Choroidal neovascularization in tilted disc syndrome

Tilted disc in eyes with fovea plana

PURPOSE

To report the association of tilted disc (TD) with fovea plana.

METHODS

Monocentric retrospective study of consecutive eyes diagnosed with fovea plana, assessed by spectral-domain optical coherence tomography. Analysis of the medical charts and imaging findings of patients to collect demographics, the visual acuity, and the clinical context. The presence of associated conditions was checked by two independent readers in order to classify fovea plana as isolated or part of other conditions.

RESULTS

Twenty-one patients, 9 men and 12 women, aged 12 to 91 years, were included. Fovea plana was isolated and asymptomatic in 10 (47.6%) patients. In 6 (28.5%) patients, fovea plana was associated with ocular albinism and/or nystagmus. In 6 (28.5%) patients, fovea plana was associated with an obliquity of the optic disc typical of TD, isolated (5 cases), or associated with nystagmus (1 case).

CONCLUSION

An association between TD and fovea plana had been reported only once in the literature and had been considered likely coincidental. However, this association could be more common than initially reported and suggests a common pathological process in eye development during embryogenesis.

Tilted disc syndrome (TDS): New hypotheses for posterior segment complications and their implications in other retinal diseases

Tilted disc syndrome (TDS) is considered a congenital anomaly due to a delayed closure of the embryonic fissure. It is characterized by an oblique orientation of the axis of the optic disc, associated with other posterior pole anomalies such as inferior crescent, situs inversus and inferior staphyloma. The aim of this review was to summarize the data supporting the current hypotheses for the pathogenesis of TDS, and its anatomical and functional clinical consequences. Recent imaging techniques, such as magnetic resonance imaging, wide-field fundus imaging, and 2- and 3-D optical coherence tomography have provided a new perspective on TDS and its complications. Different abnormalities have previously been reported, both in the anterior and posterior segments. The focus was on vision-threatening chorioretinal changes or complications, including choroidal neovascularization and serous retinal detachments and their therapeutic options. Based on clinical observations, assumptions were proposed to understand the occurrence of complications such as chorioretinal degenerative changes, choroidal neovascularization and polypoidal choroidal vasculopathy, macular serous retinal detachment, myopic foveoschisis and chorioretinal folds. These hypotheses could be referred to as the curvature "breaking point" hypothesis, the uneven growth "tractional" hypothesis, the "container-content" imbalance hypothesis, and the "choroidal funnel" hypothesis. Because these complications could also occur in other contexts, understanding the pathogenesis of TDS complications could help to understand their pathophysiology.

Pre- and juxtapapillary arterial loops in eyes with tilted disc syndrome and inferior staphyloma

Purpose

To report and discuss the association between pre- or juxtapapillary arterial loops and tilted disc syndrome (TDS).

Observations

Three patients, aged 43–59 years, with both conditions were examined in a tertiary referral center, and underwent fluorescein angiography, optical coherence tomography (OCT) and/or OCT-angiography. They all presented with a typical inferior staphyloma associated with TDS and anomalies of insertion of retinal vessels. The vascular malformation consisted in one acquired arterial loop or cilioretinal collateral circulation occurring after central artery occlusion, and two more complex pre- and juxtapapillary arterial loops. In all cases, the vascular loops extended inferiorly, in the area of the staphyloma.

Conclusion and importance

We hypothesized that the local anatomical changes in the peripapillary area, observed in eyes with TDS and inferior staphyloma, could have promoted the occurrence and/or extent of the arterial loops.

Macular associations of tilted disc syndrome

Purpose:

The aim of this study was to describe macular changes associated with tilted disc syndrome (TDS) using multimodality imaging.

Methods:

This is a retrospective observational study of the consecutive TDS cases which were studied for macular changes using color fundus photographs and optical coherence tomography (OCT). Fundus autofluorescence, fundus fluorescein angiography, and OCT angiography were performed wherever required.

Results:

Twenty consecutive TDS cases (36 eyes) were included. OCT showed inferior depression of all layers in specific scans and macular pathologies seen included lamellar macular hole, full-thickness macular hole, retinal pigment epithelial detachment, acute and resolved subretinal fluid, central serous chorioretinopathy, and choroidal neovascular membrane. Macular involvement was seen in 13 eyes (36.11%) while in the remaining 23 eyes, outer retinal changes were seen on OCT in 9 eyes and normal retinal layers in 14 eyes (38.89%).

Conclusion:

Various macular pathologies associated with TDS are described using multimodality imaging. These provide understanding of changes which can occur with TDS. It also highlights the need for recognition, differentiation from similar confusing entities, and the necessity to follow-up of these cases carefully to detect the macular changes earlier.

CHORIORETINAL WHITE DOT LESIONS IN EYES WITH MULTIFOCAL CHOROIDITIS AND TILTED DISK SYNDROME WITH INFERIOR STAPHYLOMA

PURPOSE

To assess the influence of tilted disk syndrome (TDS) and inferior staphyloma on the macular clinical expression of MFC.

METHODS

Medical charts of patients with MFC examined since 2009 were reviewed retrospectively. All patients underwent standard examination and multimodal imaging including fundus color photography, fundus autofluorescence, and spectral domain optical coherence tomography. Two groups of patients were compared : Group 1 with TDS and inferior staphyloma and Group 2 without. The number of MFC spots were counted and normalized to the surface area in a circle centered about the fovea. In Group 1, the number of lesions inside the staphyloma was compared with that outside the staphyloma.

RESULTS

At baseline, 8 eyes in Group 1 had a mean (±SD) higher number of chorioretinal lesions outside the staphyloma (14.5 [±7.2]) than within the staphyloma (5 [±5.5]) (P = 0.017). All 11 eyes in Group 2 had chorioretinal lesions homogeneously distributed in the posterior pole. Eyes with TDS and inferior staphyloma developed choroidal neovascularization more frequently (6/8 eyes) than eyes without TDS (5/11 eyes) (P = 0.026).

CONCLUSION

Inferior staphyloma associated with TDS could modulate the clinical expression of the inflammatory and neovascular process in eyes with MFC.

Polypoidal choroidal vasculopathy associated with tilted disk syndrome

PURPOSE

To describe a complication of tilted disk syndrome-macular serous retinal detachment caused by development of polypoidal choroidal vasculopathy.

METHODS

A 65-year-old patient with visual loss and metamorphopsia was evaluated with fluorescein and indocyanine green angiography (ICG) and optical coherence tomography. Subsequently, photodynamic therapy (PDT) with verteporfin was administered.

RESULTS

Fundus examination showed classic features of tilted disk syndrome as well as a unilateral macular serous detachment secondary to a polypoidal lesion, which was clearly outlined by ICG angiography at the site of a macular lacquer crack. The lesion resolved after PDT. Two years after treatment, no recurrence was observed, and visual acuity was 20/25 without distortion.

CONCLUSIONS

In this patient with tilted disk syndrome, unilateral polypoidal choroidal vasculopathy was diagnosed by ICG angiography and treated successfully with PDT.

Choroidal thickness in eyes with tilted disk syndrome

PURPOSE

To investigate the choroidal thickness in eyes with tilted disk syndrome within/without posterior staphyloma.

METHODS

Twenty-one eyes examined in 16 patients with tilted disk syndrome were included. The thicknesses of the choriocapillaris, the medium-to-large choroidal vessels, and total choroids found 1 mm and 3 mm superior and inferior to the fovea and in the area with the thinnest choroid were measured using enhanced-depth imaging optical coherence tomography or high-penetration optical coherence tomography. The results were compared with the findings on indocyanine green angiography.

RESULTS

The mean thicknesses of total choroid found 3 mm and 1 mm inferior (114.3 μm ± 77.8 μm, 145.0 μm ± 85.9 μm) to the fovea were significantly thinner than those found superior (174.5 μm ± 89.7 μm, 145.0 μm ± 85.9 μm) to it. The minimal choroidal thickness of 80.5 μm ± 67.1 μm was obtained at a mean 1.04 mm below the fovea at the upper edge of the posterior staphyloma. The thickness of the layer of choriocapillaris was not significantly different according to the regions but the layer of medium-to-large choroidal vessels found 3 mm and 1 mm inferior to the fovea was significantly thinner than that found superior to the fovea. The ratio of choriocapillaris to medium-to-large vessels found 1 mm superior also was significantly smaller than those found inferior. The diameter of medium-to-large choroidal vessels on ICGA was not significantly different in the areas although less number of vessels were seen around the area inferior to the fovea.

CONCLUSION

In the eyes of patients with tilted disk syndrome, the choroid is thinnest at approximately 1 mm inferior to the fovea at the upper edge of the posterior staphyloma rather than at the bottom of the posterior staphyloma. Thinning of the layer of medium-to-large choroidal vessels seems to be associated with the thinning of choroid thickness.

Spectral domain optical coherence tomography analysis of macular changes in tilted disk syndrome

PURPOSE

To evaluate the prevalence of macular complications in tilted disk syndrome by spectral domain optical coherence tomography (OCT).

METHODS

A monocentric retrospective study of consecutive patients with tilted disk syndrome, whose eyes were examined by spectral domain OCT (Cirrus; Zeiss) and fundus photography.

RESULTS

Fifty consecutive patients (39 women and 11 men; age range, 41-96 years) with uni- or bilateral tilted disk syndrome were enrolled. All affected eyes (n = 92) were imaged by spectral domain OCT and fundus photography. Fluorescein and/or indocyanine green angiography were performed in 33 patients (66%). Macular anomalies or complications were observed in 71 eyes (77.1%). Specifically, retinal pigment epithelial changes were described in 34 eyes (36.9%), choroidal neovascularization in 24 eyes (26%), and macular serous retinal detachment in 16 eyes (17.3%). Epiretinal membrane in 9 eyes (9.7%), myopic foveoschisis in 5 eyes (5.4%), and lamellar macular hole in 3 eyes (3.2%) were also detected relatively frequently by spectral domain OCT. Surprisingly, fovea plana was observed in 5 eyes (5.4%). Eleven eyes, complicated by choroidal neovascularization, were treated with ranibizumab, with a mean visual gain of 7.9 letters on Early Treatment Diabetic Retinopathy Study chart.

CONCLUSION

Tilted disk syndrome can be associated with potentially severe macular complications. Spectral domain OCT allowed the recognition of additional macular changes associated with tilted disk syndrome, such as epiretinal membranes, myopic foveoschisis, and fovea plana.

Macular gradient measurement in myopic posterior staphyloma using optical coherence tomography

Purpose

To evaluate clinical characteristics and the macular gradient in myopic posterior staphyloma with time domain (TD) optical coherence tomography (OCT).

Methods

Sixty-four staphyloma eyes of 40 patients were examined. Macular gradient (tangent θ) and the location of staphyloma were assessed with OCT imaging. The macular gradient was measured at points 1 mm and 2 mm distant from the fovea. The relationships of the macular gradient with age, axial length, and spherical equivalent were analyzed.

Results

In 8 eyes (12.5%), the bottoms of the staphylomas were in the fovea, and there was no macular gradient. However, in the other 56 eyes (87.5%), the bottoms of the staphylomas were not in the foveal area, and macular gradients existed. Staphylomas were commonly located in the infero-nasal retinal area. The mean macular gradient (tangent θ) was 0.26 ± 0.08 at 1 mm distance from the fovea and 0.28 ± 0.10 at 2 mm. No significant relationships were observed between macular gradient and axial length, patient age, or spherical equivalent.

Conclusions

TD OCT reveals staphyloma location. If the location is outside of the fovea, a macular gradient exists and can be measured by OCT. Axial length measurement error may occur in eyes with poor visual fixation and steep macular gradients.

Tilted optic disks

Tilted optic disks are a common finding in the general population. An expression of anomalous human development, the tilted disk appears rotated and tilted along its axes. Visual sequelae described with tilted optic disks include myopia, astigmatism, visual field loss, deficient color vision, and retinal abnormalities. Although the natural course of tilted optic disks is nonprogressive, the anomaly can be mistaken for tumors of the anterior visual pathway, edema of the optic nerve head, or glaucoma. A thorough examination of patients with tilted disk includes refraction, dilated fundus examination, and visual field testing. At times, neuroimaging may be necessary to arrive at the correct diagnosis. Until normative data are validated for tilted disks, the role of new imaging technologies for the optic nerve head is limited. Familiarity with the spectrum of ophthalmoscopic appearance and the clinical manifestations of tilted disks may be the most critical factors in avoiding misdiagnosis.

Ranibizumab in the treatment of choroidal neovascularization on the border of an inferior staphyloma associated with tilted disc syndrome

Purpose

To describe a case of choroidal neovascularization (CNV) on the border of an inferior staphyloma associated with tilted disc syndrome treated with intravitreal ranibizumab.

Patients

Observational case report.

Methods

A patient with CNV on the border of an inferior staphyloma associated with tilted disc syndrome was imaged using fluorescein angiography, autofluorescence and spectral domain optical coherence tomography, and treated with intravitreal injections of ranibizumab.

Results

The patient received 3 ranibizumab injections during the 9-month follow-up. The visual acuity improved from 20/40 to 20/32 and the foveal thickness reduced from 470 microns to 248 microns. The angiograms showed resolution of leakage associated with CNV. There were no adverse events.

Conclusion

Intravitreal ranibizumab is an efficacious and safe treatment in the management of choroidal neovascularization on the border of an inferior staphyloma associated with tilted disc syndrome.

Tilted disc syndrome in Congolese patients

PURPOSE

To determine the frequency of tilted disc syndrome and its associations with ocular parameters in Congolese patients.

METHODS

We performed a cross-sectional and descriptive analysis of the data from patients diagnosed with tilted disc syndrome. Data were collected between January 2005 and August 2008 in a general ophthalmology practice. Patients received a complete ophthalmic examination that included measurement of visual acuity, refraction, slit-lamp biomicroscopy, Goldmann applanation tonometry, examination of the visual field using the Goldmann perimeter and ophthalmoscopy. The diagnosis of tilted disc syndrome was based on ophthalmoscopic findings and fundus photographs.

RESULTS

Out of 4600 patients seen during the study period, 30 (57 eyes) had a diagnosis of tilted disc syndrome, giving a frequency of 0.6%. The mean age of the patients was 42+/-15 years (SD) (range, 16-66 years). Twelve (40%) of the patients were men and 18 (60%) were women. TDS was bilateral in 95% of cases. Mean VA was 0.02+/-0.17 logMAR (range, 0.5 to-0.18). The refractions (in spherical equivalents) varied from -11.00 to +1.5 diopters (mean, -2.27+/-4.47 D). Refractive astigmatism varied from 0 D to 2.5 D (mean, 0.73+/-0.80 D). Myopia was found in 50% and astigmatism greater than 0.5 D in 42% of eyes. Mean intraocular pressure was 13.7+/-5mmHg. Superior temporal or temporal visual field defects were found in 75% of eyes. Of 30 patients with TDS, a 25-year-old female patient had TDS associated with oculocutaneous albinism, pseudoxanthoma elasticum, and epicanthus.

CONCLUSION

This study confirmed that TDS affects all ethnic populations and can also occur in the sub-Saharan region. It is found more in females and is associated with myopia. This study shows that TDS demonstrates similar findings to those found previously in Caucasians and Asians.

T-shaped pigmentary changes in tilted disk syndrome

PURPOSE

Many complications associated with tilted disk syndrome may occur in the area bordering on the inferior staphyloma, including macular pigmentary changes, choroidal neovascularization, macular serous retinal detachment, polypoidal choroidal vascular anomalies, and radially orientated chorioretinal folds. The purpose of the present article is to describe an additional complication, T-shaped pigmentary changes, orientated radially from the border of the inferior staphyloma, in eyes with tilted disk syndrome.

METHODS

Retrospective series of 6 eyes of 6 patients (3 men and 3 women) aged from 35 to 67 years. All eyes were studied by fluorescein angiography.

RESULTS

All 6 eyes exhibited pigmentary changes located along the border of the staphyloma, and also radially to it, giving a particular T-shaped pattern of pigmentary changes. These changes were visible as either a linear strip or a triangular or oval-shaped area. Three eyes had a documented history of subretinal leakage that mimicked central serous chorioretinopathy, a well-known complication of tilted disk syndrome.

CONCLUSIONS

T-shaped pigmentary changes may develop in the course of tilted disk syndrome, and should be added to the list of this syndrome's possible retinal complications. These changes may indicate the presence of chronic leakage in the area around the superior border of the inferior staphyloma.

Tilted disk syndrome with superior staphyloma

BACKGROUND

Tilted disk syndrome is a common condition that consists of inferonasal tilting of the optic disk and is usually associated with staphyloma in the inferonasal fundus.

CASE REPORT

We describe a 50-year-old woman whose fundus exhibited, in both eyes, all the characteristics of tilted disk syndrome but in an upside-down pattern: superior instead of inferior staphyloma and thinning of the retinal pigment epithelium, a superior instead of an inferonasal crescent, and an inferior instead of a superior visual field defect.

CONCLUSION

We have no satisfactory explanation for this unusual case.

Clinical and multifocal-electroretinographic findings of congenital tilted disc syndrome associated with choroidal neovascularization: a case report

PURPOSE

To report a case of a tilted disc syndrome associated with choroidal neovascularization.

METHODS

A 55-year-old male patient presented with blurred vision and metamorphopsia of the left eye. He underwent complete ophthalmologic examination, fluorescein angiography, optical coherence tomography (OCT) and multifocal-electroretinogram (mf-ERG).

RESULTS

All features are consistent with a tilted disc syndrome complicated with a small neovascular membrane. OCT confirmed the presence of a serous retinal detachment. Mf-ERG confirmed a decrease of electrical activity of the photoreceptors in area 1 (fovea). The patient refused to be treated.

CONCLUSION

Macular serous retinal detachment due to subretinal leakage is a rare complication of tilted disc syndrome. To the author's knowledge, this is the first time a tilted disc syndrome with choroidal neovascularization is documented by means of OCT and mf-ERG. These are the only objective tools in order to assess objectively the anatomical and functional damage accordingly.

Chorioretinal folds as a consequence of inferior staphyloma associated with tilted disc syndrome

BACKGROUND

Tilted disc syndrome is a common condition which is usually associated with an inferior staphyloma.

MATERIALS AND METHODS

Observational case report.

RESULTS

An 82-year-old woman presented with features typical of tilted disc syndrome, as well as chorioretinal folds orientated radially to the upper edge of the inferior staphyloma.

CONCLUSION

The orientation of the folds suggested that the progressive increase of the inferior staphyloma exerted traction on the RPE, Bruch's membrane and choriocapillaris complex, leading to chorioretinal folds radiating from the upper edge of the staphyloma.

Retinal pigment epithelial changes and choroidal neovascularisation at the edge of posterior staphylomas; a case series and review of the literature

PURPOSE

To report five myopic patients who presented with a variety of changes at the edge of posterior staphyloma.

METHODS

Retrospective, observational case series. The clinical and angiographic records of five patients who showed changes at the edge of posterior staphyloma were reviewed. One of these patients had been referred querying macular dystrophy.

RESULTS

On fundus examination, three patients showed retinal pigment epithelial (RPE) changes at the edge of the staphyloma and two showed RPE atrophy with surrounding haemorrhages. Fluorescein angiography revealed areas of hyperfluorescence at the point of change of curvature of the staphyloma suggestive of RPE atrophy in all patients. In two patients, a choroidal neovascular membrane was seen. Indocyanine green angiogram carried out in one patient showed the presence of an occult choroidal neovascular membrane with preservation of the adjacent choriocapillaris.

CONCLUSION

This case series illustrates the variety of changes that can occur at the edge of posterior staphylomas, which ranged from RPE disturbance to choroidal neovascular membrane formation. In one of the patients, these changes were mistaken for macular dystrophy. Our observations also support the hypothesis that chorioretinal changes occur at the edge of staphylomas and may predispose to choroidal neovasularisation.

Population prevalence of tilted optic disks and the relationship of this sign to refractive error

PURPOSE

To assess the prevalence of tilted disks and its association with refractive error and visual field defects.

DESIGN

Population-based cohort study.

METHODS

The Blue Mountains Eye Study examined urban Australians aged 49 years or older between 1992-1994. Of 4,433 eligible participants, 3,654 (82.4%) participated. The eye examination included logMAR visual acuity, standardized refraction, cover testing, stereoscopic optic disk photography, and Humphrey automated perimetry. Inferior or nasal optic disk tilting was graded from stereoscopic photographs.

RESULTS

Of 3,583 participants with gradable photographs, inferior or nasal optic disk tilting was observed in 77 eyes of 56 participants (1.6%). The prevalence of tilted disks increased from 0.4% in eyes with astigmatism < 1.0 diopters to 17.9% in eyes with astigmatism >or= 5.0 diopters. The mean astigmatic error was 2.2 diopters in eyes with tilted disks compared with 0.7 diopters in eyes with normal disk appearance, P <.001. Myopia was present in 66.2% of eyes with tilted disks compared with 12.4% of eyes with a normal disk appearance, P <.001. The most common associated features were astigmatism (93.5%), pallor, and tessellation of the adjacent chorioretinal tissues (74.0%), situs inversus of the retinal vessels (70.1%), beta-peripapillary atrophy (64.9%), strabismus (30.4%), visual field defects (19.4%), posterior staphyloma (18.2%), inferonasal pigmentary accumulation (9.1%), and chorioretinal atrophy (5.2%). Superotemporal (33.3%) and superior (25.0%) visual field defects were most frequent.

CONCLUSIONS

A tilted disk appearance was not a rare finding in our study population and was strongly associated with astigmatism and higher levels of spherical refractive error, particularly myopia. The tilted disk and its associated visual field defect should be distinguished from other sinister causes.

Juxtapapillary subretinal pigment epithelial polypoid pseudocysts associated with unilateral tilted optic disc: case report with clinicopathologic correlation

OBJECTIVE

To describe the unique preoperative appearance, successful postoperative clinical course, and histopathologic features of a cluster of progressively enlarging pseudocysts that arose at the temporal margin of a unilateral tilted optic disc.

STUDY DESIGN

Case report.

METHODS

Clinical observation, color fundus photography, fluorescein angiography, and optical coherence tomography, as well as routine histologic and immunohistochemical studies of tissue removed by subretinal surgery.

RESULTS

Subretinal surgical excision of the lesions resulted in retinal reattachment with improved postoperative visual acuity. Histologic examination disclosed a cluster of fluid-filled polypoid pseudocysts lined by small vessels of choroidal origin lying beneath the basement membrane of the overlying retinal pigment epithelium (RPE).

CONCLUSIONS

We postulate that buds of small vessels of choroidal origin grew through or around the edge of Bruch's membrane at the temporal margin of the tilted optic disc and then passed under the juxtapapillary RPE. Ensuing leakage of proteinaceous fluid from these vessels eventuated in formation of a cluster of polypoid pseudocysts and subsequent localized papillomacular retinal separation with visual loss. The lesions were amenable to subretinal surgical removal with restoration of visual acuity.

Macular serous retinal detachment caused by subretinal leakage in tilted disc syndrome

OBJECTIVE

To describe a previously unreported complication of tilted disc syndrome: serous retinal detachment, caused by subretinal leakage, that mimics chronic idiopathic central serous chorioretinopathy (ICSC).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Five patients (five eyes) participated.

MAIN OUTCOME MEASURES

Fluorescein angiographic features were measured.

RESULTS

All patients presented with visual loss and metamorphopsia. Fundus examination showed features typical of tilted disc syndrome, including obliquely directed long axis of the disc, situs inversus, retinal pigment epithelium conus, hypopigmentation and staphylomatous ectasia inferonasal to the optic disc, as well as a serous retinal detachment. Fluorescein angiography showed a site of leakage or multiple focal areas of staining and atrophy of the retinal pigment epithelium that correlated to the linear pigmentary changes observed at the junction with the inferior staphyloma. The fluorescein angiographic pattern was very similar to that of chronic ICSC. Spontaneous healing occurred in one case, and successful photocoagulation of the site of leakage was applied in two cases; two eyes could not be photocoagulated because of diffuse leakage in the macular region.

CONCLUSIONS

To the authors' knowledge, macular serous retinal detachment due to subretinal leakage has not been reported as a complication of tilted disc syndrome. The authors hypothesize that choriocapillary and pigment epithelial disturbances at the junction of the inferior staphyloma permit the subretinal leakage, but the pathogenesis of this complication remains unclear. A study of larger series of such patients is needed to identify the most appropriate management of these cases, which first need to be differentiated from a chronic form of ICSC.

Chorioretinal degenerative changes in the tilted disc syndrome

Ninety patients (163 eyes) with tilted disc syndrome were examined in order to show possible chorioretinal degenerative lesions associated with the typical ectasia of the infero-nasal fundus observed in this anomaly. Eighteen out of the 163 eyes had pigmentary accumulations, either branched, linear or dotted and five had roundish areas of chorioretinal atrophy. Furthermore, in 7 eyes areas of pigmentary atrophy at the posterior pole were observed. The most serious lesions were represented by macular choroidal neovascular membranes, seen in 3 eyes, which were responsible for the loss of vision in these eyes. A relationship was found between the depth of the ectasia, the degree of tilt of the optic disc and the development of chorioretinal degeneration. Because of possible complication by macular choroidal neovascularization, the tilted disc syndrome can not be regarded in every case as a benign and not evolutive ocular anomaly.