Peripapillary retinoschisis in glaucomatous eyes

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.

Intraocular Pressure Lowering Associated With Worsening Optic Pit-Like Retinoschisis

In this article, we present a case of optic pit-like macular retinoschisis in the absence of advanced glaucomatous cupping. Intraocular pressure (IOP)-lowering therapy, which was started due to an early concern for glaucoma, caused a worsening of the retinoschisis, which subsequently resolved on discontinuation of the IOP-lowering therapy. Lower IOP likely triggered intraretinal fluid accumulation by facilitating a translaminar gradient from the subarachnoid to intraretinal space. [Ophthalmic Surg Lasers Imaging Retina 2024;55:100-102.].

NOn-Pachychoroid PEripapillary Schisis (NOPPES) of the Retina: A New Phenotype and its Differential Diagnosis

PURPOSE

The presence of peripapillary intraretinal fluid (IRF) has a broad differential diagnosis, including several types of neovascular and pachychoroid-related diseases. However, the clinician may encounter cases without signs of neovascular or pachychoroid disease, or any other previously described diagnosis. For these patients, we propose the term NOn-Pachychoroid PEripapillary Schisis (NOPPES) of the retina, and we discuss the differential diagnosis.

DESIGN

A retrospective chart study set in a tertiary referral center for retinal diseases in Amsterdam, the Netherlands.

METHODS

Using multimodal imaging, cases suspected of peripapillary pachychoroid syndrome were reviewed. Cases without signs of neovascular or pachychoroid disease were included in this study. These cases were discussed in a group of senior retinal specialists to establish a diagnosis, and if there was no evidence for any previously described diagnostic entity, these cases were categorized as NOPPES.

RESULTS

Four cases of NOPPES were identified, 3 female patients and 1 male patient, aged between 58 and 75 years. Two patients were myopic, and 1 patient had a mild hyperopia. Three out of 4 cases showed unilateral peripapillary IRF, and 1 case had bilateral IRF. No improvement was seen after intravitreal bevacizumab or aflibercept, nepafenac eye drops, oral acetazolamide, vitrectomy with internal limiting membrane peeling, or surgery for carotid stenosis. One case showed a reduction in IRF after starting prednisolone eye drops.

CONCLUSIONS

We describe NOPPES, a new form of peripapillary schisis-like IRF. NOPPES seems relatively therapy-resistant. More research is needed to delineate the clinical spectrum of NOPPES and its pathogenesis and treatment.

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.

Macular Retinoschisis from Optic Disc without a Visible Optic Pit or Advanced Glaucomatous Cupping (No Optic Pit Retinoschisis [NOPIR])

PURPOSE

To review eyes with peripapillary and macular retinoschisis without a visible optic pit or advanced glaucomatous optic atrophy, or No Optic Pit Retinoschisis (NOPIR).

DESIGN

Retrospective multicenter case series.

SUBJECTS

The study included 11 eyes of 11 patients.

METHODS

Retrospective study of eyes with macular retinoschisis without a visible optic pit, advanced optic nerve head cupping, or macular leakage on fluorescein angiography.

MAIN OUTCOME MEASURES

Visual acuity (VA), retinoschisis resolution, months to resolution, and recurrence of retinoschisis RESULTS: The mean age was 68.1 ± 17.6 years, mean intraocular pressure was 17.4 ± 3.8 mmHg, and the mean spherical equivalent refractive error was -3.1 ± 2.9 diopters. No subject had pathologic myopia. Seven subjects were treated for glaucoma, and 9 subjects had nerve fiber layer defects on OCT. All eyes had retinoschisis in the outer nuclear layer (ONL) in the nasal macula and extending to the edge of the optic disc, and 8 subjects had fovea-involving retinoschisis. Three nonfoveal and 4 fovea-involved eyes were observed, and 4 fovea-involved eyes with vision loss underwent surgery. Surgery involved preoperative juxtapapillary laser followed by vitrectomy and membrane and internal limiting membrane peeling with intraocular gas and face-down position. The mean baseline VA was significantly worse in the surgery group than that in the observation group (P = 0.020). Retinoschisis resolved and vision improved in all surgical cases. The mean resolution time for the surgery group was 2.75 ± 0.96 months, which was shorter than that for the observation group (28.0 ± 21.2 months; P = 0.014). No eye developed recurrence of the retinoschisis after surgery.

CONCLUSIONS

Peripapillary and macular retinoschisis can develop in eyes without a visible optic pit or advanced glaucomatous cupping. Eyes without foveal involvement and those with foveal involvement but only mild decrease in vision can be observed for spontaneous resolution. If there is persistent foveal involvement with vision loss, surgery can improve vision by resolving the macular retinoschisis. Surgery for fovea-involved macular retinoschisis without a visible optic pit resulted in faster anatomic resolution and better vision recovery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Severe macular complications in glaucoma: high-resolution multimodal imaging characteristics and review of the literature

PURPOSE

To describe imaging characteristics of severe macular complications occurring in glaucoma and discuss available treatments.

METHODS

Retrospective case series of glaucomatous patients with macular retinoschisis (MR) and/or serous retinal detachment (SRD). Patients underwent a complete ophthalmological examination and multimodal imaging including retinography, SD-OCT, fluorescein and indocyanine green angiography (FA & ICGA) and adaptive optics (AO).

RESULTS

Ten eyes (8 patients) were included. Initial BCVA was 1.04 ± 1.12 logMAR and IOP was 24.0 ± 9.3mmHg. All eyes presented with MR while SRD was present in 5 eyes (5 patients), with a central macular thickness of 573 ± 152 μm. FA and ICGA allowed to exclude leakage in all cases. A focal lamina cribrosa defect (LCD) was found in four eyes (4 patients) using OCT, with AO providing en-face visualization of the defect in one eye. Outer retinal hole was present in 3 eyes (3 patients). No visual improvement or resolution of the macular retinoschisis was observed in eyes with medical or surgical IOP control (N = 9). Vitrectomy with internal membrane limiting peeling and gas tamponade was performed in one eye with good visual results.

CONCLUSIONS

Multimodal high-resolution imaging is essential to diagnose severe macular complications associated with advanced glaucoma.

SPONTANEOUS RESOLUTION OF RETINOSCHISIS IN THE SETTING OF NARROW-ANGLE GLAUCOMA: A CASE REPORT

PURPOSE

To present a rare case of retinoschisis in the setting of narrow-angle glaucoma that demonstrated spontaneous resolution with conservative management.

METHODS

Case report presentation from the Vitreous Retina Macula Specialists of Toronto in December 2020.

RESULTS

A 65-year-old woman with previous bilateral laser peripheral iridotomies for narrow-angle glaucoma was referred to a tertiary retina clinic for the assessment of query macular edema in the left eye. The patient presented with a blunted foveal reflex in the left eye, and optical coherence tomography imaging demonstrated diffuse retinoschisis of outer retinal layers in the peripapillary region and nasal macula. The patient elected for conservative management, and by 10-month follow-up, her retinoschisis resolved spontaneously.

CONCLUSION

Only seven cases of retinoschisis in the setting of narrow-angle glaucoma have been identified in the literature. This is the first case in this setting to demonstrate spontaneous resolution with conservative management. Although laser peripheral iridotomies have been shown to resolve retinoschisis in narrow-angle glaucoma patients, clinicians should be aware of a conservative management approach to yield a positive improvement in retinal integrity.

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.

The role of near-infrared reflectance imaging in retinal disease: A systematic review

Near-infrared reflectance (NIR) retinal imaging aids in a better visualization of structures at the level of outer retina, retinal pigment epithelium, and choroid. It has multiple advantages, including easy acquisition in association with structural spectral domain optical coherence tomography, more comfort for patients, and enhanced contrast and spatial resolution. It helps in the diagnosis of chorioretinal diseases that present with minimal funduscopic findings and can be used to follow up many chorioretinal conditions. We describe the chorioretinal NIR imaging appearance and the clinical role of NIR imaging in ocular inflammatory disease, vascular and acquired disease, degenerative disease, tumors, associated systemic condition, toxic and traumatic disease, optic nerve head conditions, and physiological findings.

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.

Role of oral acetazolamide in refractory glaucomatous deep cup-related maculopathy

A 39-year-old man, a known case of primary open-angle glaucoma on treatment, presented with defective central vision in the left eye. On examination, his intraocular pressure (IOP) was 26 mmHg in the right eye and 30 mmHg in the left eye with best-corrected visual acuity of 6/12 in each eye. Fundus examination showed glaucomatous optic neuropathy in both eyes and macular thickening in the left eye. Optical coherence tomography of the left eye showed macular detachment with peripapillary retinoschisis and a hyporeflective tract connecting schitic retina and the deep cup in the absence of an optic disc pit. A diagnosis of glaucomatous deep cup maculopathy (DCM) was made in the left eye, which persisted despite well-controlled IOP and peripapillary laser photocoagulation. The addition of oral acetazolamide (250 mg twice daily) to his regimen resulted in prompt resolution of maculopathy. Glaucomatous DCM is relatively rare, and its primary management is adequate IOP control with antiglaucoma medications. Including oral acetazolamide in the antiglaucoma regimen can help in faster resolution of maculopathy due to its additional effect on retinal pigment epithelial pump induction and stabilization of the pressure gradient.

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.

Peripapillary and macular retinoschisis - A vision-threatening sequelae of advanced glaucomatous cupping

Purpose:

To present a selected case series of advanced glaucoma-associated peripapillary and macular retinoschisis and response to various treatment strategies with a comprehensive literature review.

Methods:

Retrospective observational case series. Retrospective review of five selected cases of advanced glaucoma with peripapillary and macular retinoschisis.

Results:

All five patients had advanced glaucomatous damage with macular and peripapillary retinoschisis, three (patients 2, 3, and 5) had a neurosensory detachment of the macula. Increased intraocular pressure was managed with maximal antiglaucoma medications and G6 micropulse diode laser treatment in the first patient, transscleral diode laser in the second patient, mitomycin-C augmented trabeculectomy in the third patient, maximal antiglaucoma medications alone in the fourth patient, pars plana vitrectomy followed by trabeculectomy in the fifth patient.

Conclusion:

We speculate that peripapillary and macular retinoschisis may indicate a vision-threatening sequelae of advanced glaucoma. The probable inciting factor for this vision-threatening pathology being elevated intraocular pressure, fluctuations in intraocular pressure, and chronic glaucoma with advanced cupping. We emphasize that meticulous examination of the macula in patients with advanced glaucoma is mandatory. It is imperative to do OCT macula in patients with advanced glaucoma to diagnose this distinct entity at an earlier stage and preserve the existing visual potential.

The Progression of Peripapillary Retinoschisis May Indicate the Progression of Glaucoma

Purpose

To identify the temporal correlation between the increase in peripapillary retinoschisis (PPRS) and glaucoma progression during PPRS fluctuation.

Methods

We performed a comparative clinical timeline analysis for PPRS and glaucomatous progression in eyes with PPRS. In particular, the interval between the increase in PPRS extent and glaucoma progression was analyzed. Temporal correlation was defined when the interval was less than one year between glaucoma progression and PPRS increase, including both de novo development and an increase in the amount of retinoschisis on serial optical coherence tomography.

Results

We included 33 eyes of 30 patients, with an average follow-up period of 7.5 ± 3.0 years and a total of 253 glaucoma examinations. Glaucoma progression was observed in 21 of 33 eyes; 19 (90.5%) of the 21 eyes with glaucoma progression and 29 (74.4%) of the 39 episodes of PPRS increase showed temporal correlation. The de novo development of PPRS during the follow-up period over baseline PPRS was more frequently observed in the glaucoma progression group than in the no-progression group (P = 0.006).

Conclusions

In glaucomatous eyes with PPRS, the increase in PPRS temporally correlated with glaucoma progression. Possible glaucoma progression may be considered around the time of increase and de novo development of PPRS.

Optic disc pit with multiquadrant peripapillary retinoschisis and choroidal coloboma

An 18-year-old man presented with decreased vision in the right eye (OD) noticed for 1 month. On examination, OD best-corrected visual acuity was 3/60 and the left eye (OS) was 6/6 with intraocular pressure of 12 mm Hg in both the eyes (OU). OD fundus revealed an inferior optic-disc-pit with macular-retinoschisis and an inferior choroidal coloboma. OS fundus was normal. On swept-source optical coherence tomography (SSOCT) radial scans, peripapillary-retinoschisis was seen not only in the macular region but in all the four quadrants. To the best of our knowledge, no such case has been reported of optic disc pit with multiquadrant peripapillary retinoschisis and choroidal coloboma coexisting in the same eye. SSOCT radial scans can help detect subclinical retinoschisis as in this case.

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.

Factors Determining the Morphology of Peripapillary Retinoschisis

Purpose

We conducted cross-sectional examinations to determine the frequency of peripapillary retinoschisis (PRS) in eyes with glaucoma and suspected glaucoma and analyzed the pathogenesis of PRS by using spectral-domain optical coherence tomography (SD-OCT).

Patients and Methods

In 1516 cases involving glaucoma and suspected glaucoma, we retrospectively reviewed the disc and macular volume scans obtained by SD-OCT and categorized PRS into two groups based on whether the retinoschisis was closer to the optic nerve over the Bruch’s membrane opening (BMO) (ahead group) or did not go past the BMO (behind group) and then compared the characteristics between both groups.

Results

The total frequency of PRS was 1.49% (20/1342 eyes) in primary open-angle glaucoma (POAG) eyes and 0.59% (10/1687 eyes) in glaucoma suspects. In the behind group, PRS was mostly detected in the inner layers of the retina (retinal nerve fiber layer: 30.9%, ganglion cell layer: 21.8%, inner plexiform layer: 7.3%). However, in the ahead group, PRS was detected in the outer layers (inner nuclear layer: 10%, outer plexiform layer: 20%, outer nuclear layer: 50%). In addition, the eyes in the ahead group had significantly greater axial lengths and significantly smaller spherical equivalent values. These two differences suggest that the pulling force of the vitreous traction may play an important role in PRS only in the behind group and that the scleral stretching force may play a role in the development of PRS in the ahead group.

Conclusion

The frequency of PRS in patients with POAG is higher than that in patients with suspected glaucoma. Both forms of PRS are affected by posterior vitreous detachment and axial length elongation. Careful follow-up is required to assess the development of PRS in glaucoma suspects. The pathogenesis of PRS has been elucidated to some degree by classifying the morphological condition of the PRS and BMO.

Detection of Glaucoma Deterioration in the Macular Region with Optical Coherence Tomography: Challenges and Solutions

PURPOSE

Macular imaging with optical coherence tomography (OCT) measures the most critical retinal ganglion cells (RGCs) in the human eye. The goal of this perspective is to review the challenges to detection of glaucoma progression with macular OCT imaging and propose ways to enhance its performance.

DESIGN

Perspective with review of relevant literature.

METHODS

Review of challenges and issues related to detection of change on macular OCT images in glaucoma eyes. The primary outcome measures were confounding factors affecting the detection of change on macular OCT images.

RESULTS

The main challenges to detection of structural progression in the macula consist of the magnitude of and the variable amount of test-retest variability among patients, the confounding effect of aging, lack of a reliable and easy-to-measure functional outcome or external standard, the confounding effects of concurrent macular conditions including myopia, and the measurement floor of macular structural outcomes. Potential solutions to these challenges include controlling head tilt or torsion during imaging, estimating within-eye variability for individual patients, improved data visualization, the use of artificial intelligence methods, and the implementation of statistical approaches suitable for multidimensional longitudinal data.

CONCLUSIONS

Macular OCT imaging is a crucial structural imaging modality for assessing central RGCs. Addressing the current shortcomings in acquisition and analysis of macular volume scans can enhance its utility for measuring the health of central RGCs and therefore assist clinicians with timely institution of appropriate treatment.

Newly Onset Optic Disc Pit Maculopathy (ODP-M) in a Patient With Primary Angle-closure Glaucoma (PACG) After Surgical Iridectomy: A Case Report

Supplemental Digital Content is available in the text.

Optic disc pit maculopathy (ODP-M) is a subtype of ODP, characterized by a serous retinal detachment and/or macular retinoschisis. Currently, ODP and ODP-M pathogenesis remain unknown although many hypotheses exist about their clinical features. In this study, we report a case of new ODP-M detected after surgical iridectomy in a patient with primary angle-closure glaucoma (PACG) with a preoperative normal retina and optic nerve. Fine optic disc and the macular area structures were investigated using several imaging techniques. Findings revealed that the course of ODP and ODP-M provide us with some insights and understanding of their underlying pathogenesis.

Evidence-based understanding of disc hemorrhage in glaucoma

Disc hemorrhage is a characteristic finding that is highly associated with glaucoma development or progression. Consequently, the literature commonly designates disc hemorrhage as a "risk factor" for glaucoma progression; however, the exact cause-and-effect relationship or mechanism remains unclear. In this review, we discuss the emerging evidence that disc hemorrhage is a secondary development that follows glaucomatous damage. As our understanding of disc hemorrhage has progressed in recent decades, we suggest the terminology be changed from "risk factor" to "indicator" of ongoing glaucomatous development or progression for a more accurate description, better indication of the clinical implications and, ultimately, a better guide for future research.

Papillomacular retinoschisis associated with glaucoma: Response to topical carbonic anhydrase inhibitor

Purpose

Observations

Conclusionsand Importance

Case Report: Glaucoma-associated Peripapillary Retinoschisis with Corresponding Lamina Cribrosa Defect

SIGNIFICANCE

Peripapillary retinoschisis is associated with primary and secondary glaucoma. It is important that clinicians are familiar with the presentation and management of peripapillary retinoschisis to understand its effects on the patient's glaucoma and to avoid unnecessary referral when the macula is not involved.

PURPOSE

We present a case of peripapillary retinoschisis found incidentally on routine optical coherence tomographic (OCT) surveillance of primary open-angle glaucoma.

CASE REPORT

A 70-year-old man presented for his annual diabetic eye examination. Surveillance with OCT revealed a splitting of the inner peripapillary retina corresponding to a previously noted notch in the right optic nerve. Further imaging of the right eye using enhanced depth imaging OCT revealed a defect in the lamina cribrosa that may have contributed to the formation and persistence of peripapillary retinoschisis. Retinal nerve fiber layer analysis showed a 5-year history of progressive temporal and inferotemporal thickening in the right eye. The patient was managed conservatively with instruction on regular Amsler grid testing.

CONCLUSIONS

As seen in this case, peripapillary retinoschisis typically alters retinal nerve fiber layer thickness on OCT and can be mistakenly attributed to glaucomatous change. Glaucoma-associated peripapillary retinoschisis is usually not vision threatening and can be managed conservatively; in rare cases of progression to macular involvement, patients should be referred to a retina specialist.

Vitrectomy with peripapillary internal limiting membrane peeling for macular retinoschisis associated with normal-tension glaucoma

Purpose

Although vitrectomy has been reported to be effective for the treatment of macular retinoschisis associated with glaucoma in a few case series, the surgical techniques have yet to be established. This article aimed to describe the cases of two patients with macular retinoschisis who underwent vitrectomy with peripapillary internal limiting membrane peeling around the defective area of the retinal nerve fiber layer.

Observations

Both patients had been diagnosed with normal tension glaucoma and treated with eye drops to stabilize intraocular pressure. Progression of macular retinoschisis and accompanied vision loss were observed in both cases. Twelve months after the surgery, both patients had resolution of the retinoschisis and improvement in best corrected visual acuity.

Conclusions and importance

Our surgical technique may be effective for the resolution of macular retinoschisis in eyes with normal tension glaucoma.

[Papillomacular retinoschisis associated with glaucoma]

Peripapillary and macular retinoschisis is one of the rare manifestations of advanced glaucoma of different types. The article presents a case report and a mini-review. Peripapillary and macular retinoschisis with visual deterioration was diagnosed in a patient with advanced decompensated open-angle glaucoma and pseudoexfoliation syndrome. Surgical treatment of glaucoma led to intraocular pressure normalization, gradual regress of retinoschisis and improvement of visual functions. The retinal structure fully restored 1.5 years after the operation. The observation period was 3 years, retinoschisis did not recur. The article discusses the pathogenesis and potential algorithm for the treatment of the disease. Risk factors for the development of retinoschisis include high intraocular pressure, significant visual field defects and a wide range of diurnal intraocular pressure fluctuations. The source of the intra-retinal fluid is the vitreous body. Management of the patient consists of medical, laser and surgical normalization of intraocular pressure and regular monitoring. In case of persisting retinoschisis, patient undergoes vitreoretinal surgery or barrier laser coagulation. Retinal structure recovers gradually after the intervention and takes on average 1 year.

Peripapillary Retinoschisis in Glaucoma: Association With Progression and OCT Signs of Müller Cell Involvement

Purpose

To examine demographic and clinical factors associated with glaucomatous peripapillary retinoschisis (PPRS) and assess its association with glaucoma progression.

Methods

Using a case control study design and longitudinal data from a cohort of 166 subjects with a diagnosis of glaucoma or glaucoma suspect, we compared functional, structural, clinical, and demographic characteristics between PPRS cases and controls.

Results

The frequency of PPRS was 6.0% (12 eyes from 10/166 subjects) with two eyes having PPRS in different sectors for a total of 15 retinoschisis events. There were no significant differences (P > 0.05) in age, sex, visual acuity, central corneal thickness, intraocular pressure, or presence of vitreous adhesion between PPRS and controls. However, eyes with PPRS tended to have a higher cup-to-disc ratio (P = 0.06), thinner RNFL (P = 0.02), and worse visual field mean deviation (MD, P = 0.06) than controls. The rate of RNFL thinning was faster in PPRS (average: −2.8%/year; range: −7.4% to 0.0%/year) than controls (−1.3%/year; range: −4.4% to 0.6%/year; P = 0.021). The rate of visual field MD change was faster in PPRS (−0.49 dB/year; range: −2.0 to 0.9 dB/year) than controls (−0.06 dB/year; range: −0.8 to 0.3 dB/year; P = 0.030). OCT scans showed hyperreflective structures spanning the PPRS whose morphology and spacing (50 ± 7 μm) are consistent with Müller glia, causing signal attenuation casting “shadows” onto distal retina.

Conclusions

This is the first report showing that glaucomatous PPRS is associated with a faster overall rate of RNFL thinning and visual field deterioration and to specifically identify OCT signs of Müller cell involvement.

A proposed mechanism influencing structural patterns in X-linked retinoschisis and stellate nonhereditary idiopathic foveomacular retinoschisis

OBJECTIVE

To explore the structural differences between X-linked retinoschisis (XLR) and stellate nonhereditary idiopathic foveomacular retinoschisis (SNIFR) using swept-source optical coherence tomography angiography (SS-OCTA).

METHODS

A case series of two patients, a 9-year-old male with XLR and a 58-year-old woman with SNIFR were imaged with swept-source optical coherence tomography angiography (SS-OCTA; PLEX Elite 900, Carl Zeiss Meditec, Inc, Dublin, CA). Automated segmentation was manually adjusted to include the areas of retinoschisis within en face flow and structural slabs. The flow data were binarized using ImageJ 1.51s (Wayne Rasband, National Institutes of Health, USA, http://imagej.nih.gov.ij ) and superimposed onto the structural slab.

RESULTS

In the eye with XLR, OCTA flow data superimposed on the structural slab demonstrated flow signal within numerous bridging structures connecting the inner and outer plexiform layers containing the intermediate (ICP) and deep (DCP) capillary plexuses. In contrast, the same technique applied to the eye with SNIFR demonstrated an absence of flow signal in the cystic retinal spaces within Henle's fiber layer.

CONCLUSIONS

The vascular pattern of bridging vessels between the ICP and DCP is closely related to the structural "retinoschisis" pattern of XLR and appears to be structurally different from that seen in SNIFR. Moreover, the connecting vessels appear to be highly represented and regularly distributed, thereby supporting a serial arrangement of the retinal capillary plexuses within the perifoveal macula.

Macular retinoschisis in eyes with glaucomatous optic neuropathy: Vitrectomy and natural course

PURPOSE

Our purpose was to determine the effectiveness of vitrectomy in resolving the macular retinoschisis in an eye with glaucomatous optic neuropathy and also to determine the natural course of macular retinoschisis.

METHODS

This was a retrospective case series of patients who were diagnosed with macular retinoschisis and glaucomatous optic neuropathy. Fourteen eyes of 13 patients were studied. Patients with high myopia, vitreomacular traction syndrome, and the pit macular syndrome were excluded.

RESULTS

There were three men and ten women, and 12 had unilateral and one had bilateral macular retinoschisis. Vitrectomy was performed for a serous retinal detachment, macular hole, or severe visual loss in five eyes. The mean follow-up time was 68.8 months in these five eyes, and the macular retinoschisis was resolved and the best-corrected visual acuity (BCVA) at the final visit was significantly improved in all eyes (P = 0.007). However, two of these fiv e eyes developed a macular hole and required a second vitrectomy. Of the nine eyes without treatment with a mean follow-up time of 29.0 months, the BCVA at the final visit remained unchanged from the baseline BCVA in all eyes. The macular retinoschisis was resolved or reduced in three eyes without treatment.

CONCLUSIONS

Vitrectomy was effective for the resolution of macular retinoschisis in eyes with glaucomatous optic neuropathy and serous retinal detachment or macular hole or severe reduction of the BCVA. Macular retinoschisis can be resolved without a reduction of the BCVA in some cases without treatment.

Peripapillary retinal splitting visualized on OCT in glaucoma and glaucoma suspect patients

Purpose

To identify the risk factors for development of peripapillary retinal splitting (schisis) in patients with glaucoma or suspicion of glaucoma

Setting

Glaucoma Clinic, Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL

Methods

In this institutional cross-sectional study, 495 patients (990 eyes) who had undergone spectral-domain optical coherence tomography (OCT Spectralis HRA-OCT, Heidelberg Engineering) optic nerve head (ONH) imaging and did not have identifiable optic nerve pits, pseudopits or coloboma were included. OCT scans were reviewed by two observers.

Main outcome measures

Presence of peripapillary retinal splitting identified on OCT raster scans.

Results

Eleven of 990 glaucoma and glaucoma suspect eyes (1.1%) of 7 patients (2 females, 5 males, mean age 64.5 ± 9.2 years) had peripapillary retinal splitting. Two of these 11 eyes had extension of the splitting into the macula but none to the fovea. Of these 11 patients, 2 (28.6%) were glaucoma suspects, 3 (42.9%) had primary open-angle glaucoma, 1 (14.3%) had chronic angle-closure glaucoma and 1 (14.3%) had pigmentary glaucoma. 7/11 (63.6%) eyes had vitreous traction to the disc visualized on OCT and 6/11 eyes (54.5%) had beta-zone peripapillary atrophy.

Conclusions

We observed peripapillary retinal splitting in 1.1% of a series of 990 glaucoma and glaucoma-suspect eyes. Evidence of adherent vitreous with traction and peripapillary atrophy was found in a majority of the involved eyes. A comparison to an age and axial length matched cohort is required to determine if this is a condition that is associated with glaucoma.

Paravascular inner retinal abnormalities in healthy eyes

PURPOSE

To investigate the prevalence and characteristics of paravascular inner retinal abnormalities in healthy eyes.

MATERIALS AND METHODS

In this prospective observational case series, we included 178 healthy eyes (178 patients) with no ocular diseases. Eyes with co-existing ocular diseases, e.g., epiretinal membrane, glaucoma, or high myopia, were excluded from the current study. The posterior pole and paravascular areas of the temporal arcade vessels were comprehensively examined by dense radial scanning of optical coherence tomography (OCT) with the extended field imaging technique.

RESULTS

On fundus photography, no inner retinal abnormalities were detected along the temporal arcade vessels. On OCT sections, paravascular inner retinal abnormalities were seen in 77 (43.3%) eyes. In 71 (39.9%) eyes, inner retinal cystoid or fissure-like spaces that had no connection to the vitreous cavity were seen adjacent to the temporal arcade vessels. Most of these lesions were detected only on several consecutive OCT sections. In four (2.2%) eyes, inner retinal cleavages with openings to the vitreous cavity were seen adjacent to the temporal arcade vessels. These lesions were more frequently detected in the inferior hemisphere and along the major retinal veins. No eyes showed typical broad defects of the inner retinal tissue. There were no significant differences in age, gender, visual acuity, refractive error, or axial length between eyes with or without paravascular inner retinal abnormalities.

CONCLUSIONS

Paravascular cystoid or fissure-like spaces were frequently seen in the inner retina of healthy eyes. However, we detected no typical paravascular inner retinal defects in healthy eyes.

Transient Peripapillary Retinoschisis in Glaucomatous Eyes

Purpose. To investigate transient focal microcystic retinoschisis in glaucomatous eyes in images obtained with several imaging techniques used in daily glaucoma care. Methods. Images of 117 glaucoma patients and 91 healthy subjects participating in a large prospective follow-up study into glaucoma imaging were reviewed. Participants were measured with spectral domain optical coherence tomography (SD-OCT), scanning laser polarimetry (SLP), scanning laser tomography (SLT), and standard automated perimetry (SAP). The presence of a focal retinoschisis in SD-OCT was observed and correlated to SLP, SLT, and SAP measurements, both cross-sectionally and longitudinally. Results. Seven out of 117 glaucoma patients showed a transient, localised, peripapillary, heterogeneous microcystic schisis of the retinal nerve fiber layer (RNFL) and sometimes other retinal layers as well in SD-OCT. None of the healthy eyes showed this phenomenon nor did any of the other imaging techniques display it as detailed and consistently as did the SD-OCT. SAP showed a temporarily decreased focal retinal sensitivity during the retinoschisis and we found no signs of glaucomatous progression related to the retinoschisis. Conclusions. Transient microcystic retinoschisis appears to be associated with glaucomatous wedge defects in the RNFL. It was best observed with SD-OCT and it was absent in healthy eyes. We found no evidence that the retinoschisis predicted glaucomatous progression.

Retinoschisis and neurosensory detachment in advanced focal glaucoma

CLINICAL CASE

A 71-year-old woman with normotensive primary open-angle glaucoma presented with an asymptomatic temporal peripapillary retinoschisis, associated with serous retinal detachment in the eye with the more advanced glaucoma. It was located at the inferior pole of the optic disc, in the proximity of a glaucomatous focal disc defect.

DISCUSSION

Although congenital optic pits are strongly related with juxta-papillary retinoschisis, retinoschisis can also arise from acquired defects in the proximity of glaucomatous optic discs. As symptoms depend on the extent of the retinoschisis, the prevalence of this complication could be greater than that reported in glaucomatous eyes.

Peripapillary schisis in open-angle glaucoma

PurposeTo report clinical features, topographic findings and outcome of 10 eyes with peripapillary schisis in open-angle glaucoma.Patients and methodsA retrospective review of patients with open-angle glaucoma who were noted to have peripapillary schisis on optical coherence tomography (OCT) were included. Serial peripapillary and macula infrared and OCT images, visual acuity, visual fields, and schisis appearance were reviewed.ResultsTen eyes of nine patients with open-angle glaucoma were detected to have the presence of peripapillary schisis. Nerve fibre layer schisis was detected in all eyes and one eye had an associated macular schisis. None of the eyes had an acquired pit of the optic nerve or pathological myopia. The mean intraocular pressures at detection was 18.3±4.3 mm Hg and the schisis resolved in four eyes after a mean follow-up of 21.2±8.8 months. Visual field worsening was noted in 4 of the 10 eyes and the resolution of schisis resulted in significant reduction in the retinal nerve fibre layer (RNFL) thickness.ConclusionsPeripapillary schisis detected during the normal course of open-angle glaucoma can resolve spontaneously and rarely involves the macula. Its resolution leads to reduction in RNFL thickness; therefore, caution is advised while interpreting serial scans.

Defects Along Blood Vessels in Glaucoma Suspects and Patients

PURPOSE

To examine the relationship between small hypodense regions ("holes") in the retinal nerve fiber layer (RNFL) seen on circumpapillary optical coherence tomography (OCT) images of glaucoma patients and suspects and the paravascular inner retinal defects (PIRDs) seen with OCT line scans near blood vessels in individuals without optic nerve disease but with high myopia and/or epiretinal membranes (ERMs).

METHODS

Based upon the availability of wide-field, swept-source OCT scans, 19 eyes from 15 glaucoma patients or suspects were selected from a larger group of eyes with holes on circumpapillary frequency-domain OCT scans. Paravascular defects (PDs) were identified using en face slab images generated (ATL 3D-Suite) from 52-μm slabs just below the vitreal border of the inner limiting membrane by averaging reflective intensity. Paravascular defects were confirmed with B-scans from these images.

RESULTS

For 13 of the 19 eyes, the appearance of the PDs fit the previously described PIRDs and extended well beyond the circumpapillary region. In the other 6 eyes, the PDs were restricted to a small region and did not fit the previously described appearance of PIRDs. In these eyes, the holes were associated with an arcuate defect of the RNFL. Of the 13 with PIRDs, 9 had ERMs and/or high myopia previously associated with PIRDs in otherwise healthy eyes.

CONCLUSIONS

Holes seen on circumpapillary OCT scans of glaucoma patients and suspects are associated with local glaucomatous damage, as well as with PIRDs associated with high myopia and ERMs.

Peripapillary Retinoschisis in Glaucoma Patients

Purpose. To investigate peripapillary retinoschisis and its effect on retinal nerve fiber layer (RNFL) thickness measurements by using spectral-domain optical coherence tomography (SD-OCT) in glaucomatous eyes. Methods. Circumpapillary RNFL (cpRNFL) B-scan images of 940 glaucoma patients (Group 1) and 801 glaucoma-suspect patients (Group 2) obtained by SD-OCT were reviewed. The structural and clinical characteristics of the retinoschisis were investigated. The RNFL thickness measurements taken at the time of retinoschisis diagnosis and at the follow-up visits were also compared. Results. Twenty-nine retinoschisis areas were found in 26 of the 940 glaucoma patients (3.1%) in Group 1 and seven areas were found in 801 patients (0.87%) in Group 2. In glaucomatous eyes, the retinoschisis was attached to the optic disc and overlapped with the RNFL defect. At the time of retinoschisis, the RNFL thickness was statistically greater in the inferior temporal quadrant when compared with the follow-up scans (p < 0.001). No macular involvement or retinal detachment was observed. Conclusion. The present study investigated 33 peripapillary retinoschisis patients. Increase in RNFL thickness measurements was observed at the time of retinoschisis. It is important to examine the cpRNFL B-scan images of glaucoma patients so that the RNFL thickness is not overestimated.

Laser treatment of macular retinoschisis due to acquired optic nerve pit from glaucoma

Macular retinoschisis can be caused by acquired optic nerve pit from glaucoma. This study evaluated the efficacy of laser treatment for this disorder. We report on five eyes from three patients with macular retinoschisis and a history of glaucoma. Spectral domain optical coherence tomography was used for diagnosis and follow-up. Treatment was performed with barrier laser on the temporal margin of the optic nerve. Following treatment, patients' average vision improved by 1 line on the Snellen chart at average follow-up of 12.3 months. All five eyes showed significant improvement in macular retinoschisis. The tracts connecting the optic pit to the retinoschisis completely closed in three eyes and nearly closed in two eyes. These cases demonstrate that laser photocoagulation is an effective treatment of macular retinoschisis from acquired optic nerve pit. It can serve as first-line treatment before more invasive options such as vitrectomy are considered.

The Effect of Peripapillary Detachment on Retinal Nerve Fiber Layer Measurement by Spectral Domain Optical Coherence Tomography in High Myopia

Purpose: The aim of this study was to investigate the repercussions of peripapillary detachment on retinal nerve fiber layer (RNFL) measurements in patients with highly myopic eyes. Methods: A total of 244 highly myopic eyes underwent a complete ophthalmologic examination that included optical coherence tomography (OCT) to analyze the peripapillary retina and RNFL thickness. Based on the OCT findings, patients were grouped as follows: group A: eyes with a peripapillary intrachoroidal cavitation (PIC); group B: eyes with a peripapillary neurosensory retinal detachment (PNRD), and group C: eyes without a peripapillary detachment. Results: The OCT scans identified a peripapillary detachment in 42 eyes (17.21%). Out of these 42 eyes, 22 showed PIC (52.38%; group A) and 20 had a PNRD (47.62%; group B). The average overall RNFL thickness in groups A, B and C was 74.11 ± 10.88, 88.26 ± 25.72 and 72.75 ± 16.24 μm, respectively (ANOVA test, p = 0.00). Conclusion: Eyes with a PNRD had a significantly greater average RFNL thickness than those without peripapillary detachment in pathologic myopia due to a misidentification of the outer profile of the RFNL. This fact makes the interpretation of RNFL thickness in highly myopic eyes more challenging.