Disappearance of extramacular drusen after chronic retinal detachment

Sir,

We present a patient who developed a chronic retinal detachment and following successful surgical repair, she had a dramatic resolution of extramacular drusen.

A 90-year-old white female presented with a 1½ month history of decreased vision in her left eye. Her past ocular history included being pseudophakic for the last 10 years with long-term extensive bilateral symmetrical extramacular drusen. Her past medical history included hypertension. On examination her vision was 20/30 in the right eye and hand motions in the left. The left eye had an almost total retinal detachment that was successfully repaired with combined vitrectomy and scleral buckle. Postoperatively her vision improved to 20/60 and almost all the extramacular drusen in the operated eye had disappeared [Figure 1].

Figure 1.

Composite fundus photographs showing extensive extramacular drusen in the right eye and almost total resolution of the drusen in the left eye following repair of a chronic retinal detachment. The depigmented area at the top of the operated eye is the retinotomy site. Before the operation both fundus showed similar distribution and intensity of extramacular drusen

It is well documented that drusen can disappear spontaneously, often resulting in patches of retinal pigment epithelial atrophy.[1] The absorption of drusen can also be stimulated with low fluence laser treatment although the mechanism is unknown. No study to date has demonstrated such treatment improves the visual outcome.[2] There has also been a report of a patient who had some resolution of macular drusen subsequent to macular hole surgery.[3]

To our knowledge, this particular cause of extramacular drusen disappearance has not been described in the literature. There is one similar case, wherein, the drusen disappeared after rhegmatogenous retinal detachment repair, but that case involved subfoveal drusen only.[4] The mechanism of the drusen disappearance is not fully understood, but it can be postulated that chronic exposure of the apical pigment epithelium to subretinal fluid may have allowed diffusion of the drusen material into subretinal space. Alternatively, the lack of outer segment disposal during the period of retinal detachment may have allowed drusen to clear through Bruch's membrane. There is no sign of atrophic change associated with the drusen disappearance and the patient's vision improved. This suggests that efforts to atraumatically reverse drusen formation may ultimately prove beneficial in conditions such as age-related macular degeneration.