Optical coherence tomography study of tilted optic disk associated with macular detachment

Factors associated with serous retinal detachment in highly myopic eyes with inferior posterior staphyloma

PURPOSE

To investigate the factors associated with persistent serous retinal detachment in highly myopic eyes with inferior posterior staphyloma.

METHODS

A total of 27 highly myopic patients (44 eyes) with an inferior posterior staphyloma were recruited. Serous retinal detachment was investigated; 13 eyes had persistent sub-macular fluid (study group), and 31 eyes lacked sub-macular fluid (control group). All patients underwent complete ophthalmologic examinations, including axial length measurement and fluorescein angiography (FA). Triton Deep Range Imaging (DRI) optical coherence tomography (OCT) (Topcon Corp., Tokyo, Japan) scans through the fovea measured choroidal thicknesses, macular bend height, and vitreoretinal interface factors.

RESULTS

Of the 44 eyes, 13 had neurosensory retinal detachment and 31 did not. No significant differences were found in any of the studied variables (age, gender, spherical equivalence, axial length, vitreomacular traction, epiretinal membrane, internal limiting membrane detachment), except a higher macular bend height (p = 0.01), and a reduced macular choroidal thickness (p = 0.02), which were associated with the risk of serous retinal detachment. No statistically significant differences in best-corrected visual acuity (BCVA) were observed between the study and control groups. Serous retinal detachment always occurred at the bisected retinal pigment epithelium of the macula corresponding to the upper edge of the staphyloma, and was characterised by multiple hyperfluorescent granular patches on fluorescein angiography.

CONCLUSIONS

A higher macular bend height and a reduced macular choroidal thickness may be important factors in the development of serous retinal detachment in patients with inferior posterior staphyloma.

Outcomes of Anti-vascular Endothelial Growth Factor Treatment for Foveal Serous Retinal Detachment Associated with Inferior Staphyloma

PURPOSE

To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) treatment of eyes with foveal serous retinal detachment (SRD) associated with inferior staphyloma and to investigate choroidal thickness changes following anti-VEGF therapy.

METHODS

In this observational case series, eyes with inferior staphyloma accompanied by foveal SRD were treated with a single intravitreal anti-VEGF injection, followed by further injections as needed. Changes in height and width of subretinal fluid (SRF) and visual acuity after treatment were assessed. Choroidal thickness was measured at the subfovea, 1.5 mm superior and inferior to the fovea using enhanced depth imaging optical coherence tomography at baseline and 1 month after initial anti-VEGF therapy.

RESULTS

Six eyes from six patients were included. One month after the initial injection, the mean SRF height and width had decreased significantly from 112.5 ± 40.1 to 44.5 ± 48.7 μm (p = 0.046) and from 1,401.8 ± 627.3 to 690.7 ± 634.7 μm (p = 0.028), respectively. Mean choroidal thickness at the superior point decreased from 218.7 ± 59.3 to 200.5 ± 61.0 μm (p = 0.046). SRF resolved completely in three of the six eyes (50%) with a mean of 6.8 ± 5.9 injections (range, 1 to 15). All eyes experienced at least one recurrence of exudation, at a mean interval of 4.8 months. Mean visual acuity improvement was 0.17 logarithm of the minimum angle of resolution units at a mean of 28.7 months follow-up.

CONCLUSIONS

Anti-VEGF therapy resulted in an SRF decrease and modest visual improvement in eyes with foveal SRD associated with inferior staphyloma. Reduction in superior choroidal thickness appeared to contribute to the clinical improvements that were observed.

Bilateral Serous Retinal Detachment Associated with Inferior Posterior Staphyloma Treated with Scleral Shortening and Vitrectomy

Purpose

We report a case of bilateral serous retinal detachment (SRD) associated with inferior posterior staphyloma (IPS) treated successfully with scleral shortening.

Patient and Methods

A 63-year-old woman presented with bilateral visual loss due to an SRD with IPS. The best-corrected visual acuity levels were 0.6 (20/30) and 0.5 (20/40) in the right and left eye, respectively. The patient underwent vitrectomy and scleral shortening in the right eye. The lamellar scleral crescent was resected 4 mm in width from the 5- to 8-o'clock positions. Seven interrupted 5-0 polyester sutures were placed at the edge of the lamellar scleral crescent. After 25-gauge three-port vitrectomy, the sutures were tightened. Optical coherence tomography showed decreased curvature at the staphyloma border. The choroidal thickness decreased in the superior flat portion of the fundus and increased slightly in the staphyloma. The SRD resolved 3 months postoperatively. The best-corrected visual acuity in the right eye improved to 0.8 (20/25) 6 months postoperatively. Angiography 6 months postoperatively showed decreased diffuse dye leakage at the fovea in the right eye; indocyanine green angiography did not show marked changes.

Discussion

Scleral shortening with vitrectomy changes the eye wall shape, may improve the retinal pigment epithelial integrity, and may be a treatment option for SRD with IPS

Choroidal thickness in eyes with tilted disk syndrome

PURPOSE

To investigate the choroidal thickness in eyes with tilted disk syndrome within/without posterior staphyloma.

METHODS

Twenty-one eyes examined in 16 patients with tilted disk syndrome were included. The thicknesses of the choriocapillaris, the medium-to-large choroidal vessels, and total choroids found 1 mm and 3 mm superior and inferior to the fovea and in the area with the thinnest choroid were measured using enhanced-depth imaging optical coherence tomography or high-penetration optical coherence tomography. The results were compared with the findings on indocyanine green angiography.

RESULTS

The mean thicknesses of total choroid found 3 mm and 1 mm inferior (114.3 μm ± 77.8 μm, 145.0 μm ± 85.9 μm) to the fovea were significantly thinner than those found superior (174.5 μm ± 89.7 μm, 145.0 μm ± 85.9 μm) to it. The minimal choroidal thickness of 80.5 μm ± 67.1 μm was obtained at a mean 1.04 mm below the fovea at the upper edge of the posterior staphyloma. The thickness of the layer of choriocapillaris was not significantly different according to the regions but the layer of medium-to-large choroidal vessels found 3 mm and 1 mm inferior to the fovea was significantly thinner than that found superior to the fovea. The ratio of choriocapillaris to medium-to-large vessels found 1 mm superior also was significantly smaller than those found inferior. The diameter of medium-to-large choroidal vessels on ICGA was not significantly different in the areas although less number of vessels were seen around the area inferior to the fovea.

CONCLUSION

In the eyes of patients with tilted disk syndrome, the choroid is thinnest at approximately 1 mm inferior to the fovea at the upper edge of the posterior staphyloma rather than at the bottom of the posterior staphyloma. Thinning of the layer of medium-to-large choroidal vessels seems to be associated with the thinning of choroid thickness.

Tilted optic disks

Tilted optic disks are a common finding in the general population. An expression of anomalous human development, the tilted disk appears rotated and tilted along its axes. Visual sequelae described with tilted optic disks include myopia, astigmatism, visual field loss, deficient color vision, and retinal abnormalities. Although the natural course of tilted optic disks is nonprogressive, the anomaly can be mistaken for tumors of the anterior visual pathway, edema of the optic nerve head, or glaucoma. A thorough examination of patients with tilted disk includes refraction, dilated fundus examination, and visual field testing. At times, neuroimaging may be necessary to arrive at the correct diagnosis. Until normative data are validated for tilted disks, the role of new imaging technologies for the optic nerve head is limited. Familiarity with the spectrum of ophthalmoscopic appearance and the clinical manifestations of tilted disks may be the most critical factors in avoiding misdiagnosis.

Polypoidal choroidal vasculopathy in tilted disk syndrome and high myopia with staphyloma

PURPOSE

To describe polypoidal choroidal vasculopathy as a complication of tilted disk syndrome and high myopia with staphyloma.

DESIGN

Retrospective interventional case series.

METHODS

This report was a multicenter evaluation of six patients (eight eyes) with tilted disk syndrome or high myopia that was complicated by posterior staphyloma. Complete ophthalmic examination that included fluorescein angiography, optical coherence tomography (OCT), and indocyanine green angiography (ICG-A) was performed in all patients.

RESULTS

All patients had macular abnormalities and visual loss. Fundus examination and fluorescein angiography showed typical features of tilted disk syndrome (five patients; six eyes) or high myopia (one patient; two eyes) with staphyloma that was associated with polypoidal choroidal vasculopathy. OCT and ICG-A confirmed the presence of polypoidal dilations in the choroid. Seven eyes were treated with laser photocoagulation or verteporfin-photodynamic therapy (V-PDT), although one eye did not require treatment. Visual acuity at the final visit had improved in three eyes, deteriorated in three eyes, and remained unchanged in two eyes.

CONCLUSION

Polypoidal choroidal vasculopathy is a potential cause of visual loss in tilted disk syndrome and high myopia. We postulate that choroidal abnormalities at the border of staphylomas induce blood-flow disturbances that are similar to those disturbances that are observed in chronic central serous chorioretinopathy, which is another condition that occasionally is associated with polypoidal choroidal vasculopathy. The pathogenesis remains unclear, and further study is required to better understand the formation of choroidal polypoidal dilations in these conditions.