RD Case Report

Successful Anatomical and Functional Preservation in a Case of Traumatic Funnel Retinal Detachment with Mature Cataract: A Comprehensive Case Report

Abstract

Background: Pediatric ocular trauma resulting in funnel-shaped retinal detachment (RD) associated with a mature cataract is exceedingly rare and poses significant diagnostic and surgical challenges. Delay in presentation, media opacities, and proliferative vitreoretinopathy (PVR) further complicate the prognosis. Historically, such cases were associated with poor anatomical and functional outcomes.

Case Presentation: We present the case of an 11-year-old male who presented with a history of longstanding visual loss in the left eye following a firecracker injury sustained at the age of three. The patient had light perception at presentation, with a mature white cataract obscuring the fundus view. B-scan ultrasonography confirmed a total funnel RD with advanced PVR. The patient underwent micro-incision vitrectomy surgery (MIVS), including cataract extraction, vitrectomy, intravitreal corticosteroid injection, laser photocoagulation, perfluorocarbon-assisted retinal flattening, and silicone oil tamponade. Postoperatively, the retina reattached successfully, and the visual acuity improved to 6/36 at one-year follow-up—an unexpected yet highly encouraging result. Anterior chamber migration of silicone oil was managed surgically.

Conclusion: This case demonstrates that even in delayed pediatric presentations of complex RD with mature cataract, tailored surgical intervention using contemporary vitreoretinal techniques can achieve not only anatomical preservation but also meaningful functional recovery.

Keywords: Pediatric ocular trauma, funnel retinal detachment, micro-incision vitrectomy, mature cataract, silicone oil, perfluorocarbon, PVR, visual rehabilitation

1. Introduction

Pediatric ocular trauma is a leading cause of non-congenital monocular blindness globally, with firecracker-related injuries being a significant contributor in developing countries, particularly during festive periods (John et al., 2015; Varshney & Bhattacharjee, 2024). Among traumatic ocular sequelae, posterior segment complications such as retinal detachment (RD) are associated with the poorest visual outcomes, particularly when compounded by proliferative vitreoretinopathy (PVR) or media opacities like mature cataracts (Kuhn et al., 1996; Nuzzi, Lavia, & Spinetta, 2017).

Funnel-shaped RD is characterized by a tightly rolled, circumferentially contracted retina with anterior and posterior folding due to advanced vitreoretinal fibrosis. Visualization and surgical manipulation in such cases are hindered by coexisting cataracts. In pediatric eyes, the risks are compounded by amblyopia, inflammation, and challenges in long-term follow-up.

The present case highlights the importance of aggressive surgical intervention and the potential for functional vision recovery, even in seemingly hopeless eyes. We emphasize a stepwise surgical approach, intraoperative decision-making, and postoperative management to mitigate complications and optimize outcomes.

2. Case Presentation

2.1 Patient Information

An 11-year-old male was referred to our tertiary eye care center with a history of complete vision loss in the left eye for over 8 years. The visual loss followed a firecracker explosion injury at the age of 3. The patient received no formal ophthalmic evaluation or treatment at the time. The family reported gradual whitening of the affected eye over the years, without associated pain or redness. There was no history of systemic illness or relevant family history.

2.2 Clinical Findings

·       Visual Acuity (Snellen):

o   Right Eye (OD): 6/6

o   Left Eye (OS): Light perception (LP) present at presentation

·       Intraocular Pressure (IOP):

o   OD: 16 mmHg

o   OS: 12 mmHg

·       Anterior Segment (OS):

o   White, mature cataract completely obstructing fundus view

o   Cornea clear; anterior chamber deep and quiet

·       Posterior Segment Evaluation (OS):

o   Indirect ophthalmoscopy was not possible

o   B-scan ultrasonography findings:

§  Funnel-shaped total RD

§  Mobile, echogenic membranes with evidence of vitreoretinal traction

§  No intraocular foreign body or choroidal detachment

2.3 Diagnostic Assessment

Given the dense media opacity from the mature cataract, B-scan ultrasonography was pivotal for both diagnosis and preoperative surgical planning. The scan revealed a total retinal detachment with a classic funnel configuration and extensive vitreoretinal traction, consistent with advanced proliferative vitreoretinopathy (PVR). Based on these findings, the detachment was classified as PVR Grade C2, according to the Retina Society classification system (Kuhn et al., 1996). Axial length measurements were within the expected range for the patient’s age.

A guarded visual prognosis was anticipated due to the following high-risk factors:

·     Longstanding duration of the detachment

·     Light perception present at presentation

·     High-grade PVR (Grade C2 or greater)

·     Absence of prior surgical or medical intervention

The differential diagnosis included traumatic retinal detachment with secondary PVR and other causes of leukocoria, such as retinoblastoma and Coats disease; however, B-scan imaging excluded intraocular masses and vascular anomalies.

2.4 Therapeutic Intervention

A single-stage combined anterior and posterior segment surgery was planned. The procedure was performed under general anesthesia.

Intraoperative Steps:

1.   Limbal-based approach:

o   Anterior chamber entry using a clear corneal incision

o   Phacoaspiration of the white cataract with gentle hydrodissection

o   Posterior continuous curvilinear capsulorrhexis (PCCC) created to access the posterior segment

2.   Pars plana vitrectomy (23G MIVS):

o   Core and peripheral vitrectomy performed

o   Posterior hyaloid detachment induced using triamcinolone staining

o   Careful removal of membranes and fibrous tissue over the retina

3.   Intravitreal Methylprednisolone (40 mg/mL):

o   Used intraoperatively to reduce postoperative inflammation

4.   Perfluorocarbon Liquid (PFCL):

o   Flattened retina progressively, aiding subretinal fluid displacement. The combination of perfluorocarbon liquids and silicone oil tamponade has been shown to improve anatomical success in complex retinal detachment surgeries (Zanzottera et al., 2021; Berrocal, Chenworth, & Acaba, 2017).

5.   360° Endolaser Photocoagulation:

o   Applied around existing retinal tears and periphery

6.   PFCL-Air-Silicone Oil Exchange:

o   5000 cSt silicone oil tamponade instilled for long-term retinal support

The surgical course was uneventful with good retinal flattening achieved intraoperatively.

2.5 Follow-Up and Outcomes

Postoperative Timeline:

·     Week 1:

o   Retina attached on indirect ophthalmoscopy

o   Silicone oil bubble observed partially in anterior chamber

o   IOP: 8 mmHg; cornea clear; no signs of inflammation

·     Month 1:

o   Vision improved from light perception to hand motion detection

o   Anterior chamber oil reduced spontaneously

o   Retina remained attached; aphakia noted

·     Month 6:

o   Visual acuity improved to counting fingers at 1 meter, then at 3 meters with occlusion therapy

o   Keratopathy developing from oil contact with endothelium

·     Month 12:

o   Vision improved to 6/36 with aphakic correction

o   Anterior segment showed persistent corneal edema and endothelial pigment changes

o   Silicone oil removed via limbal incision under general anesthesia

o   Retina remained attached without oil tamponade

Secondary intraocular lens implantation was deferred due to axial elongation and risk of posterior segment traction. Amblyopia therapy was advised using occlusion of the dominant eye and low vision aids. Visual rehabilitation in pediatric RD patients is still achievable despite delayed presentation, as demonstrated in similar surgical cohorts (Read et al., 2017; Bhende, Kashyap, & Nadig, 2024).

3. Discussion

This case illustrates multiple key points in the management of complex pediatric trauma:

1.   Importance of Early Intervention: Despite an 8-year delay, surgical repair led to unexpected and significant visual improvement (Light perception to 6/36). This challenges the traditional assumption that longstanding RD always results in irreversible vision loss, especially in pediatric eyes with plasticity.

2.   Use of PFCL and Corticosteroids: PFCL proved essential for intraoperative retinal manipulation, particularly in eyes with funnel-shaped RD and organized membranes (Zanzottera et al., 2021; Berrocal et al., 2017), while intravitreal corticosteroids minimized postoperative inflammation, reducing the risk of PVR recurrence.

3.   Complication Management: Silicone oil migration is a well-documented complication in aphakic pediatric eyes and warrants timely recognition and removal to prevent keratopathy (Guner et al., 2022). Prompt recognition and surgical removal mitigated further endothelial damage.

4.   Visual Outcome: Vision improvement to 6/36, though subnormal, is functionally significant for mobility, education, and quality of life. It demonstrates the importance of not giving up on such cases and setting realistic yet hopeful expectations with caregivers.

This case reinforces the need for public education on immediate ophthalmic referral after pediatric ocular trauma, regardless of initial symptom severity. Timely surgical intervention, even after years of neglect, can achieve surprising anatomical and visual recovery in pediatric populations (Rossin et al., 2020; Read et al., 2017).

4. Conclusion

This case highlights that even with delayed presentation and complex pathology, modern surgical strategies can lead to meaningful functional and anatomical outcomes in pediatric traumatic RD. A stepwise and individualized surgical approach using MIVS, PFCL, laser photocoagulation, and long-term follow-up is essential. Such interventions not only preserve the globe but can also achieve visual rehabilitation, as supported by growing evidence in pediatric vitreoretinal surgery (Berrocal et al., 2017; Read et al., 2017).

Ethics Statement

Written informed consent was obtained from the patient’s parents for both surgical procedures and publication of clinical data and anonymized images. Ethical approval was not required for this single case report. This report was prepared in accordance with the CARE guidelines for clinical case reports.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

No external funding was received for the preparation of this case report.

References

Bhende, P., Kashyap, H., & Nadig, R. (2024). Surgical management of a case of giant retinal tear with closed funnel retinal detachment in a pediatric patient. Indian Journal of Ophthalmology, 72, 765. https://doi.org/10.4103/IJO.IJO_1598_23

Varshney, A. S., & Bhattacharjee, D. (2024). Firework-related ocular injuries: A systematic review and meta-analysis of clinical outcomes and preventive strategies. Delhi Journal of Ophthalmology, 34(4), 261–269. https://doi.org/10.4103/DLJO.DLJO_182_24

Oderinlo, O., Umeh, V., Hassan, A., Oshunkoya, L., & Bulus, S. (2023). Technique and outcomes of vitreoretinal surgery for complications of proliferative sickle cell retinopathy. Nigerian Journal of Ophthalmology, 31. https://doi.org/10.4103/njo.njo_17_23

Guner, M., Guner, M., Cebeci, Z., & Kır, N. (2022). Preoperative and postoperative factors affecting functional success in anatomically successful retinal detachment surgery. Korean Journal of Ophthalmology, 36, 477–485. https://doi.org/10.3341/kjo.2022.0057

Zanzottera, E., Marchese, A., Bandello, F., & Coppola, M. (2021). Intraocular perfluorodecalin and silicone oil tamponade (double filling) in the management of complicated retinal detachment: Functional and anatomical outcomes using small-gauge surgery. Graefe’s Archive for Clinical and Experimental Ophthalmology, 260, 1105–1112. https://doi.org/10.1007/s00417-021-05395-7

Rossin, E., Tsui, I., Wong, S., Hou, K., Prakhunhungsit, S., Blair, M., ... & Yonekawa, Y. (2020). Traumatic retinal detachment in patients with self-injurious behavior: An international multicenter study. Ophthalmology Retina. https://doi.org/10.1016/j.oret.2020.11.012

Read, S., Aziz, H., Kuriyan, A., Kothari, N., Davis, J., Smiddy, W., ... & Berrocal, A. (2017). Retinal detachment surgery in a pediatric population: Visual and anatomic outcomes. Retina, 38, 1393–1402. https://doi.org/10.1097/IAE.0000000000001725

Berrocal, M. H., Chenworth, M. L., & Acaba, L. A. (2017). Management of giant retinal tear detachments. Journal of Ophthalmic and Vision Research, 12, 93. https://doi.org/10.4103/2008-322X.200158

Nuzzi, R., Lavia, C., & Spinetta, R. (2017). Paediatric retinal detachment: A review. International Journal of Ophthalmology, 10(10), 1592–1603. https://doi.org/10.18240/ijo.2017.10.18

Lai, W., & Wu, T. (2016). Successful management in a case of traumatic retinal detachment due to open globe injury using microincisional vitrectomy. Case Reports in Ophthalmology, 7, 198–202. https://doi.org/10.1159/000450638

John, D., Philip, S. S., Mittal, R., John, S. S., & Paul, P. (2015). Spectrum of ocular firework injuries in children: A 5-year retrospective study during a festive season in Southern India. Indian Journal of Ophthalmology, 63(11), 843–846. https://doi.org/10.4103/0301-4738.171966

Yorston, D., & Jalali, S. (2002). Retinal detachment in developing countries. Eye, 16(4), 353–358. https://doi.org/10.1038/sj.eye.6700188

Greven, C., Collins, A., Slusher, M., & Weaver, R. (2002). Visual results, prognostic indicators, and posterior segment findings following surgery for cataract/lens subluxation-dislocation secondary to ocular contusion injuries. Retina, 22, 575–580. https://doi.org/10.1097/00006982-200210000-00007

Cekiç, O., Batman, C., Totan, Y., Aslan, O., & Ozalp, S. (1999). Management of traumatic retinal detachment with vitreon in children. International Ophthalmology, 23(3), 145–148. https://doi.org/10.1023/a:1010637503058

Kuhn, F., Morris, R., Witherspoon, C. D., Heimann, K., Jeffers, J. B., & Treister, G. (1996). A standardized classification of ocular trauma. Ophthalmology, 103(2), 240–243. https://doi.org/10.1016/s0161-6420(96)30710-0

Corresponding Author:

Dr. Ankit Sanjay Varshney

Email: ankitsvarshney@yahoo.com

Address: Shree Bharatimaiya College of Optometry & Physiotherapy, Surat, India

The PDF view of the article