The Progression of Peripapillary Retinoschisis May Indicate the Progression of Glaucoma

Peripapillary fluid: Obvious and not so obvious!

Intraretinal or subretinal fluid in the peripapillary area can be clinically visualized in conditions such as peripapillary choroidal neovascularization, optic disc pit maculopathy, and optic nerve head tumors and granulomas. Optical coherence tomography (OCT) helps to visualize peripapillary fluid in many other chorioretinal conditions such as peripapillary pachychoroid syndrome, posterior uveitis, central retinal vein occlusion, malignant hypertension, hypotonic maculopathy as well as neuro-ophthalmological conditions such as glaucoma, microcystic macular edema and disc edema due papilledema, non-arteritic anterior ischemic optic neuropathy, neuroretinitis, and diabetic papillopathy. Often, the differential diagnosis of peripapillary fluid is a bit tricky and may lead to misdiagnosis and improper management. We describe a diagnostic algorithm for peripapillary fluid on OCT and outline the salient features and management of these conditions.

Association of Bergmeister Papilla and Deep Optic Nerve Head Structures With Prelaminar Schisis of Normal and Glaucomatous Eyes

PURPOSE

To investigate factors associated with the severity of prelaminar schisis (PLS) in heathy subjects and glaucoma patients.

DESIGN

Prospective cross-sectional study.

METHODS

A total of 217 eyes of 217 subjects (110 normal eyes and 107 open angle glaucoma eyes) were studied. Frequency and severity of PLS were compared between normal and glaucomatous eyes. Multivariate logistic models were used to assess factors associated with the severity of PLS. Factors considered were age, axial length, glaucomatous damage indices, Bruch membrane opening (BMO) and anterior scleral canal opening parameters, tractional forces (posterior vitreous staging and presence of Bergmeister papilla), circumpapillary choroidal thickness, lamina cribrosa (LC) parameters, and peripapillary scleral (PPS) angle.

RESULTS

The frequency of PLS was 70.9% in normal eyes and 72.0% in glaucomatous eyes. There was no difference in frequency and severity between the groups. The presence of Bergmeister papilla was the strongest predictor of a more severe PLS in both normal and glaucomatous eyes (odds ratio [OR] + 9.78, 12.5; both P < .001). A larger PPS angle in normal eyes (OR = 1.19; P = .003) and a larger BMO area and a deeper LC depth in glaucomatous eyes (OR = 1.08, 1.05; both P = .038) were associated with severity of PLS.

CONCLUSIONS

The severity of PLS was strongly associated with the presence of Bergmeister papilla, suggesting a traction-related phenomenon. Correlation of PLS severity with larger BMO area and deeper LC depth, which are optic nerve head structures associated with glaucoma, suggested its possible relationship with glaucomatous damage.

Impact of peripapillary retinoschisis on visual field test results in glaucomatous eyes

BACKGROUND/AIMS

To investigate the influence of peripapillary retinoschisis (PRS) on visual field (VF) test results in patients with primary open angle glaucoma (POAG).

METHODS

Thirty eyes of 30 patients with POAG who had PRS at least once were included. All eyes were followed-up for a minimum 5 years at 4-6-month intervals. The occurrence of PRS was determined by circumpapillary retinal nerve fibre layer B-scan on spectral-domain optical coherence tomography (OCT). The global and regional VF deviations just prior to and immediately after PRS formation, or just prior to and immediately after PRS resolution (if it occurred), were compared. VF sensitivity within the region corresponding to the OCT sector where PRS occurred was determined according to the Garway-Heath map.

RESULTS

Global MD (p=0.345) and regional VF deviations (p=0.255) did not differ significantly between immediately after and just prior to PRS formation. Global MD (p=0.846) and regional VF deviations (p=0.758) were also similar between immediately after and just prior to PRS resolution.

CONCLUSION

PRS has no short-term effect on the VF sensitivity. Therefore, VF test can still be useful for evaluating glaucomatous damage even in the presence of PRS compared with OCT.

Glaucomatous optic nerve damage in the contralateral eye of a patient with peripapillary retinoschisis: a case report

BACKGROUND

Peripapillary retinoschisis (PPRS) is often associated with glaucomatous eyes. It usually occurs in eyes with a more advanced stage of glaucoma with obvious optic nerve damage. We report a patient who was found to have PPRS in one eye during a routine physical examination without obvious glaucoma symptoms. Further examination revealed glaucomatous visual field loss and retinal nerve fiber layer defects in the contralateral eye.

CASE PRESENTATION

A 55-year-old man presented for a routine physical examination. The anterior segment was normal in both eyes. Fundus examination revealed an elevated and red optic disc in the right eye. In addition, scattered patchy red lesions were seen on the retina on the temporal side of the optic disc. The color and boundary of the left optic disc were normal, and the cup-to-disc ratio was 0.6. Optical coherence tomography showed retinoschisis on the optic nerve head of the right eye throughout the entire circumference, extending to the retina on the temporal side of the optic disc. The intraocular pressure was 18 mmHg OD and 19 mmHg OS. The patient was diagnosed with PPRS (OD). However, no optic disc pit or optic disc coloboma was found. Further examination showed that the visual field of the patient's right eye was generally normal, while a glaucomatous visual field defect was found in the left eye, which manifested as a nasal step visual field defect. Moreover, stereophotography and a red-free fundus image revealed two retinal nerve fiber layer defects in the supratemporal and infratemporal regions of the retina of the left eye. Continuous intraocular pressure measurement found that the intraocular pressure fluctuated between 18 and 22 mmHg OD and 19-26 mmHg OS during the daytime. Primary open-angle glaucoma was then diagnosed.

CONCLUSIONS

In this case, we found that PPRS was associated with glaucomatous optic nerve changes and visual field defects in the fellow eye.

Peripapillary Retinoschisis as a Manifestation of Ocular Hypotony

The aim of this case report was to present an unusual case of peripapillary retinoschisis (PPRS) associated with ocular hypotony after glaucoma surgery. It refers to a 78-year-old man with primary open-angle glaucoma who developed PPRS while hypotonous. Optical coherence tomography of the peripapillary and the macular area of the right eye revealed PPRS temporally and nasally to the optic disc, more prominent at the level of the outer nuclear layer and less so at the inner nuclear layer. The PPRS completely regressed after 1 month of treatment and restoration of intraocular pressure to normal levels. This case report highlights the fact that PPRS in glaucoma patients may present in the setting of ocular hypotony and appears to resolve when the hypotony is successfully managed. Hydrostatic pressure gradient across retinal vasculature that allows movement of fluid into the extracellular spaces is a potential mechanism for the development of PPRS in ocular hypotony.

Peripapillary retinoschisis associated with glaucomatous optic neuropathy (clinical cases)

Peripapillary retinoschisis is a rare condition and is detected more often in patients with glaucoma or glaucoma suspects, while data on the pathophysiological mechanisms of development and the effect on the course of glaucoma are limited. The article presents two clinical cases of unilateral peripapillary retinoschisis detected accidentally during a routine examination of patients with glaucoma.

Non-vasogenic cystoid maculopathies

Besides cystoid macular edema due to a blood-retinal barrier breakdown, another type of macular cystoid spaces referred to as non-vasogenic cystoid maculopathies (NVCM) may be detected on optical coherence tomography but not on fluorescein angiography. Various causes may disrupt retinal cell cohesion or impair retinal pigment epithelium (RPE) and Müller cell functions in the maintenance of retinal dehydration, resulting in cystoid spaces formation. Tractional causes include vitreomacular traction, epiretinal membranes and myopic foveoschisis. Surgical treatment does not always allow cystoid space resorption. In inherited retinal dystrophies, cystoid spaces may be part of the disease as in X-linked retinoschisis or enhanced S-cone syndrome, or occur occasionally as in bestrophinopathies, retinitis pigmentosa and allied diseases, congenital microphthalmia, choroideremia, gyrate atrophy and Bietti crystalline dystrophy. In macular telangiectasia type 2, cystoid spaces and cavitations do not depend on the fluid leakage from telangiectasia. Various causes affecting RPE function may result in NVCM such as chronic central serous chorioretinopathy and paraneoplastic syndromes. Non-exudative age macular degeneration may also be complicated by intraretinal cystoid spaces in the absence of fluorescein leakage. In these diseases, cystoid spaces occur in a context of retinal cell loss. Various causes of optic atrophy, including open-angle glaucoma, result in microcystoid spaces in the inner nuclear layer due to a retrograde transsynaptic degeneration. Lastly, drug toxicity may also induce cystoid maculopathy. Identifying NVCM on multimodal imaging, including fluorescein angiography if needed, allows guiding the diagnosis of the causative disease and choosing adequate treatment when available.

Clinical Features of Advanced Glaucoma With Optic Nerve Head Prelaminar Schisis

PURPOSE

To investigate the clinical characteristics of optic nerve head (ONH) prelaminar schisis in eyes with advanced glaucoma.

DESIGN

Cross-sectional study.

METHODS

One hundred sixteen eyes with advanced glaucoma (30-2 mean deviation <-12 dB) were included. ONH prelaminar schisis was identified using the spectral-domain optical coherence tomography independently by 2 evaluators and only eyes that reached consensus for the presence of ONH prelaminar schisis were included. Bruch membrane opening-minimum rim width (BMO-MRW), thickness and depth of lamina cribrosa (LC), peripapillary retinal nerve fiber layer (RNFL) thickness, macular thickness (total, RNFL, ganglion cell layer, inner plexiform layer), and peripapillary and subfoveal choroidal thickness were additionally obtained. Clinical characteristics were compared between the 2 groups based on the presence of ONH prelaminar schisis.

RESULTS

ONH prelaminar schisis was identified in 48 of 116 eyes. Multivariate logistic regression analysis revealed that short axial length, thin and deep LC, and thick macula were associated with the presence of ONH prelaminar schisis. When the structure-function relationships were determined, macular structural parameters tended to have a better relationship with functional parameters than the BMO-MRW and peripapillary RNFL thickness parameters in eyes with ONH prelaminar schisis.

CONCLUSIONS

The ONH prelaminar schisis was associated with thin and deep LC, short axial length, and generally thick macula. In patients with this features, the macular measurements, rather than peripapillary or ONH measurements, better predict the functional status of the eye. Our findings may have significant clinical implications for management of advanced glaucoma eyes with and without ONH prelaminar schisis.

Disc hemorrhage following peripapillary retinoschisis in glaucoma: a case report

BACKGROUND

Disc hemorrhage (DH) is an important factor often associated with the development and especially progression of glaucoma. In contrast, some studies have reported peripapillary retinoschisis in glaucoma, but it is not recognized as a pathognomonic finding, and opinions on the clinical significance of retinoschisis are not consistent. Here,we present the case of DH following peripapillary retinoschisis in the same area within the same glaucomatous eye.

CASE PRESENTATION

A 70-year-old man with high intraocular pressure (IOP) was referred to the glaucoma clinic. At the time of the baseline study, the IOP was 30mmHg, and peripapillary retinoschisis was discovered at 7 o'clock on the periphery of the optic nerve with swept-source optical coherence tomography. Accompanying retinal nerve fiber layer defect were manifest in the inferotemporal part with red-free fundus photography. Under the impression of open-angle glaucoma, we prescribe latanoprost ophthalmic solution. Eight months later, the IOP was 17mmHg, and the peripapillary retinoschisis had disappeared. DH was observed in the inferotemporal area in the same direction as that of the previous peripapillary retinoschisis.

CONCLUSIONS

The case presented here are the first to report on the relationship between peripapillary retinoschisis and DH. Hopefully future studies will reveal the actual connection between peripapillary retinoschisis and DH.