Serous macular detachment associated with dome-shaped macula and tilted disc

Evaluating the microcirculation of the dome-shaped macula and its complications in adults with highly myopic eyes by swept-source optical coherence tomography angiography

PURPOSE

The aim of this study was to investigate the microcirculatory characteristics of the dome-shaped macula (DSM), its complications in highly myopic eyes and to explore the factors associated with a DSM.

METHODS

This cross-sectional case-control study included a total of 98 subjects (98 eyes): 49 eyes with DSM and 49 eyes without DSM. The axial length (AL) of the myopic eyes was matched 1:1 to eliminate the effect of AL differences on the results. Choroidal (CT) and scleral thickness (ST) and other structural parameters were assessed by swept-source optical coherence tomography (SS-OCT). OCT angiography was used to measure microcirculatory parameters in highly myopic eyes.

RESULTS

Subjects with DSM had thinner subfoveal choroidal thickness (46.01 ± 13.25 vs. 81.62 ± 48.26 μm; p < 0.001), thicker subfoveal scleral thickness (SFST; 331.93 ± 79.87 vs. 238.74 ± 70.96 μm; p < 0.001) and thinner foveal CT (66.86 ± 24.65 vs. 107.85 ± 52.65 μm; p < 0.001) compared to subjects without DSM. The foveal choroidal perfusion area (0.72 ± 0.04 vs. 0.76 ± 0.04 mm2; p < 0.001) and foveal choroidal vascularity index (0.15 ± 0.04 vs. 0.33 ± 0.14; p < 0.001) were significantly lower in eyes with DSM. Retinoschisis (81.6% vs. 38.8%; p < 0.001) was more common in eyes with DSM. Eyes with horizontal DSM had worse best-corrected logMAR visual acuity than eyes with round DSM (0.34 ± 0.22 vs. 0.23 ± 0.22; p = 0.03). DSM height (98.95 ± 65.17 vs. 104.63 ± 44.62 μm; p = 0.05) was lower in the horizontal DSM. SFST (OR = 1.06, p = 0.04) and foveal choroidal vascularity index (OR = 0.711, p = 0.02) were significantly associated with DSM. DSM width (p < 0.001), foveal choroidal perfusion area (p = 0.01), foveal choriocapillaris perfusion area (p = 0.02) and parafoveal choroidal vascularity index (p = 0.03) were the most significantly associated factors with DSM height.

CONCLUSIONS

The microcirculatory characteristics of eyes with DSM differed from those without DSM. Microcirculatory abnormalities were significantly associated with a DSM. The height of the DSM was associated with decreased blood perfusion.

Prevalence of Dome-Shaped Macula and Tilted Disc Syndrome in High Myopia

BACKGROUND AND OBJECTIVE

Dome-shaped macula (DSM) and tilted disc syndrome (TDS) are two macular abnormalities that may occur in eyes with high myopia. The aim of this study was to determine the prevalence of both entities in our population.

PATIENTS AND METHODS

This was a prospective and observational study. Optical coherence tomography of the macula was performed in eyes with high myopia (spherical equivalent [SE] of -8D or greater) to assess the prevalence of DSM and TDS.

RESULTS

Sixty-eight eyes were included. Three eyes (4.41%) had DSM and 8 (11.76%) eyes had TDS. The most common macular anomaly was posterior staphyloma (PS) (12 [17.65%]). From the eyes with DSM (n = 3), only two presented PS. An older age and a higher SE were predisposing factors for PS (P = 0.003).

CONCLUSIONS

A lower prevalence of DSM and a higher prevalence of TDS was observed in our population compared to those reported in literature. [Ophthalmic Surg Lasers Imaging Retina 2023;54:568-572.].

Tilted disc syndrome (TDS): New hypotheses for posterior segment complications and their implications in other retinal diseases

Tilted disc syndrome (TDS) is considered a congenital anomaly due to a delayed closure of the embryonic fissure. It is characterized by an oblique orientation of the axis of the optic disc, associated with other posterior pole anomalies such as inferior crescent, situs inversus and inferior staphyloma. The aim of this review was to summarize the data supporting the current hypotheses for the pathogenesis of TDS, and its anatomical and functional clinical consequences. Recent imaging techniques, such as magnetic resonance imaging, wide-field fundus imaging, and 2- and 3-D optical coherence tomography have provided a new perspective on TDS and its complications. Different abnormalities have previously been reported, both in the anterior and posterior segments. The focus was on vision-threatening chorioretinal changes or complications, including choroidal neovascularization and serous retinal detachments and their therapeutic options. Based on clinical observations, assumptions were proposed to understand the occurrence of complications such as chorioretinal degenerative changes, choroidal neovascularization and polypoidal choroidal vasculopathy, macular serous retinal detachment, myopic foveoschisis and chorioretinal folds. These hypotheses could be referred to as the curvature "breaking point" hypothesis, the uneven growth "tractional" hypothesis, the "container-content" imbalance hypothesis, and the "choroidal funnel" hypothesis. Because these complications could also occur in other contexts, understanding the pathogenesis of TDS complications could help to understand their pathophysiology.

IMI Pathologic Myopia

Pathologic myopia is a major cause of visual impairment worldwide. Pathologic myopia is distinctly different from high myopia. High myopia is a high degree of myopic refractive error, whereas pathologic myopia is defined by a presence of typical complications in the fundus (posterior staphyloma or myopic maculopathy equal to or more serious than diffuse choroidal atrophy). Pathologic myopia often occurs in eyes with high myopia, however its complications especially posterior staphyloma can also occur in eyes without high myopia.

Owing to a recent advance in ocular imaging, an objective and accurate diagnosis of pathologic myopia has become possible. Especially, optical coherence tomography has revealed novel lesions like dome-shaped macula and myopic traction maculopathy. Wide-field optical coherence tomography has succeeded in visualizing the entire extent of large staphylomas. The effectiveness of new therapies for complications have been shown, such as anti-VEGF therapies for myopic macular neovascularization and vitreoretinal surgery for myopic traction maculopathy.

Myopia, especially childhood myopia, has been increasing rapidly in the world. In parallel with an increase in myopia, the prevalence of high myopia has also been increasing. However, it remains unclear whether or not pathologic myopia will increase in parallel with an increase of myopia itself. In addition, it has remained unclear whether genes responsible for pathologic myopia are the same as those for myopia in general, or whether pathologic myopia is genetically different from other myopia.

Resolution of bilateral foveal cysts in dome-shaped macula after treatment with topical dorzolamide

Dome-shaped macula (DSM) is characterised by a convex anterior bulging of the macular area. It can further get complicated by accumulation of subretinal fluid (SRF). Foveal cysts that are bilateral, in a setting of DSM, are an entity not yet reported. Management options for DSM with SRF showed variable success. Topical carbonic anhydrase inhibitors (CAIs) have been successful in treating certain macular pathologies. The authors report a rare case of bilateral intraretinal foveal cyst in a myopic child with DSM with favourable response to topical dorzolamide. Topical CAIs may be considered a safe and effective option in such cases.

Structural profile of dome-shaped macula in degenerative myopia and its association with macular disorders

Background

To evaluate the detailed structural profile of dome-shaped macula and its association with myopic macular complications.

Methods

This retrospective study included 147 eyes of 93 patients who were diagnosed with degenerative myopia. The height of the scleral dome and diameter of the dome base were measured via enhanced depth imaging optical coherence tomography images with 1:1 μm setting. Spherical equivalent and best-corrected visual acuity were compared in eyes with and without dome-shaped macula. In eyes with dome-shaped macula, the height and diameter of the dome were compared in eyes with and without myopic macular complications including choroidal neovascularization, myopic foveoschisis, and macular hole.

Results

Dome-shaped macula was noted in 60 eyes (40.8%) of 42 patients. The mean height of the dome in the eyes with dome-shaped macula was 126.5 ± 69.4 μm (53 to 345 μm) and the mean diameter of the dome base was 2862.1 ± 794.9 μm (1567 μm to 4886 μm). In comparing eyes with and without dome-shaped macula, eyes with dome-shaped macula had higher myopia (− 13.7 diopters vs − 12.1 diopters, P = 0.022). There was no difference in visual acuity in eyes with or without dome-shaped macula (P = 0.132). The height and diameter of the dome in eyes with and without myopic foveoschisis were 78.6 ± 20.6 μm and 134.9 ± 71.6 μm, 2499.2 ± 303.1 μm and 2969.3 ± 645.7 μm, respectively (P = 0.009 and P = 0.017). However, the height and diameter of the dome were not related to the incidence of a macular hole (P = 0.324 and P = 0.605) and choroidal neovascularization (P = 0.835 and P = 0.905).

Conclusions

The prevalence of dome-shaped macula was about 40% in the eyes with degenerative myopia. Although dome-shaped macula was associated with higher degrees of myopia, a prominent dome seemed to be protective against myopic foveoschisis.

Effective Intravitreal Injections of Bevacizumab in a Case of Serous Macular Detachment from the Superior Border of the Posterior Staphyloma

Purpose

We present an atypical case of submacular fluid leading to serous macular detachment.

Method/Patient

A 69-year-old man was evaluated for metamorphopsia in the left eye.

Results

Best-corrected visual acuity was 20/25 in both eyes. He had undergone cataract surgeries in both eyes 12 years ago. The axial length was 25.93 mm (OD) and 24.12 mm (OS). Optical coherence tomography showed posterior staphylomas and subretinal fluid on the superior border of the staphylomas in both eyes; in the left eye, submacular fluid was noted extending up to the macula. Fundus fluorescein angiography revealed leakage from the superior border of the staphylomas in both eyes. The fluid persisted for 4 months. Four consecutive, monthly injections of bevacizumab (1.25 mg/0.05 mL) were administered in the left eye; subsequently, the subretinal fluid gradually dissipated from the macula and became localized at the superior border of the staphyloma. This localization persisted for 12 months.

Conclusions

We have detailed a case of submacular fluid that spread from the superior border of the posterior staphyloma in a patient with macular detachment, in whom intravitreal injections of bevacizumab were highly effective in eliminating the fluid.

Serous Retinal Detachment Associated with Dome-Shaped Macula and Staphyloma Edge in Myopic Patients before and after Treatment with Spironolactone

Objective. Serous retinal detachment (SRD) is a common anatomical complication associated with dome-shaped macula (DSM) and staphyloma margin in myopic patients. Here we described the anatomical and functional outcomes obtained with the use of oral spironolactone, a mineralocorticoid antagonist, in the management of myopic patients with SRD associated with DSM and staphyloma margin. Methods. We evaluated both eyes of twelve myopic patients with long-standing SRD associated with DSM or staphyloma margin. The patients were treated daily for six months with oral spironolactone 50 mg. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT), determined by optical coherence tomography, were evaluated on the first day and on monthly follow-up visits. Results. Pretreatment BCVA (mean ± standard deviation) was 0.406 ± 0.324 LogMAR, and posttreatment BCVA was 0.421 ± 0.354 LogMAR (P = 0.489). Pretreatment CRT was 323.9 ± 78.6 μm, and after six months of treatment it was significantly lower, 291.2 ± 74.5 μm (P = 0.010). There were no treatment-related complications. Conclusions. We evaluated a novel treatment for SRD associated with DSM and staphyloma margin in myopic patients. After six months of treatment with the mineralocorticoid antagonist spironolactone, the subretinal fluid and CRT were significantly reduced; however, there was no improvement in BCVA.

Dome-Shaped Macula Associated with Best Vitelliform Macular Dystrophy

Purpose

Dome-shaped macula (DSM) has been described recently as an inward convexity of the macula typical of myopic eyes detectable on spectral-domain optical coherence tomography (SD-OCT). The authors describe a case of monolateral DSM associated with Best vitelliform macular dystrophy (VMD).

Methods

Case report.

Results

A 60-year-old man already diagnosed with VMD in vitelliruptive stage underwent SD-OCT that revealed the typical vitelliform material accumulation associated in the left eye with a convex elevation of the macula. No change was registered over a 1-year follow-up.

Conclusions

This is the first report describing a monolateral DSM associated with VMD. Dome-shaped macula could be considered as a nonspecific scleral alteration, probably due to increased scleral thickness, which can accompany many retinal disorders.

Resolution of foveal detachment in dome-shaped macula after treatment by spironolactone: report of two cases and mini-review of the literature

Dome-shaped macula (DSM) was recently described in myopic patients as a convex protrusion of the macula within a posterior pole staphyloma. The pathogenesis of DSM and the development of associated serous foveal detachment (SFD) remain unclear. The obstruction of choroidal outflow and compressive changes of choroidal capillaries have been proposed as causative factors. In this paper, we report two cases of patients with chronic SFD associated with DSM treated with oral spironolactone. After treatment, there was a complete resolution of SFD in both patients. To the best of our knowledge, this is the first report of successful treatment of SFD in DSM by a mineralocorticoid receptor antagonist.

Proposed classification of posterior staphylomas based on analyses of eye shape by three-dimensional magnetic resonance imaging and wide-field fundus imaging

PURPOSE

To determine the incidence and types of posterior staphylomas in eyes with pathologic myopia by analyzing the entire eye shape by 3-dimensional (3D) magnetic resonance imaging (MRI).

DESIGN

Observational, case series.

PARTICIPANTS

A total of 105 patients with pathologic myopia (spherical equivalent <-8.0 diopters or axial length ≥26.5 mm) were examined by 3D MRI and Optos (Optos, PLC, Dunfermline, Scotland).

METHODS

Staphyloma was defined as an outpouching of the wall of the eye that had a radius of curvature less than the surrounding curvature of the wall of the eye. The presence and types of staphylomas were determined by the entire eye shape in 3D MRI scans. Fundus abnormalities suggesting the staphyloma border were analyzed in the fundus images, fundus autofluorescence images, and infrared images by Optos.

MAIN OUTCOME MEASURES

Incidence and types of posterior staphylomas, and the correlation between the type of staphyloma by MRI and the Optos images.

RESULTS

A total of 198 eyes (105 patients) met the inclusion criteria of pathologic myopia (mean age, 64.3±11.5 years; mean axial length, 30.0±2.3 mm). Among 198 eyes, 98 (49.5%) had no staphylomas in 3D MRI scans and showed a barrel-shaped globe. The other 100 eyes (50.5%) had posterior staphyloma by 3D MRI. The most predominant type was wide, macular staphyloma (74% of eyes with staphyloma), followed by narrow, macular staphyloma (14% of eyes with staphyloma). In eyes with peripapillary and nasal staphylomas, the change of the curvature was slight and the eye had a nasally distorted shape. Optos images showed pigmentary abnormalities or abnormal reflectance along the staphyloma border. The patients with staphylomas were significantly older and had significantly worse visual function and more frequent chorioretinal changes than patients without staphyloma.

CONCLUSIONS

Three-dimensional MRI was useful in analyzing the shape of eyes with and without staphyloma. Even in elderly individuals with severe myopia, approximately one half of the patients did not show clear outpouching suggesting staphyloma. Correlating the MRI data to Optos images provided useful information on the relationship between the eye shape and the fundus appearances in the Optos images.

Analyses of shape of eyes and structure of optic nerves in eyes with tilted disc syndrome by swept-source optical coherence tomography and three-dimensional magnetic resonance imaging

PURPOSE

To evaluate the deeper structures of the optic nerve and to analyze the shape of eyes with tilted disc syndrome (TDS) by swept-source optical coherence tomography (OCT) and three-dimensional magnetic resonance imaging (3D MRI).

METHODS

The medical records of 54 eyes of 36 patients with TDS were reviewed. The patients with TDS and high myopia were analyzed separately from those without high myopia. All the eyes were examined with a swept-source OCT, and 22 of the eyes were examined by 3D MRI.

RESULTS

A total of 38 eyes of 29 patients were highly myopic and 16 eyes of 15 patients were not highly myopic. The representative OCT findings of the optic disc were: a sloping of the lamina cribrosa posteriorly from the upper part to the lower part, a protrusion of the upper edge of Bruch's membrane, and choroid. The distance and the depth of the most protruded point from the fovea were significantly greater in the eyes with non-highly myopic TDS than those with highly myopic TDS. In the 3D MRI, the lower part of the posterior segment was protruded outward, and the optic nerves attached at the upper nasal edge of the protrusion.

CONCLUSIONS

The abnormalities detected by swept-source OCT and 3D MRI analyses indicate the possibility that the essential pathology of TDS is a deformity of the inferior globe below the optic nerve, and the positional relation between the fovea and the inferior protrusion determines the degree of myopia.