Navigating Therapeutic Challenges in Adult-Onset Coats' Disease: Successful Vitrectomy for Tractional Retinal Detachment Following Laser Photocoagulation

Introduction: Adult-onset Coats' disease is an infrequent variant of idiopathic exudative retinopathy, characterized by retinal telangiectasia and progressive exudation. While first-line treatments like laser photocoagulation are often effective for peripheral leakage, they can paradoxically incite inflammatory responses leading to rare but severe complications. This report details a case of adult-onset Coats' disease where initial laser therapy was followed by the development of a vision-threatening tractional retinal detachment (TRD), presenting a significant therapeutic dilemma. Case Presentation: A 35-year-old male presented with a 15-day history of blurred vision in his right eye. His best-corrected visual acuity (BCVA) was 20/20. Fundus examination and fluorescein angiography confirmed Stage 2B Coats' disease with extensive temporal subretinal exudates and telangiectatic vessels. He was treated with sectoral argon laser photocoagulation. One month post-treatment, his BCVA declined to 20/60, and examination revealed increased exudation, vitreous cholesterolosis, and an epiretinal membrane. By the two-month follow-up, a progressive TRD involving the superior macula was confirmed on optical coherence tomography (OCT). A 23-gauge pars plana vitrectomy (PPV) with membrane peeling, endolaser, and cryotherapy was performed. Post-operatively, the retina was successfully re-attached, and at the six-month follow-up, his BCVA improved to 20/40 with resolution of macular traction and significant reduction in exudates. Conclusion: This case highlights the potential for iatrogenic progression of Coats' disease following ablative therapy and underscores the efficacy of early surgical intervention with PPV for managing complex tractional complications. It demonstrates that while laser remains a primary modality, clinicians must be vigilant for subsequent tractional changes. Vitrectomy proved to be a definitive and successful management strategy for salvaging vision in this challenging clinical scenario, offering valuable insight into the staged management of adult-onset Coats' disease.