Paracentral and Cecocentral Scotomas After Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment

Purpose: To describe novel paracentral and cecocentral visual scotomas after pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) repair over a 5-year period.

Design: Retrospective case series.

Methods: This was a retrospective review of all patients who reported visual scotomas after 23- or 25-gauge PPV (Constellation Vision System, Alcon, Fort Worth, Texas, USA) for RRD repair by a single surgeon (RNK) from January 2013 through December 2018. All patients had multimodal imaging (fundus photography, fluorescein angiography, autofluorescence, and spectral-domain optical coherence tomography [OCT] and standardized central Humphrey visual field [HVF] testing) to further characterize the visual scotomas.

Results: Nine patients reported visual scotomas after PPV for RRD from January 2013 to December 2018 with incidence of 6.4% (9/140). The average age was 61 years (range 53-71 years) and 3 of 9 were female. The preceding RRD was macula-sparing for 6 of 9 patients; all of them involved the right eye. Seven of 9 patients reported the central scotoma within the first week after surgery. All 9 patients noted paracentral or cecocentral location of scotomas involving the inferior temporal visual field. Multimodal imaging was only significant for corresponding focal superior nasal ganglion cell loss on spectral-domain OCT. Two of 9 patients had symptomatic visual loss from the scotoma because it involved the center of fixation.

Conclusions: We report a novel central/paracentral visual field defect after PPV for RRD repair. The paracentral scotoma is located inferotemporally and correlates anatomically with ganglion cell loss on spectral-domain OCT. The visual field defect and corresponding anatomic ganglion cell loss suggests a focal retinal injury. We propose that it could be caused by trauma from air flow from the infusion cannula during the air-gas exchange, angled directly toward the superior nasal paracentral retina. Surgeons should be aware of this complication and take precautions to slowly inject the gas after the air-gas exchange.