After a radial conjunctival incision, the bare sclera was exposed. A full-thickness scleral incision (5 to 6 mm wide, 2 to 3 mm long, and square bracket shaped) was made in the quadrant between the rectus muscles. The anterior margin of the incision was usually 6 to 8 mm from the corneoscleral limbus. A small amount of supra-choroidal fluid was spontaneously drained after the sclerotomy. The underlying choroid was then exposed by meticulous dissection. The full-thickness scleral flap was then loosely sutured with 8-0 vicryl at two corners of the rectangle for a loose approximation at its original position (Fig. 1).

A 43-year-old man was referred to our retinal clinic due to decreased visual acuity in the left eye lasting for one month. He had been wearing glasses for hyperopia since he was younger than ten years. A gradual decrease in visual acuity led him to seek care at another hospital, where he was found to have a serous retinal detachment in the left eye. He was subsequently referred to our clinic.

At presentation, his best-corrected visual acuity (BCVA) was 0.3 and 0.01 logarithm of minimum angle resolution (logMAR), and spherical equivalents were +14.0 diopters (D) and +16.0 D in the right and left eyes, respectively. Fundus examination revealed nanophthalmic fundi in both eyes. In the left eye, there was uveal effusion involving the macula. The axial length was 16.41 mm in the right eye and 16.24 mm in the left eye on A-scan and B-scan ultrasonograms. Optical coherence tomography (OCT) showed a thickened sclera and retinal detachment (Fig. 2A). Under general anesthesia, a drainage sclerotomy was conducted in all four quadrants of the left eye. One month postoperatively, a flat retina was seen on fundus examination and OCT (Fig. 2B). The retina remained attached during the seven-month follow-up period, and an improved BCVA of 0.3 logMAR was achieved. We did not observe subretinal fluid or choroidal effusion in the fellow eye.

This case involved a 46-year-old man with blurry vision in the left eye for one week. For 15 years, he had receiving treatment with an intraocular pressure lowering medication at another hospital, and he was treated at our hospital with trabeculectomy one month prior to this second presentation under the diagnosis of congenital glaucoma. The refractive error was +3.5 D bilaterally, and BCVA was 0.4 logMAR before his experience with blurred vision. The anterior segment was normal with a proper filtering bleb, but examination of the posterior segment showed a total retinal and choroidal detachment (Fig. 2C). Retinal detachment with choroidal effusion was confirmed on ultrasound examination. The scleral thickness and axial length in the left eye measured by ultrasound were 1.94 and 22.94 mm, respectively. Treatment with oral steroids (50 mg oral prednisolone per day) was ineffective. We performed three rounds of drainage sclerotomy. Sclerotomy was performed at the superonasal and inferonasal quadrants during the first surgery. An abnormally rigid and thick sclera was observed during surgery. The first surgery resulted in recurrence of uveal effusion three days postoperatively. During the second surgery, we added two drainage sclerotomies in the same quadrants as those of the first surgery. UES recurred eight weeks postoperatively, and then a third surgery was performed in the inferotemporal quadrant. After the final surgery, the subretinal fluid gradually resolved at one month postoperatively (Fig. 2D). The final BCVA measured one month after the last surgery was 0.02 logMAR.

A 77-year-old man presented to the emergency room with a ten-day history of a shadow that affected the upper part of the vision in his left eye. He had no relevant ocular history, but had undergone cataract surgery in both eyes four years prior to presentation. BCVA without any refractive error was 1.0 and 0.4 logMAR in the right and left eyes, respectively. Fundus examination revealed marked shifting of the subretinal fluid underneath the retinal detachment of the left eye. On OCT examination, the retinal findings looked like an atypical central serous chorioretinopathy (Fig. 2E). For further workup, ultrasonography, FAG, and ICGA were performed. The axial length was 21.74 mm in the right eye and 21.56 mm in the left eye, which was not compatible with nanophthalmos. There were no definite leaking points on ICG, but leopard-spot patterns were noted on FAG. On the basis of these findings, we diagnosed him with UES. Despite treatment with steroids (50 mg oral prednisolone per day), the retinal findings and vision did not improve. Drainage sclerotomy was conducted in the inferotemporal and inferonasal quadrants. External subretinal fluid drainage was also performed. Ten days later, only a small amount of subretinal fluid was noted on fundus examination. His visual acuity improved to 0.6 logMAR three months after surgery, and no subretinal fluid was noted on OCT (Fig. 2F). His visual acuity improved to 0.9 logMAR, and the retina was stable at the last visit seven months postoperatively.

A 63-year-old man presented with impaired visual acuity in both eyes since his youth. He had no specific ocular or medical history, except for a ten-year history of diabetes mellitus. His BCVA was 0.03 logMAR in the right eye and 0.01 logMAR in the left eye with +13.0 D bilaterally. The intraocular pressure was found to be 14 mmHg in the right eye and 11 mmHg in the left eye using a Goldmann applanation tonometer. Slit lamp biomicroscopy examination showed anterior chambers as deep as four times the central corneal thickness in both eyes, and there was moderate nuclear sclerosis in the crystalline lens. Fundus examination demonstrated no diabetic retinopathy, but suspicious supraciliary effusion was noted in both eyes. The axial length as measured by ultrasound was 16.0 and 16.2 mm on the right and left eyes, respectively. The sclera had a thickness greater than 2.25 mm on both sides. Cataract surgery was performed on each eye with one week between the two surgeries. The patient was followed-up for two months in the clinic and then did not present to the clinic for two years. He subsequently returned to the clinic with a complaint of decreased visual acuity. There was serous subretinal fluid and moderate non-proliferative diabetic retinopathy in the right eye. Drainage sclerotomy was conducted under general anesthesia in the inferotemporal and inferonasal quadrants. The subretinal fluid in the right eye disappeared one month after the surgery. Twelve months after the drainage sclerotomy, we performed panretinal photocoagulation for diabetic retinopathy. However, serous retinal detachment was noted in his left eye at that time, and the same drainage sclerotomy was performed on the left eye. One and a half years after the first surgery on the right eye and six months after the surgery on the left eye, both retinas remained flat. The final BCVA was 0.01 logMAR in both eyes.