Macular hole surgery complicated by accidental massive subretinal indocyanine green, and retinal tear

To report a case of macular hole (MH) surgery complicated by accidental massive subretinal indocyanine green (ICG), and a retinal tear through the papillomacular bundle.

A 64-year-old woman complained of one-year history of poor vision in her left eye (LE) and of one month in her right (RE). Dilated fundus examination, fluorescein angiography, and optical coherence tomography (OCT) demonstrated a bilateral full-thickness MH with cystic changes and no posterior vitreous detachment RE and a full-thickness hole with significant surrounding retinal edema and cystic changes LE.

A vitrectomy and posterior vitreous mechanical detachment were performed to close the MH RE. Approximately 0.3 ml of 0.5% ICG was applied to stain the internal limiting membrane (ILM). The assistant surgical nurse at the beginning of the instillation pushed the ICG syringe’s embolus with too much force into the vitreous cavity with a 20-gauge cannula. Subretinal ICG was accidentally introduced through the macular hole, and an iatrogenic macular retinal tear though the papillomacular bundle was created. Infusion was resumed immediately, and ICG was removed from the vitreous cavity, and the ILM was removed in a circular fashion in the usual manner. The eye was left with 14% perfluoropropane gas. Fundus examination and OCT performed after the intraocular gas was reabsorbed one month after the surgery revealed that the macular hole was completely closed with choroidal hypereflectivity due to RPE and choriocapillaris atrophy. Best-corrected visual acuity was 20/150 with a closed macular hole and ICG still present in the subretinal space seven months after surgery.

Our anatomic and functional results were poor with retinal and retinal pigment epithelium (RPE) atrophy, and a visual acuity of 20/150. Subretinal ICG and contact of ICG with the RPE should be avoided, and precautions should be taken when using intravitreous ICG to stain the ILM. Further studies are necessary to determine ICG safety in vitreoretinal surgery.