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Choroidal Neovascular Lesion
Originally posted on the OPHTHALMIC HYPERGUIDE March 9, 2009
A 49-year-old man presented to clinic after experiencing a blurry vision in his right eye for 1 year. He also noted an intermittent central scotoma in the right eye for 6 weeks. He was found to have 20/400 vision in the right eye and 20/20 vision in the left eye. His anterior segment examination was unremarkable with the exception of mild nuclear sclerotic cataracts.
Examination of the fundus in the right eye revealed a subfoveal disciform scar with subretinal fluid (Slide 1). No evidence of punched-out lesions, angioid streaks, or significant myopia was present in either eye. The macula in the left eye was normal. A Heidelberg Spectralis (Heidelberg Engineering, Germany) optical coherence Tomography (OCT) was performed and revealed a subfoveal CNV membrane with associated subretinal fluid and vitreomacular traction (Slide 2). A diagnosis of idiopathic CNV membrane with vitreomacular traction was made.
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Slide 1. Fundus photo of the right eye revealing a subfoveal disciform scar. An area of geographic atrophy surrounds the retinal-choroidal anastomosis. (Image courtesy of Steve Charles, MD) |
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Slide 2. Heidelberg Spectralis (Heidelberg Engineering) OCT of the right eye revealing a subfoveal CNV membrane and vitreomacular traction with minimal subretinal fluid. (Image courtesy of Steve Charles, MD) |
Clinical course of action
The patient underwent a pars plana vitrectomy with removal of vitreomacular traction followed by peeling of the internal limiting membrane, then removal of submacular CNV membrane and, finally, fluid-gas exchange. A 25-gauge transconjunctival sutureless technique was used to perform a core vitrectomy to allow fluid-air exchange. A 25-gauge machinery vapor recompressor blade was used to create a small retinotomy by teasing apart the nerve fibers at the supero-temporal margin of the CNV lesion. The anterior portion of the lesion was grasped with 25-gauge disposable forceps (DSP ILM forceps, Alcon Laboratories, Inc., Fort Worth, TX). The IOP was elevated to 60 mm Hg to reduce bleeding and the membrane was slowly removed. Once the membrane was removed, it was kept in the forceps and used to gently approximate the edges of the retinotomy. The membrane was then removed with the vitreous cutter. The retinotomy site was managed with a fluid-air exchange without laser retinopexy to diminish the chance of a scotoma or a new CNV lesion.
Post-operative care and outcome
The patient maintained a seated, standing or prone face-down position for 7 days. One month after surgery, the patient’s vision improved to 20/200+ and he noted significant improvement in the size of the central scotoma. On fundus examination, no evidence of retinal defect or hemorrhage was visible (Slide 3).
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Slide 3. Postoperative fundus photo of the right eye with no evidence of CNV. There is an area of mild RPE depigmentation temporal to macula. (Image courtesy of Steve Charles, MD) |