Vitrectomy for optic disc pit maculopathy: a long-term follow-up study

Changes in Outcomes of Macular Optical Coherence Tomography Angiography Following Surgery for Optic Disc Pit Maculopathy

PURPOSE

we aimed to report on the optical coherence tomography angiography (OCTA) outcomes of eight patients with optic disc pit maculopathy (ODP-M) who were treated with 23-gauge pars plana vitrectomy (PPV).

METHODS

We examined sixteen eyes of eight patients-eight eyes with ODP-M and eight healthy fellow eyes. Fundus color photography, fundus autofluorescence, fundus fluorescein angiography, optical coherence tomography (OCT), and OCTA were performed. The vascular density, choriocapillaris blood flow (CCBF), and foveal avascular zone (FAZ) were analyzed using OCTA. Moreover, the correlation between the best-corrected visual acuity (BCVA) and macular OCTA parameters was assessed.

RESULTS

Compared with the healthy fellow eyes, the eyes with ODP-M preoperatively were found to have decreased BCVA, superficial capillary plexus (SCP) vascular density (i.e., total, foveal, parafoveal, and perifoveal), deep capillary plexus (DCP) vascular density (i.e., total, parafoveal, and perifoveal), and CCBF but a significantly increased FAZ (p < 0.05). When the eyes with ODP-M were analyzed pre- and postoperatively at month 12 after surgery, the BCVA, SCP vascular density (i.e., perifoveal), and CCBF had significantly increased, and the FAZ had significantly decreased (p < 0.05). When the eyes with ODP-M were compared with the healthy fellow eyes postoperatively at month 12, the BCVA, SCP, and DCP vascular density parameters had increased, along with CCBF, and the FAZ had decreased in eyes with ODP-M, though not to the levels of the healthy fellow eyes (p < 0.05). Moreover, a positive correlation was found between the postoperative BCVA and SCP total vascular density (p < 0.05).

CONCLUSION

The BCVA and macular OCTA parameters improved in eyes with ODP-M at month 12 following surgery. However, the BCVA and OCTA of the eyes operated on did not reach the levels of the healthy fellow eyes, possibly due to impaired choroidal blood flow (CBF) recovery and the presence of a larger FAZ. In summary, OCTA seems to be useful for assessing qualitative and quantitative perioperative microvascular changes.

OPTIC DISK PIT STUFFING-TO DO OR NOT TO DO

PURPOSE

Optic disk pit (ODP) is a subset of spectrum of congenital cavitary anomalies. Optic disk pit maculopathy causes progressive visual deterioration and is addressed with pars plana vitrectomy (PPV) with or without ODP stuffing.

PATIENT AND METHODS

We report a case of progressive ODP maculopathy who was taken up for 23-G 3-port PPV, with complete vitreous removal and stuffing of the ODP with autologous sclera and sequential analysis of change in the retinal nerve fiber layer (RNFL) thickness.

RESULTS

Spectral-domain optical coherence tomography RNFL analysis at 1 and 12 months follow-up postoperatively showed total RNFL thickness decrease from 130 µm to 103 µm respectively. Hemiquadrant analysis showed slight reduction of superior RNFL thickness from 142 µm to 139 µm. However, in the inferior hemiquadrant, the reduction in mean RNFL thickness seems to be significant from 133 µm to 100 µm at 1 and 12 months respectively. Sector-wise analysis of the RNFL thickness showed maximum reduction in the inferotemporal quadrant and other sectors seemed to be relatively preserved corresponding to the area of scleral stuffing.

CONCLUSION

Retrospective or prospective analysis of RNFL health of patients undergoing surgery for ODP-M with stuffing needs to evaluated.

Inner retinal fenestration for paediatric optic disc pit maculopathy: a case series

OBJECTIVES

To evaluate the efficacy of inner retinal fenestration as a surgical technique for the treatment of optic disc pit maculopathy (ODPM) in the paediatric population.

METHODS

This is a retrospective, interventional case series of paediatric patients with ODPM treated at two tertiary hospitals in London by a single surgeon (SCW). All patients underwent pars plana vitrectomy with the creation of two inner retinal fenestrations and endogas tamponade. The partial-thickness retinotomies were made radial to the optic disc pit using a 25-gauge MVR blade. Anatomic and visual outcomes were determined by optical coherence tomography central retinal thickness and best-corrected visual acuity (BCVA), respectively.

RESULTS

A total of six eyes were included. Average patient age was 12.0 ± 3.5 years. Preoperatively all eyes demonstrated intraretinal fluid and/or serous detachment of the central macula. Patients were followed for a mean of 22.7 ± 16.1 months after surgery. Mean preoperative BCVA was logMAR 0.71 ± 0.29 (20/100). Mean postoperative BCVA was 0.49 ± 0.30 (20/63) at 2 weeks, 0.35 ± 0.33 (20/45) at 3 months and 0.16 ± 0.29 (20/32) at 1 year. Progressive resolution of intraretinal and subretinal fluid (SRF) was observed in all eyes, with central retinal thickness significantly improved by 2 weeks postoperatively (637.83 ± 209.09 µm preoperatively and 465.40 ± 169.86 µm postoperatively, p = 0.04). Recurrence of subretinal or intraretinal fluid was not observed.

CONCLUSION

Dual inner retinal fenestration is an effective technique that resolves fluid and restores vision in paediatric patients with ODPM. These results support the hypothesis that enabling egress of fluid into the vitreous cavity can achieve long-lasting amelioration of ODPM.

The outcomes of intravitreal C3F8 gas tamponade combined with laser photocoagulation treatment for optic disc pit maculopathy

Purpose

To share the anatomical results and visual outcomes of intravitreal gas tamponade combined with laser photocoagulation treatment for optic disc pit maculopathy (ODPM).

Methods

Intravitreal gas tamponade combined with laser photocoagulation treatment was performed on six consecutive patients with ODPM. A 0.3 mL of 100% perfluoropropane (C₃F₈) gas was injected intravitreally. The patients were then asked to maintain prone position until the C₃F₈ gas disappeared. Laser photocoagulation was performed the day after the procedure. The outcomes were determined by spectral-domain optical coherence tomography and best-corrected visual acuity (BCVA).

Results

In the present study, visual improvement and reduction in serous macular detachment were observed in 83% of the ODPM patients. Complete retinal reattachment was achieved in 66% of the ODPM patients. In one patient, no regression was observed after the repeated treatment, and pars plana vitrectomy was performed. The final BCVA improved in five eyes and unchanged in one eye. No postoperative complications were observed during the follow-up period in any patient.

Conclusions

Intravitreal C₃F₈ gas tamponade combined with laser photocoagulation procedure is an effective, minimally invasive, and cost-effective treatment method for ODPM.

The characteristics of optic disc pit maculopathy and the efficacy of vitrectomy: a systematic review and meta-analysis

PURPOSE

To evaluate the basic characteristics of optic disc pit maculopathy (ODPM) and the efficacies of pars plana vitrectomy (PPV) treatment with different adjunctive strategies.

METHODS

The databases PubMed, EMBASE and Ovid up to April 2020 were searched to identify relevant studies. Statistical analyses were conducted with R software version 3.6.3.

RESULTS

Fifty-nine studies were eventually included for different aspects of statistical analyses. The pooling results suggest the general incidence of maculopathy in optic disc pit (ODP) is 51%, and the rate of serous macular detachment and retinoschisis is 49% and 58%, respectively. The incidence of sub-retinal fluid (SRF) only is 10%, intra-retinal retinal (IRF) fluid only is 14%, and SRF plus IRF is 69%. A lamellar macular hole (LMH) is present in 53% of cases, and 58% have communication between the macula with the pit. The incidence of posterior vitreous detachment (PVD), vitreo-papillary traction and vitreomacular traction (VMT) is 7%, 28% and 13%, respectively. Besides, the rate of complete anatomic success and visual improvement after PPV are both around 85%. Subgroup analysis reveals the anatomic, and visual success rates of PPV alone are 89% and 100%, respectively. Gas tamponade, laser or internal limiting membrane peeling (ILMP) during vitrectomy are less promising, while PPV with ILM flap stuffing could achieve better outcomes than cases without it.

CONCLUSION

Optic disc pit-associated maculopathy has different fundus characteristics. Based on the current evidence, PPV is effective for ODPM, and the combined application of gas tamponade, laser and ILMP should be used with caution.

Risk factors for failure of resolving optic disc pit maculopathy after primary vitrectomy without laser photocoagulation

PURPOSE

To determine factors significantly correlated with the failure of macular reattachment by pars plana vitrectomy (PPV) without laser photocoagulation of the optic disc margin to treat optic disc pit (ODP) maculopathy.

DESIGN

Retrospective, interventional case series.

METHODS

We reviewed the medical records of 35 consecutive patients with ODP maculopathy who underwent PPV without laser photocoagulation. PPV with the creation of a posterior vitreous detachment (PVD) was performed in 34 eyes. An epiretinal membrane and internal limiting membrane present in the other eye with a PVD were removed. Patients were followed for 12-193 months (mean 58 months) after surgery. The main outcome measures were the postoperative rate of retinal reattachment and best-corrected visual acuity. The preoperative clinical characteristics of the successful cases were compared to those of the unsuccessful cases.

RESULTS

A complete retinal reattachment was attained in 31 of 35 eyes and it required about one year. The 4 other eyes that did not achieve a macular reattachment after the primary PPV underwent additional therapies. The factors that were significantly associated with a failure of a retinal reattachment after primary PPV were the presence of a retinal detachment connected to the optic disc (P < 0.001) and the presence of preoperative headaches (P = 0.030).

CONCLUSIONS

Clinicians should be aware that the presence of a preoperative macular detachment connected to the optic disc margin and preoperative headaches are indicators for an unsuccessful outcome of PPV without laser photocoagulation in eyes with ODP maculopathy.

Treatment outcomes of optic disc pit maculopathy over two decades

Aim

To study the long-term outcomes of optic disc pit maculopathy.

Methods

Electronic medical records of 154 patients with optic disc pit were reviewed and 50 patients with optic disc pit maculopathy who met the study criteria were included in the study. Demographic profile of patients, along with clinical characteristics, optical coherence tomography (OCT) features and change in best-corrected visual acuity (BCVA) was recorded. Patients were treated either by observation, barrage laser alone or pars plana vitrectomy (PPV) with optional additional surgical procedures. The primary outcome measures were the change in BCVA and resolution of fluid on OCT.

Results

The mean age of patients was 29.96 years (3-62 years) with a follow-up of 27.16 months. The mean baseline BCVA in observation, laser and vitrectomy group was log MAR 0.94, 0.76 and 0.87 and final BCVA was log MAR 0.9, 0.67 and 0.46, respectively. There was a statistically significant improvement in the final BCVA and reduction in subretinal fluid with resolution of the schisis cavity in vitrectomy group than in other groups. On regression analysis significant association was found between final BCVA with baseline BCVA (R ² = 0.815, p = 0.002), use of C3 F8 endotempanode (p = 0.004) ILM peeling (p = 0.012) and use of triamcinolone (TA; p = 0.003). No significant association was found with juxtapapillary endolaser (p = 0.062).

Conclusions

In patients with disc pit maculopathy, PPV lead to better functional and anatomical outcomes as compared to laser or observation alone. Use of surgical adjuvants like ILM peeling, TA and C3F8 tamponade improved the outcomes, unlike juxtapapillary endolaser treatment.

Management of optic disc pit-associated maculopathy: A case series from a tertiary referral center

PURPOSE

To report outcomes of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) stuffing technique in patients with optic disc pit associated maculopathy (ODP-M).

METHODS

Data including best-corrected visual acuity (BCVA), central macular thickness (CMT), foveal center point thickness (FCP), and maximum height of fluid (max_fluid) (intraretinal or subretinal) were collected from the medical records of the patients.

RESULTS

Six eyes of six patients with a mean age of 28.0 ± 17.68 years (range: 9-53 year) underwent PPV + ILM plug surgery. The mean follow-up duration was 25.62 ± 26.11 months (range: 11.80-78.00 month) duration. The mean BCVA increased from 1.25 ± 1.04 logMAR (20/355, Snellen equivalent) to 0.86 ± 1.09 logMAR (20/144, Snellen equivalent) at last follow-up (p = 0.043). Compared to baseline, CMT, FCP, and max_fluid significantly decreased at all visits after the surgery (p < 0.05 for all visits). At last follow-up, 66.6% of the eyes (four eyes) showed complete resolution of fluid at a mean of 5.25 ± 4.99 months (range: 1-12 months) after the surgery.

CONCLUSION

PPV with ILM plug seemed to be an effective surgical technique in ODP-M. Studies with longer follow-up and higher number of patients are needed to confirm our results.

Optic Pit Maculopathy: Adjunctive Treatment Using Oral Spironolactone and Topical Dorzolamide

Purpose

There is no consensus for the treatment of optic disc pit maculopathy (ODPM). We describe a case of ODPM refractory to vitrectomy that was successfully treated with systemic spironolactone and topical dorzolamide 2%.

Methods

Case report.

Results

A 27-year-old male was referred for decreased vision in the right eye secondary to macular edema. Fundus examination and optical coherence tomography imaging revealed an optic pit maculopathy with significant macular schisis and intraretinal fluid. After an initial observation period, we performed pars plana vitrectomy with internal limiting membrane peeling, fibrin glue, and gas endotamponade. At the 2 months postoperative follow-up, anatomic and functional outcomes remained unimproved. Oral spironolactone and topical dorzolamide 2% were, therefore, added. Significant reduction in the intraretinal fluid and macular schisis was demonstrated at the last follow-up 2 years postoperative.

Conclusion

The mechanisms underlying optic disc pit maculopathy remain controversial, and treatment guidelines are unclear. To our knowledge, this is the first description of an OPDM treated with a combination systemic mineralocorticoid receptor antagonist and topical carbonic anhydrase inhibitor as adjuvant therapy to vitrectomy with favorable outcomes. We also review the literature and propose mechanisms through which these treatment entities may act.

Optic Disc Pit Maculopathy: One-Year Outcomes of Pars Plana Vitrectomy with Foveal Sparing Inverted Internal Limiting Membrane Flap

Purpose

To evaluate the anatomical and visual outcomes in optic disc pit maculopathy following pars plana vitrectomy (PPV) with inverted internal limiting membrane (ILM) flap

Methods

Retrospective interventional case series of 10 patients diagnosed with serous macular detachment secondary to optic disc pit who underwent PPV with inverted ILM flap and were followed up for a year.

Results

A p-value of less than 0.05 was defined as statistically significant. The mean age of patients was 27.2 ± 10.6 years, preoperatively the mean best-corrected visual acuity of the logarithm of the minimum angle of resolution was 0.91 ± 0.42 (approximate Snellen equivalent 20/162), which improved to the logarithm of the minimum angle of resolution of 0.58 ± 0.29 (approximate Snellen equivalent 20/76) at end of one year, (p=0.008). The mean central macular thickness was 804.9 ± 294.1 m which improved to 273.4 ± 102.54 m, (p=0.002). After surgery, at end of one year, 60% of patients (6/10) had 15- or more-than-15-letter improvement of vision on Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity testing, 20% (2/10) gained a 10-letter improvement and 20% (2/10) retained the same vision.

Conclusion

PPV with inverted ILM flap can be considered as a good approach for the management of serous macular detachment secondary to optic disc pit and produce good anatomical and visual results at one year with stabilization of the disease.

A prospective long-term follow-up study of optic disc pit maculopathy treated with pars plana vitrectomy, drainage of subretinal fluid and peeling of internal limiting membrane

PURPOSE

To describe the long-term results of surgical repair of patients with optic disc pit maculopathy (ODP-M).

METHODS

Prospective, consecutive, noncomparative follow-up study including 12 patients with ODP-M treated by pars plana vitrectomy (PPV), peeling of internal limiting membrane followed by gas tamponade. Subretinal fluid (SRF) was drained in 11 eyes through a retinotomy without laser photocoagulation. Preoperatively, macular detachment with retinoschisis was seen in 9 out of 12 eyes with three eyes having only subretinal fluid in the macular area. The median age at surgery was 20 years (range 9-60 years).

RESULTS

Follow-up time from initial surgery was 63 months (median). Eight eyes were anatomically reattached after one operation without remaining SRF in the macula. Two patients required a reoperation due to leakage from the retinotomy and another two underwent a second PPV procedure due to late recurrences. Successful healing was at follow-up control observed in 11 of 12 eyes. There was no statistically significant difference in visual acuity between patients before and after surgery (p = 0.24). Central visual field defects with depressed mean deviation were detected in all treated eyes.

CONCLUSION

In this long-term study of ODP-M final outcome regarding healing was relatively efficacious, however, a relatively large proportion had complications associated to retinotomies. We conclude that drainage of SRF should likely be avoided since it appears to contribute little to the resorption rate of SRF and seems to linked to unnecessary risks.

Surgical outcomes in patients with optic disc pit maculopathy: does peeling the ILM lead to better outcomes?

PURPOSE

Optic disc pits (ODPs) are rare congenital anomalies. Several patients develop optic disc pit maculopathy (ODP-M): visual impairment caused by intra- and/or subretinal fluid. Treatment mode remains controversial. This study was designed to investigate the effectiveness of pars plana vitrectomy (PPV) and gas tamponade with or without internal limiting membrane (ILM)-peeling in improving visual acuity and reducing subretinal fluid in ODP-M patients.

METHODS

We retrospectively reviewed the charts of 16 patients who underwent surgery for ODP-M from 2002-2015. Six patients underwent PPV with gas tamponade (group 1); ten patients additionally received ILM-peeling (group 2). Pre- and postoperative visual acuity and central retinal thickness (CRT) were compared between groups, as well as retinal morphology and the number of secondary vitrectomies and complications.

RESULTS

Median visual acuity improved by 2 ETDRS lines in both groups (p = 0.713, Mann-Whitney U test). Median CRT decreased by 426.5 µm and 460 µm (p = 0.931). One patient in group 1 underwent repeat vitrectomy for persistent retinoschisis. Three patients in group 2 required repeat vitrectomy: two to treat a macular hole, one for peripheral retinal holes with retinal detachment.

CONCLUSION

In our cohort, PPV with gas tamponade proved to be an effective first-line treatment for ODP-M. Additional ILM-peeling did not give a significant benefit in this study.

Surgical Options for Optic Disc Pit Maculopathy: Perspectives and Controversies

Optic disc pit (ODP) is a rare congenital optic nerve head abnormality, which can be complicated by intraretinal and subretinal fluid at the macula (ODP-maculopathy) with progressive visual loss. The source of this fluid remains unclear and the most dominant hypotheses have pointed to vitreous cavity or cerebrospinal fluid. Although spontaneous resolution has been reported, the majority of untreated cases of ODP-maculopathy result in final visual acuity less than 20/200 or worse. A wide array of interventions, either individually or in combination with adjuvant treatments, have been tried with varying degrees of success. Recently, different surgical procedures to fill the ODP by self-sealing materials in combination with pars plana vitrectomy have been reported as an effective adjuvant treatment. However, given the relative rarity of this condition, the majority of reports describe a small retrospective case series, making it difficult to compare among different treatments options and create a consensus regarding the optimal treatment for ODP-maculopathy. In this situation, a mini-review about surgical treatment modalities and their results can be a useful approach to identify the most effective surgical option in the management of ODP-maculopathy.

Optic disc pit maculopathy: tamponade of maculoschisis

Purpose

To present rapid and safe closure of the pit-macula communication (PMC) by core vitrectomy and adequate duration gas tamponade as our preferred method of resolving optic disc pit (ODP) maculopathy and to define the term "maculoschisis" in ODP maculopathy as an alternative to the term "schisis-like."

Patient and methods

A twenty-four-year-old female presented with an optical coherence tomography (OCT) confirmed ODP and a "giant" communicating maculoschisis cavity. Central macular thickness (CMT) measured 906 microns, and macular volume was twice normal, at 20.8 mm³. Snellen corrected visual acuity was 20/70. Two months after initial vitrectomy performed elsewhere with short-term gas tamponade (SF₆ 20%), CMT and visual acuity were not significantly improved. Combined lens extraction/intraocular lens placement and repeat vitrectomy with C₃F₈ 15% gas tamponade were performed, with one supplemental (office) gas injection.

Results

OCT imaging six weeks postoperatively showed definitive closure of the PMC with CMT reduced by 405 microns. Sequestered from its ODP source, foveal schisis fluid then resolved by 12 weeks postoperatively. At final follow-up 3.4 years postoperatively, the macula remained dry with a CMT of 322 microns and a concave foveal contour. Macular volume was reduced to (a normal) 10.2 mm³ and visual acuity had improved to 20/25.

Conclusion

No report heretofore has documented rapid, sustained closure of the PMC by gas tamponade as the preferred method of expeditiously resolving ODP maculopathy. However, tamponade PMC closure sequesters ODP fluid and uniquely provides early assurance of ultimate maculopathy resolution. In all other techniques, PMC closure is a trailing phenomenon and success remains uncertain during months to a year or more of (unsequestered) fluid resolution. We suggest that more invasive techniques (laser barrier application to the peripapillary choroid, vitreoretinal interface maneuvers, and pit-plugging) be withheld unless a recurrence is detected during subsequent examinations.

Optic disk pit maculopathy: current management strategies

Introduction

Optic disk pit (ODP) is a rare congenital abnormality of the optic nerve head and can lead to visual impairment when macular detachment occurred. Recent advances in retinal imaging brought new insights into the pathophysiology of the disease, while new therapeutic options have been also described.

Methods

We made a comprehensive search of the literature regarding the current treatment modalities for the treatment of ODP maculopathy.

Results

Although there have been reported some cases of spontaneous resolution, current management of ODP maculopathy involves several surgical approaches. The most commonly used treatment alternative for ODP maculopathy management is vitrectomy, either alone or in combination with other treatment modalities, such as gas tamponade or laser photocoagulation. Other options, such as scleral buckling and inner fenestration, are also used, based on the recent findings about pathophysiology of the disease.

Conclusion

The management of ODP maculopathy remains challenging. Even though there are further advances in the understanding of the disease pathophysiology, the applied treatment is not single and therapeutic modalities differ in the success rate, related to the anatomical and functional results.