PMC8195657_01
(a) A wide-field preoperative photograph shows limited moderate submacular hemorrhage associated with a parafoveal choroidal rupture and an irregular-shaped posterior retinal tear. (b) A swept-source cross-sectional optical coherence tomography (OCT) image in the horizontal plane shows a submacular hemorrhage that appears hyperreflective; it is hemoglobin-rich (*) and hyporeflective when the serous component is predominant. Due to the presence of blood, there is attenuation of the IS/OS (inner segment/outer segment) band and RPE (retinal pigment epithelium) line. (c) Posterior pole preoperative clinical photography and (d) corresponding swept-source cross-sectional OCT image in the vertical plane depict an elevated preoperative central submacular hemorrhage and an RPE attenuation-like defect.
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fig1
The macula was dome-shaped and elevated because of the presence of a moderately thick SMH (Figures 1(a)- 1(d)). Cross-sectional images (Figures 1(b) and 1(c)) were acquired along the horizontal and vertical planes through the foveal center using a Swept-Source DRI Optical Coherent Tomography Triton device (Topcon Medical Systems, Inc., Oakland, NJ).
(a) Six weeks after surgery. The 20% remaining perfluoropropane (C3F8) bubble with a posterior temporal retinal tear treated with laser. (b) The 6-week spectral-domain optical coherence tomography (SD-OCT) corresponding to the submacular hemorrhage is almost completely reabsorbed. The IS/OS and external limiting membrane (ELM) lines show irregularity and are compacted against the protruded hyperreflective retinal pigment epithelium (arrowhead). The retinal pigment epithelium shows bulging without rupture but only mild disruption and fused IS/OS with the ELM (c, d). The 6-month postoperative cross-sectional horizontal and (e, f) vertical planes through the foveal center on SD-OCT.
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fig2
At the 6-week follow-up visit (Figures 2(a) and 2(b)), the blood had been inferiorly displaced, the BCVA was 20/140, eye pressure was normal, the retina was attached with some blood remnants inferiorly, and the macula had flattened, without underlying blood remnants.  Figure 3 shows that the BCVA was 20/30, the medium was very clear, the retina was attached, and the posterior retinal tear had a tight seal with the retinal pigment epithelium (RPE).
Preoperative and 6-month postoperative fundus color photographs. (a) Submacular hemorrhage associated with an adjacent parafoveal choroidal rupture. (b) Six months after surgery: a clinically normal foveal appearance and subretinal reparative scarring along the choroidal rupture temporal to the fovea.
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fig3
At the 6-week follow-up visit (Figures 2(a) and 2(b)), the blood had been inferiorly displaced, the BCVA was 20/140, eye pressure was normal, the retina was attached with some blood remnants inferiorly, and the macula had flattened, without underlying blood remnants.  Figure 3 shows that the BCVA was 20/30, the medium was very clear, the retina was attached, and the posterior retinal tear had a tight seal with the retinal pigment epithelium (RPE).
Preoperative spectral-domain optical coherence tomography (SD-OCT) of the corresponding macular locus images. Preoperative SD-OCT (left vertical column), 6-week postoperative SD-OCT (central vertical column), and 6-month postoperative comparative SD-OCT (right vertical column). (a-c) SD-OCT cross-sectional images acquired along the horizontal plane through the foveal center depict the involuted presence of blood and the sequential slow improvement of the retinal pigment epithelium, IS/OS, and external limiting membrane layers.
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fig4
The postoperative spectral-domain optical coherence tomography (SD-OCT-Spectralis OCT, Heidelberg Engineering, Germany) pattern showed a resolved submacular hemorrhage, an ellipsoid (IS/OS) line, and external limiting membrane (ELM) SD-OCT biomarker lines preserved but distorted and fused with the protruding RPE line (Figure 4).
Comparative campimetric and multifocal electroretinography (mfERG). Right eye (a) 10-2 and (b) 30-2 visual field view testing show deficits in retinal sensitivity to the central points of the stimuli. The mean deficits are 9.0 and 7.8 dB, respectively, compared with the contralateral normal eye (normal mean deficit: 0.5-2.0 dB). (c) Subnormal retinal response and reduction of the N1 and P1 wave amplitudes. The 61-hexagon 30  test had decreased by 75.0%, 41.9%, 27.0%, 10.5%, and 6.15%, respectively, from the <2-degree to >15-degree central rings compared to the normal control parameters (normal range of the mean deficit permitted is 1-3%). (d) mfERG as a 3-D topographic field map of the macular function shows subnormal foveal photoreceptor sensitivity with a normal spatial resolution, due to stable fixation and location pattern. Left eyes comparative normal figures of the left eye show (e) 10-2, (f) 30-2, and (g, h) mfERG within the normal range.
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fig5
Figures 5(a) and 5(b) show the 10-2 and 30-2 automated central field testing (Visual Field Perimeter, Vision Monitor MonPackONE, MetroVision, France), which revealed mean deficits in the retinal sensitivity of 9.0 dB and 7.8 dB, respectively, at the central points of the stimuli. The nV amplitude of the P1 waves significantly decreased with subnormal implicit times in all central rings studied in the affected eye, compared to the normal contralateral eye.  Figure 5(d) shows the mfERG as a 3-D topographic field map of the macular function that shows subnormal foveal photoreceptor sensitivity with a normal spatial resolution due to stable fixation and location pattern.
Comparative 6-month microperimetry. (a) The clinical aspect depicts a normal central fovea with a juxtafoveal choroidal rupture. (b) Retinal sensitivity measured with a microperimetry device (MAIA) shows a very diminished retinal sensitivity temporal to the fovea and an abnormal response 6 months following the surgery. The red figures and numbers indicate abnormally low retinal sensitivities (dB). (c) Stable foveal fixation pattern of the affected eye. (d) Corresponding foveal plotting with low retinal sensitivity on the temporal side of the fovea. (e-h) Correspond to normal left eye microperimetry.
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fig6
There was no correlation between the reduced retinal sensitivity locus and the corresponding retinal thickness on OCT (Figure 6).
Visual evoked potentials. Comparative visual evoked potentials of the affected eye. N75-74.115 ms, P100-100.225 ms, and P135 were not recorded. Normal left eye VEP functional traces were considered between the normal ranges.
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fig7
The visual evoked potentials (RETeval, LKC Technologies; Gaithersburg, MD) were measured with a midoccipital active scalp electrode placed (Oz) in the midline 3-4 cm above the inion, a reference electrode on the forehead, and the ground electrode placed on the earlobe where normal (Figure 7).