RetinaToday, 2007; 4(1): <http://www.retinatoday.org/rt/rt.nsf/url?OpenForm&id=25>
Myopic Macular Schisis – A case for more routine use of OCT
D. Haider, MD; A. Jalil, MD; J. P. Mathews, MD; P. E. Stanga, MD.
Manchester Royal Eye Hospital, Oxford Road, Manchester
The authors have no proprietary interest in any aspect of this manuscript.
Received: May 2007; Published: May 2007.
Correspondence: Mr. Paulo E. Stanga, Consultant Ophthalmologist and Vitreoretinal
Surgeon, Manchester Royal Eye Hospital, Oxford Road, Manchester. Phone: 0161 276
5580; Fax: 0161 272 6618 ; Email: firstname.lastname@example.org
Optical Coherence Tomography (OCT) is increasingly finding popularity in macular disorders. We report a case where OCT was integral in diagnosing macular retinoschisis secondary to vitreous traction in a myopic lady who also had CNV. This case is the first thought to be reported of myopic macular schisis with concurrent CNV. The findings support the more routine use of OCT in myopic patients with reduced central vision, even in the presence of a clinically obvious cause to concomitant pathology.
Key words: Myopia, macular schisis, CNV, Fluorescein angiography, OCT.
A 44 year old highly myopic woman presented
with a 2 week history of metamorphopsia. Visual acuity was 6/9 bilaterally.
Examination revealed an area of macular retinal thickening in the left eye.
A fluorescein angiogram (FFA) revealed a 100% classic juxtafoveal choroidal
neovascular membrane (Figure 1).
Figure1: Red-free fundus
photograph (RF) and Fluorescein angiogram (FFA) at presentation. a. RF
showing an area of retinal thickening with pigmentation. b. 46 seconds.
c. 2minutes 45 seconds. d. 11 minutes. FFA frames revealing a 100% classic
juxtofoveal choroidal neovascular membrane: early hyperfluorescence with
late leakage are present.
Click to enlarge
Photodynamic therapy with Verteporfin® was performed on the left eye. Three
months later, leakage was still present on FFA (Figure 2), therefore a further
treatment of PDT was performed.
Figure2: RF and FFA at
three months after the first PDT session. b. 28 seconds. c. 53 seconds.
d. 11 minutes. Leakage was still present and therefore a further PDT session
was carried out.
Three months later, no leakage was
present on FFA (Figure 3) and visual acuity was Log MAR 0.34 (6/12). At this
stage an OCT scan was performed to confirm absence of leakage.
Figure3: RF and FFA three
months after the second PDT session. a. RF showing increased pigmentation
and better delineation of the neovascular complex suggesting good response
to treatment. b. 17 seconds. c. 27 seconds. d. 11 minutes. Staining of
subretinal fibrosis was present. Optical Coherence Tomography (OCT) scans
were requested to confirm absence of leakage.
This test showed images compatible
with an inactive subretinal neovascular membrane co-existing with macular retinoschisis
(Figure 4). There was no leakage on FFA corresponding with the area of schisis
seen on OCT, differentiating schisis from cystoid macular oedema.
Figure4: OCT 6mm single
line scan image. The presence of fluid leaked by the neovascular complex
was ruled out. Co-existing macular retinoschisis possibly secondary to
traction was shown (hollow arrow). Insert black and white image shows
real time video image demonstrating location and length of the OCT scan.
There was no leakage on FFA corresponding with the area of schisis (intraretinal
low reflectivity – solid arrow) seen on OCT and therefore differentiating
schisis from cystoid macular oedema.
Myopic macular retinoschisis can be
seen on OCT as thickening of the neuroretina in the posterior pole. The condition
was first described by Takano and Kishi using OCT in 1999.1 They found this
type of retinoschisis to be common in high myopia. The pathogenesis is unknown
but is believed to be caused by vitreous traction.1-3
Myopic macular retinoschisis appears to be a progressive condition, especially
in the presence of vitreoretinal traction and might lead to retinal detachment.4
Although opinion remains divided, vitrectomy does appear to be beneficial for
some cases.3 To our knowledge myopic macular retinoschisis has not been described
in combination with a CNVM. The impact of the retinoschisis on visual acuity
in the presence of CNV is not known, though visual acuity in myopic retinoschisis
alone has been shown to vary considerably.2 No surgical intervention is planned
for our patient as the visual acuity is stable and because no large interventional
studies exist confirming the benefits of vitrectomy.
We recommend considering OCT on myopic patients presenting with central vision
problems, even in the presence of visible pathology such as CNV. This would
allow increased detection of otherwise overlooked retinoschisis which may be
a contributing factor to the visual abnormality and may be treatable with vitrectomy.5
Takano M, Kishi
S. Foveal retinoschisis and retinal detachment in severely myopic eyes with
posterior staphyloma. Am J Ophthalmol 1999;128:472-6.
Benhamou N, Massin
P, Haouchine B, Erginay A, Gaudric A. Macular retinoschisis in highly myopic
eyes. Am J Ophthalmol 2002;133:794-800.
Ikuno Y, Tano
Y. Early macular holes with retinoschisis in highly myopic eyes. Am J Ophthalmol
Shimada N, Ohno-Matsui
K, Baba T, Futagami S, Tokoro T, Mochizuki M. Natural course of macular
retinoschisis in highly myopic eyes without macular hole or retinal detachment.
Am J Ophthalmol 2006;142:497-500.
Kanda S, Uemura
A, Sakamoto Y, Kita H. Vitrectomy with internal limiting membrane peeling
for macular retinoschisis and retinal detachment without macular hole in
highly myopic eyes. Am J Ophthalmol 2003;136:177-80.