edema and complete recovery of visual acuity (Figure 3a, 3b).

Discussion

Retinal folds may involve the inner or outer retina or be full thickness. Whereas serous retinal detachment, cystoid macular edema (peak 30-180days postOP, incid 10.6% [2], epiretinal traction membrane formation and vision reduction due to structural changes are generally not related to surgical technology, retinal folds may result from incomplete drainage of subretinal fluid, incorrect perfluorocarbon liquid (PFCL) volume, insufficient or excessive amount of gas instillation, uneven retinal stretching (especially when ILM is not peeled), finalizing the procedure before the retina is fully attached or poor postoperative positioning [4,5]. While surgical revision is mostly considered for macular and chorioretinal folds and epiretinal traction membranes [1,3], peripheral folds may respond well to medical resp. laser treatment [1,3]. In the patient reported here, laser retinopexy combined with Faricimab injections provided a successful outcome. Thus, the risks of retinal redetachment and reattachment, which are technically difficult, time-consuming, and provide uncertain results were avoided. However, identifying and addressing the root cause of the condition in a timelier manner could have prevented temporary vision loss and prolonged rehabilitation.

Conclusion

Persistent macular edema following RRD surgery with gas may be due to leakage from a retinal fold. Identifying and treating the underlying cause is essential for optimal recovery. This case demonstrates excellent anatomical and functional outcomes utilizing a minimally invasive approach.

References

1. Pole C, Chehaibou I, Govetto A, Garrity S, Schwartz SD, et al. (2021) Macular edema after rhegmatogenous retinal detachment repair: risk factors, OCT analysis, and treatment responses. Int J Retina Vitreous 7(1): 9.
2. Thais C, Finger M, Maliska G, Brillinger-Novello S (2024) Macular edema after surgery to treat rhegmatogenous retinal detachment: 1-year follow-up, incidence, and associated risk factors. Arq Bras Oftalmol 87(4): e2022.
3. Gupta R, Douglas SM, Iaboni M, Seamone DS (2019) Inner, outer, and full thickness retinal folds following rhegmatogenous retinal detachment repair: A Review. Surv Ophthalmol 64(2): 135-161.
4. Heimann H, Bopp S (2011) Retinal Folds following Retinal Detachment Surgery. Ophthalmologica 226 (Suppl 1(1)): 18-26.
5. Radeck V, Helbig H, Prahs P (2022) Subretinal air injection for treatment of retinal folds after retinal detachment surgery. Ophthalmologe 119(4): 381-387.