Bilateral macular holes in X-linked retinoschisis: now the spectrum is wider

Typical and atypical clinical presentations of X-Linked retinoschisis: A case series and literature review

X-linked retinoschisis (XLRS) is an X-linked inherited retinal dystrophy characterized by mild-to-severe visual impairment, splitting of the retinal layers, and a reduction in the dark-adapted b-wave amplitude on the electroretinogram. Typical clinical features include macular and peripheral schisis. Relatively common features reported include rhegmatogenous or tractional retinal detachment, vitreous hemorrhage, retinal pigment epithelial changes, vitreous veils, and various retinal vascular abnormalities with or without exudation. Macular hole and macular folds are atypical presentations of XLRS, along with several other rare findings. Here, we report 4 cases of XLRS with atypical clinical presentations and review the literature on XLRS, with a focus on the variable clinical features of this condition.

MACULAR HOLE-RELATED RETINAL DETACHMENT COMPLICATING AUTOSOMAL RECESSIVE BESTROPHINOPATHY: CLINICAL FEATURES, MULTIMODAL IMAGING, AND SURGICAL OUTCOME

PURPOSE

To report a case of full-thickness macular-hole related retinal detachment in a patient with autosomal recessive bestrophinopathy.

METHODS

A 3-year-old boy presented for squint assessment. In the examination, there were typical features of autosomal recessive bestrophinopathy in the left eye and a macular hole-related retinal detachment in his right eye. Color fundus photography, autofluorescence, fundus fluorescence angiography, and spectral-domain optical coherence tomography were recorded.

RESULTS

Optical coherence tomography of the right eye showed a full-thickness macular hole retinal detachment. The retina showed retinoschisis affecting the inner and outer nuclear layer at the fovea and parafoveal region. Also, hyperreflective dots were seen at the hole and on the inner retinal surface. The left eye showed subretinal fluid with stalactite-like extensions into the subretinal space, and hyperreflective material seen above the retinal pigment epithelium. Fundus autofluorescence showed hyperautofluorescence at the fovea of the right eye and punctate hyperautofluorescent spots in the mid-periphery of the left eye. After pars plana vitrectomy and temporal internal limiting membrane flap, the hole was closed and all the schitic cavities collapsed at the sixth-week follow-up visit.

CONCLUSION

A full-thickness macular hole-related retinal detachment can develop in autosomal recessive bestrophinopathy in the pediatric age group. Pars plana vitrectomy with temporal internal limiting membrane flap may be helpful for successful surgical repair.

A Female Case of X-Linked Retinoschisis with Macular Hole Bilaterally

Purpose

We aimed at reminding that X-linked retinoschisis may also be seen in female patients and share our vitreoretinal surgical experience.

Methods

The patient underwent pars plana vitrectomy including the closure of the macular holes with inverted ILM flap technique bilaterally. Lens extractions were performed by phacoemulsification during the removal of silicone oil endotamponade. Patient. An 18-year-old girl with X-linked retinoschisis and large macular holes in both eyes presented to the clinic of ophthalmology. It was confirmed that the patient had RS1 mutation

Results

Nine-month-follow-up was uneventful for retinal findings. Significant improvement in visual acuity was achieved, and macular holes were remained closed.

Conclusion

In cases with large macular holes due to XLR, an inverted ILM flap technique might be safe and effective. Four-month-silicone-endotamponade might be sufficient.

ATYPICAL MACULAR HOLES

PURPOSE

To study the etiology, clinical features, management options, and visual prognosis in various types of atypical macular holes (MHs).

METHODS

A review of the literature was performed, which focused on the etiopathogenesis of atypical or secondary MHs, their differentiating clinical features, management strategies, and varied clinical outcomes. Idiopathic or age-related, myopic, and traumatic MHs were excluded.

RESULTS

Atypical or secondary MHs arise out of concurrent ocular pathologies (dystrophy, degeneration, or infections) and laser/surgery. The contributing factors may be similar to those responsible for idiopathic or typical MHs, i.e., tangential or anteroposterior vitreofoveal traction or cystoid degeneration. The management is either observation or treatment of the underlying cause. The prognosis depends on the background pathology, duration of disease, and baseline visual acuity governed by the size of MH and morphologic health of underlying RPE and photoreceptors. The closer the morphology of atypical MH is to that of an idiopathic MH, the better the surgical outcome is.

CONCLUSION

With the advancements in retinal imaging, atypical MHs are now more frequently recognized. With increasing understanding of the underlying disease processes, and improvement in investigations and surgical treatment, management of atypical MHs may improve in the future.

Etiologies, Characteristics, and Management of Pediatric Macular Hole

PURPOSE

To report on the etiologies and prognosis of macular hole (MH) in children and to explore the indicators of spontaneous hole closure and poor final visual outcome (vision worse than 20/200).

DESIGN

Consecutive, retrospective case series.

METHODS

A consecutive series of patients aged less than 16 years with a full-thickness macular hole treated from 2013 to 2019 in a singer tertiary center was retrospectively reviewed. Data collected from charts included age, sex, best-corrected visual acuity (BCVA), etiology of MH, size of MH, clinical findings, operations, and anatomic and functional outcomes. Logistic regression models were built to establish the predisposing factors.

RESULTS

Forty eyes of 40 patients were included. Patients were predominantly male with a mean age of 8.3 years. Among the etiologies, trauma prevailed in 29 (72.5%) eyes. Twenty-nine patients underwent surgery, and 18 (62.1%) had traumatic MH. All had achieved hole closure. BCVA improved at the final visit. Spontaneous closure was found in 10 (25%) eyes after an average 2 months after trauma. Regression analysis showed that a relatively smaller macular hole (P = .006) was likely to experience spontaneous closure. Presence of macular lesions (P = .001) was identified as risk factor for poor final vision.

CONCLUSIONS

Most pediatric MH was caused by blunt trauma. BCVA improved after MH closed, regardless of surgery or spontaneous closure. Smaller MH secondary to trauma was more likely to experience spontaneous closure with an average time of 2 months. Presence of macular lesions was a risk factor for final poor vision.

Phenotypic characterization of X-linked retinoschisis: Clinical, electroretinography, and optical coherence tomography variables

Aims:

To study the phenotypic characteristics of X-linked retinoschisis (XLRS) and report the clinical, electroretinogram (ERG), and optical coherence tomography (OCT) variables in Indian eyes.

Design:

A retrospective study.

Materials and Methods:

Medical records of 21 patients with retinoschisis who were genetically confirmed to have RS1 mutation were reviewed. The phenotype characterization included the age of onset, best-corrected visual acuity, refractive error, fundus findings, OCT, and ERG.

Statistical Analysis Used:

Data from both the eyes were used for analysis. A P < 0.05 was set as statistical significance. Data were not normally distributed (P < 0.05, Shapiro wilk); hence, nonparametric tests were used for statistical analysis.

Results:

All were males whose mean age of presentation was 9 years. Visual acuity was moderately impaired (median 0.6 logMAR, interquartile range: 0.47, 1) in these eyes with a hyperopic refractive error of median +1.75 Ds (interquartile range: +0.50 Ds, +4.25 Ds). About 54.7% of the eyes had both foveal and peripheral schisis, isolated foveal schisis was seen in 28.5% of the eyes, and schisis with retinal detachment was seen in 16.6% of the eyes. The inner nuclear layer was found to be commonly involved in the schisis, followed by outer nuclear and plexiform layers as evident on OCT. On ERG, a- and b-wave amplitudes were significantly reduced in eyes with foveal and peripheral schisis when compared to the eyes with only foveal schisis (P < 0.05).

Conclusions:

XLRS has phenotypic heterogeneity as evident on OCT, ERG, and clinical findings.

SURGICAL TREATMENT OF A MACULAR HOLE IN X-LINKED RETINOSCHISIS

PURPOSE

To report a case of full-thickness macular hole in a patient with X-linked retinoschisis and the outcome after surgical repair.

METHODS

A 15-year-old boy with a history of X-linked retinoschisis presented to his ophthalmologist for routine follow-up and was found to have a Stage-3 macular hole in his left eye. His vision was 20/200. The patient underwent pars plana vitrectomy and internal limiting membrane peeling, and he received long-acting gas. Color fundus photography and spectral domain optical coherence tomography (Cirrus; Carl Zeiss Meditech Inc, Dublin, CA) recorded images at office visits, before and after surgical repair.

RESULTS

The initial spectral domain optical coherence tomography of the left eye showed a full-thickness macular hole of 1,370 μm in diameter as well as schisis cavities in the macula. After pars plana vitrectomy and repeat fluid-gas exchange, the hole was closed at the sixth-week follow-up visit. The patient noted a subjective decrease in the size of a central scotoma. Best-corrected visual acuity returned to the baseline of 20/80.

CONCLUSION

A large full-thickness macular hole can develop in X-linked retinoschisis, and pars plana vitrectomy with internal limiting membrane peeling may be helpful for successful surgical closure.

Lamellar macular hole in X linked retinoschisis

X linked retinoschisis (XLRS) is the most common juvenile onset retinal degeneration. The disorder leads to poor vision in old age. Complications, however, can lead to earlier loss of vision in this condition. This report describes two patients of XLRS, who had presented with poor vision because of having had a lamellar macular hole at a young age. Lamellar macular holes are rare and have never been reported to cause early onset poor vision in XLRS.

Macular hole in juvenile X-linked retinoschisis

An 18 year-old male with no antecedent of trauma, systemic syndrome or myopia was referred for surgical treatment of a full thickness macular hole in the left eye. A more careful inspection revealed discrete foveal cystic changes in the fellow eye and subtle peripheral depigmented retinal pigment epithelial changes in both eyes. A spectral-domain optical coherence tomography (SD-OCT) scan confirmed, in addition to the full thickness macular hole in the left eye, microcystic spaces in the nuclear layers of both retinae. The diagnosis of X-linked retinoschisis was confirmed with a full field electroretinogram displaying the typical negative ERG. Macular holes are uncommon in the young and those complicating X-linked retinoschisis are rare. This report highlights the importance of investigating the presence of a macular hole in a young patient and illustrates the clinical and SD-OCT clues beyond the foveal center which led to the correct diagnosis of X-linked juvenile retinoschisis.