Intraocular surgery for optic nerve disorders

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.

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

PURPOSE

To evaluate the clinical outcomes of vitrectomy with induction of posterior vitreous detachment for the treatment of optic disc pit maculopathy.

METHODS

We retrospectively evaluated medical records and imaging studies of 11 consecutive patients with optic disc pit maculopathy who underwent vitrectomy at Sacco University Hospital, Milan, Italy, between October 2008 and December 2015. Induction of a posterior vitreous detachment (PVD) was the aim of our surgery. Intravitreal injection of ocriplasmin (Jetrea, Thrombogenics USA, Alcon/Novartis EU) was performed before surgery in three eyes of very young patients. Gas tamponade (sulfur hexafluoride (SF6) 20%) was used only in the first five cases. Main outcome measures were anatomic results as determined by optical coherence tomography and postoperative best-corrected visual acuity (BCVA).

RESULTS

Before surgery, a macular detachment was present in 10 eyes and a lamellar hole of the outer retina was detected in 9 eyes. Intraoperatively, two iatrogenic paramacular holes developed in two patients during posterior hyaloid dissection. Time to PVD induction appeared to be greatly reduced in the three patients injected with ocriplasmin before surgery. Patients were followed up for a mean of 38 months (range, 18-84) after surgery. Postoperatively, one patient (9%) developed a retinal detachment that was repaired with one additional vitrectomy. Complete resolution of fluid in and under the fovea was achieved in 8 of the remaining 10 eyes (80%) without additional treatment. Reduction of the inner retinal fluid always preceded the decrease of outer retinal fluid, which in turn anticipated the absorption of macular detachment. The macular detachment resolved in a mean of 14 months after surgery. Postoperative BCVA (mean, 0.63) improved significantly compared with preoperative BCVA (mean, 0.27) (P = 0.005). Nine eyes (82%) had a postoperative BCVA of 0.5 or better.

CONCLUSION

Vitrectomy with induction of PVD is a safe and successful therapeutic option for the treatment of optic disc pit maculopathy. The adjunct of ocriplasmin might facilitate the induction of PVD and reduce the risk of iatrogenic retinal holes.

Congenital optic nerve anomalies

OBJECTIVE

To update the current knowledge about congenital optic disc anomalies.

METHODS

A comprehensive literature search was performed in the major biomedical databases.

RESULTS

Patients with these anomalies usually have poor vision in infancy. Refractive errors are common, and serous retinal detachment may develop in some of these anomalies. It is critically important to clinically differentiate between these congenital optic disc anomalies, as central nervous system malformations are common in some, whereas others may be associated with systemic anomalies.

CONCLUSIONS

Congenital optic disc anomalies are a heterogeneous group of pathologies with characteristic fundus appearance and systemic associations. We should always try to make a correct diagnosis, in order to ask for specific tests, as well as to provide an adequate follow-up.

23 Gauge Vitrectomy, Endolaser, and Gas Tamponade Versus Vitrectomy Alone for Serous Macular Detachment Associated With Optic Disc Pit

PURPOSE

To evaluate the clinical outcomes of 23 gauge vitrectomy, endolaser, and gas tamponade vs vitrectomy alone for the management of serous macular detachment associated with optic disc pits.

DESIGN

Retrospective, comparative case series.

METHODS

Seventeen eyes of 16 patients who underwent 23 gauge transconjunctival sutureless pars plana vitrectomy (PPV) for serous macular detachment associated with optic disc pits were evaluated in this study. Complete ophthalmologic examinations including optical coherence tomography (OCT) and fundus autofluorescence were evaluated at the baseline and during the postoperative follow-up period. Ten eyes of 9 cases that underwent 23 gauge PPV, endolaser, and gas tamponade were allocated to Group 1, and 7 eyes of 7 cases that underwent 23 gauge PPV alone were allocated to Group 2.

RESULTS

There were 6 male and 3 female patients in Group 1, and the average age of patients was 24.7 years. There were 5 male and 2 female patients in Group 2 and the average age of patients was 22.1 years. There was no difference in the postoperative visual acuity (P = .7) and postoperative central foveal thickness (P = .5) between the 2 groups. The mean time of the subretinal fluid resolution was significantly shorter in Group 1 than in Group 2. OCT showed the inner layer separation improved before than serous retinal detachment. Preoperative features of the inner/outer segment junction correlate well with improvement of postoperative visual acuity.

CONCLUSIONS

Vitrectomy alone without gas tamponade and laser photocoagulation is a safe and effective method for management of serous macular detachment resulting from optic disc pits as well as combined surgery.

Enhanced depth imaging optical coherence tomography of congenital cavitary optic disc anomaly (CODA)

AIM

To report the finding of extension of the 4th hyper-reflective band and retinal tissue into the optic disc in patients with cavitary optic disc anomalies (CODAs).

METHODS

In this observational study, 10 patients (18 eyes) with sporadic or autosomal dominant CODA were evaluated with enhanced depth imaging optical coherence tomography (EDI-OCT) and colour fundus images for the presence of 4th hyper-reflective band extension into the optic disc.

RESULTS

Of 10 CODA patients (18 eyes), five patients (8 eyes) showed a definite 4th hyper-reflective band (presumed retinal pigment epithelium (RPE)) extension into the optic disc. In these five patients (seven eyes), the inner retinal layers also extended with the 4th hyper-reflective band into the optic disc. Best corrected visual acuity ranged from 20/20 to 20/200. In three patients (four eyes), retinal splitting/schisis was present and in two patients (two eyes), the macula was involved. In all cases, the 4th hyper-reflective band extended far beyond the termination of the choroid into the optic disc. The RPE extension was found either temporally or nasally in areas of optic nerve head excavation, most often adjacent to peripapillary pigment. Compared with eyes without RPE extension, eyes with RPE extension were more myopic (mean dioptres -0.9±2.6 vs -8.8±5, p=0.043).

CONCLUSIONS

The RPE usually stops near the optic nerve border separated by a border tissue. With CODA, extension of this hyper-reflective band and retinal tissue into the disc is possible and best evaluable using EDI-OCT or analogous image modalities. Whether this is a finding specific for CODA, linked to specific gene loci or is also seen in patients with other optic disc abnormalities needs further evaluation.

Spontaneous Resolution of Long-Standing Macular Detachment due to Optic Disc Pit with Significant Visual Improvement

Purpose

To report a case of spontaneous resolution of a long-standing serous macular detachment associated with an optic disc pit, leading to significant visual improvement.

Case Presentation

A 63-year-old female presented with a 6-month history of blurred vision and micropsia in her left eye. Her best-corrected visual acuity was 6/24 in the left eye, and fundoscopy revealed serous macular detachment associated with optic disc pit, which was confirmed by optical coherence tomography (OCT). The patient was offered vitrectomy as a treatment alternative, but she preferred to be reviewed conservatively. Three years after initial presentation, neither macular detachment nor subretinal fluid was evident in OCT, while the inner segment/outer segment (IS/OS) junction line was intact. Her visual acuity was improved from 6/24 to 6/12 in her left eye, remaining stable at the 6-month follow-up after resolution.

Conclusion

We present a case of spontaneous resolution of a long-standing macular detachment associated with an optic disc pit with significant visual improvement, postulating that the integrity of the IS/OS junction line may be a prognostic factor for final visual acuity and suggesting OCT as an indicator of visual prognosis and the probable necessity of a surgical management.

Vitrectomy for optic disc pit-associated maculopathy with or without preoperative posterior vitreous detachment

Background

The purpose of this study was to evaluate the efficacy of pars plana vitrectomy for the treatment of optic disc pit-associated maculopathy with or without preoperative posterior vitreous detachment.

Methods

We reviewed the clinical records of four consecutive patients who underwent pars plana vitrectomy in one eye for the treatment of optic disc pit-associated maculopathy, with an emphasis on the preoperative condition of the posterior hyaloid membrane.

Results

Two of four eyes were confirmed to have an attached posterior hyaloid membrane, which was subsequently removed during surgery. Following vitrectomy, these two eyes experienced an improvement in visual acuity with complete retinal attachment of the macula. However, the other two eyes, which already had a posterior vitreous detachment at the time of surgery, showed a decrease in visual acuity with persistent maculopathy postoperatively.

Conclusion

Pars plana vitrectomy for optic disc pit-associated maculopathy was beneficial for improving visual acuity in two eyes without preoperative posterior vitreous detachment but not in two eyes with preoperative posterior vitreous detachment. Our study suggests that preoperative assessment of a posterior hyaloid membrane is clinically important in predicting the surgical outcome of optic disc pit-associated maculopathy.

Analysis of pars plana vitrectomy for optic pit-related maculopathy with intraoperative optical coherence tomography: a possible connection with the vitreous cavity

Optimal management of optic pit-related maculopathy remains to be determined. The fluid source for the maculopathy also remains controversial. In this article, we present a unique surgical technique for internal drainage of the intraretinal fluid and describe the intraoperative use of spectral-domain optical coherence tomography to assist in the surgical management of this condition. Pars plana vitrectomy was performed with elevation of the posterior hyaloid. Following an air-fluid exchange, aspiration over the optic nerve pit was performed. Following aspiration, intraoperative spectral-domain optical coherence tomography demonstrated collapse of the retinoschisis, strongly suggesting a connection between the vitreous cavity and the intraretinal fluid.

[Circumscribed retinal detachment after radial optic neurotomy for central retinal vein occlusion]

OBJECTIVE

It has been suggested that radial optic neurotomy (RON) may improve the functional outcome of retinal vein occlusions. We report the case of a patient presenting with a high, but circumscribed, peripapillary retinal detachment following RON for central retinal vein occlusion.

RESULTS

A 69-year-old man presented with a high retinal detachment 2.5 years after RON for central retinal vein occlusion. It was complicated by a recurring cystoid macular edema; however, best visual acuity was 0.5. The retinal detachment developed slowly. Its location was nasal and superior to the optic disc. It did not extend beyond the equator and had no detectable retinal break. The retinal detachment was successfully treated by an encircling band, pars plana vitrectomy, laser coagulation, and air endotamponade. There was no obvious persisting retinal defect at the RON site.

CONCLUSIONS

Although other mechanisms should be taken into account, this case indicates that it might be possible to create a fistula between the subarachnoid and subretinal space, leading to a slowly developing retinal detachment. A similar case report pointed out that special attention should be paid to the depth of the radial incision into the optic nerve head.

Visual improvement after long-standing central serous macular detachment associated with an optic disc pit

BACKGROUND

Approximately 50% of cases of congenital optic disc pits are associated with serous macular detachment. Long-standing serous detachments (over 1 year) with poor initial presenting acuity are usually associated with cystic degeneration of the macula and loss of pigment from the underlying retinal pigment epithelium, with resultant poor visual outcome.

METHODS

A 43-year-old male presented with an optic disc pit and associated serous elevation of the macular region with cystic changes at the fovea.

RESULTS

Over the following 2 years, the patient was aware of an improvement in vision, and acuity improved from 1/60 to 6/18 with resolution of subretinal fluid, as evidenced on optical coherence tomography.

CONCLUSIONS

We report an unusual case of an optic disc pit associated with a long-standing serous macular detachment that resolved gradually over a 2.5-year period and, despite very poor presenting visual acuity, demonstrated eventual visual recovery.

Surgical treatment of central retinal vein occlusion

The treatment of central retinal vein occlusion (CRVO) is still a subject of debate. Medical therapy efforts, as well as retinal laser photocoagulation, have mostly dealt with management of the sequelae of CRVO, and have shown limited success in improving visual acuity. The unsatisfactory results of such therapeutic efforts led to the development of new treatment strategies focused on the surgical treatment of the occluded retinal vein. The purpose of this review is to summarize the outcomes of commonly reported surgical treatment strategies and to review different opinions on the various surgical approaches to the treatment of CRVO.

Developmental abnormalities of the optic nerve and chiasm

Developmental anomalies of the optic nerve are an important and growing cause of lifelong visual handicap and they are often associated with systemic abnormalities. This review focuses on the ocular and systemic aspects of developmental anomalies arising from defects of fetal fissure closure and retinal ganglion cell development, and covers some other optic-disc anomalies that have systemic significance.

Vitreous findings in optic disc pit maculopathy based on optical coherence tomography

BACKGROUND

To assess vitreous findings in optic disc pit maculopathy using Optical Coherence Tomography (OCT).

METHODS

Thirty-eight eyes of 38 patients (14-51 years of age) with macular detachment associated with optic disc pit maculopathy were included in the study. The patients were divided into two groups. In group 1, 16 eyes were studied by OCT at presentation and after surgical treatment. In group 2, 22 eyes were examined by OCT only after treatment. In both groups thorough vitreous examination was performed over the macula and the optic disc. All patients were operated by the macular buckling procedure.

RESULTS

Vitreous abnormalities were found in 28 out of 38 eyes (74%) of both groups. In group 1, 10 of the 16 eyes had vitreous traction on the macula at presentation. The traction started from the optic disc and terminated to the macula. The posterior hyaloid that exerted the traction between the points of adhesion at the optic disc and the macula had a course parallel to the retinal surface in 9 of the 10 cases. Postoperatively, vitreous traction on the macula was not found. Of the remaining 6 eyes 4 had complete or partial posterior vitreous detachment. In group 2, 8 eyes had vitreous strands over the optic disc and 5 eyes posterior vitreous detachment. In the remaining 9 cases no vitreous involvement was noticed.

CONCLUSIONS

OCT was able to detect vitreous abnormalities such as vitreomacular traction, vitreous strands over the optic disc and complete or partial posterior vitreous detachment associated with optic disc pit maculopathy. Our observations support the view that the abnormal vitreous over the macula and optic disc is likely to play a role in the development of macular elevation in cases with optic disc pit. Prospective OCT studies could further assist to better understand the role of vitreous in this disease.

Persistent serous retinal detachment after radial optic neurotomy

We report the case of a patient presenting with serous retinal detachment following radial optic neurotomy for central retinal vein occlusion. Initially, the retinal detachment was successfully treated by a second vitrectomy and laser coagulation. After reabsorption of the gas tamponade, a recurrence of the retinal detachment was seen with no detectable retinal break. Although other mechanisms should be taken into account, this case indicates that it is possible to create a fistula between the subarachnoid and subretinal space. We conclude from this observation that special attention should be paid to the depth of the radial incision into the optic nerve head.