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Spontaneous resolution of optic disc pit maculopathy after posterior vitreous detachment

      We report the case of a 57-year-old male with optic pit maculopathy that spontaneously resolved after posterior vitreous detachment (PVD). Progressive improvements in visual acuity, clinical examination, and spectral-domain optical coherence tomography (SD-OCT) occurred over 3 months. The pathophysiology of optic pit maculopathy has yet to be completely elucidated. This case report lends additional support to the theory that the vitreous and its attachments at the optic nerve head play a critical role in the development of optic disc pit (OPD) maculopathy (ODP-M), and that the PVD may play a critical role in its treatment.
      The prevalence of ODPs is approximately 1 in 11000 persons. Approximately 25% to 75% of eyes will develop a secondary maculopathy, most commonly in early adulthood.
      • Georgalas I.
      • Ladas I.
      • Georgopoulos G.
      • Petrou P.
      Optic disc pit: a review.
      Spontaneous resolution of ODP-M has been reported in approximately 25% of cases, although often with a poor visual outcome.
      • Georgalas I.
      • Ladas I.
      • Georgopoulos G.
      • Petrou P.
      Optic disc pit: a review.
      The exact pathogenesis of ODP-M has yet to be clearly elucidated, but a multitude of treatment options have been proposed over the years, with varying degrees of success.
      • Jain N.
      • Johnson M.W.
      Pathogenesis and treatment of maculopathy associated with cavitary optic disc anomalies.
      Many authors have postulated that the vitreous and its attachments to the optic nerve play an important role in the pathogenesis of ODP-M.
      • Georgalas I.
      • Ladas I.
      • Georgopoulos G.
      • Petrou P.
      Optic disc pit: a review.
      • Haruta M.
      • Kamada R.
      • Umeno Y.
      • Yamakawa R.
      Vitrectomy for optic disc pit-associated maculopathy with or without preoperative posterior vitreous detachment.
      • Hirakata A.
      • Okada A.A.
      • Hida T.
      Long-term results of vitrectomy without laser treatment for macular detachment associated with an optic disc pit.
      • Ohno-Matsui K.
      • Hirakata A.
      • Inoue M.
      • Akiba M.
      • Ishibashi T.
      Evaluation of congenital optic disc pits and optic disc colobomas by swept-source optical coherence tomography.
      • Georgalas I.
      • Petrou P.
      • Koutsandrea C.
      • Papaconstadinou D.
      • Ladas I.
      • Gotzaridis E.
      Optic disc pit maculopathy treated with vitrectomy, internal limiting membrane peeling, and gas tamponade: a report of two cases.
      In support of this is the fact that vitrectomy surgery, simply with the creation of a PVD, has been shown to be successful in the postoperative resolution of ODP-M over time.
      • Hirakata A.
      • Inoue M.
      • Hiraoka T.
      • McCuen 2nd, B.W.
      Vitrectomy without laser treatment or gas tamponade for macular detachment associated with an optic disc pit.
      We report the first case in the literature to document with SD-OCT imaging the resolution of ODP-M after a spontaneous PVD. This case lends further support to the argument that the vitreous attachments at the optic nerve head play a critical role in the development of ODP-M and that the PVD may be critical in its management.
      A 57-year-old otherwise healthy Caucasian male presented with a several-year history of decreased vision in the right eye. He had no ocular history. On examination, best corrected visual acuity (BCVA) was 20/63 OD and 20/25 OS. Intraocular pressures were normal. The anterior segment examination was remarkable only for a mild nuclear sclerotic cataract OU. Dilated fundus examination of the right eye demonstrated an inferotemporal ODP, as well as a distinct chorioretinal coloboma inferior to the optic disc (Fig. 1). There was no clinical PVD. Atrophic pigmentary changes were noted in the fovea of the right eye. Spectral-domain enhanced depth imaging optical coherence tomography (EDI-OCT) highlighted large schisis-like changes in the outer nuclear layer of the retina that extended nasally to the optic nerve and communicated with the pit (Fig. 2A). An outer layer defect was apparent; however, no subretinal fluid was present. The posterior hyaloid was visualized on OCT to be attached to the foveal centre, as well as more nasally (Fig. 2A). Dilated fundus examination of the left eye was normal.
      Figure thumbnail gr1
      Fig. 1A, Colour fundus photograph of the right eye shows an optic disc pit (arrow) and a distinct chorioretinal coloboma inferior to the optic nerve. Atrophic pigmentary changes are observed in the fovea. B, Enhanced depth imaging spectral-domain optical coherence tomography of the macula demonstrating an attaching posterior hyaloid (arrow), outer nuclear schisis, nerve fibre layer schisis, and an optic disc pit (arrowhead).
      Figure thumbnail gr2
      Fig. 2A, Enhanced depth imaging spectral-domain optical coherence tomography (EDI SD-OCT) 6 months after initial presentation demonstrating release of the posterior hyaloid attachment. Improvement of the outer nuclear schisis. Persistence of the nerve fibre layer schisis (asterisk) and optic disc pit is shown (arrowhead). B, EDI SD-OCT 9 months after initial presentation demonstrating complete resolution of macular schisis with residual ellipsoid loss subfoveally. The nerve fibre layer schisis is reduced in size, with persistence of the optic disc pit.
      After a discussion of the risks and benefits of surgical management, the patient elected for observation. He returned 6 months later with an improvement in BCVA in his right eye to 20/40, and clinical examination confirmed a PVD with a Weiss ring. SD-OCT examination further confirmed separation of the previously attached vitreous (Fig. 2B). Over the next 3 months, his vision maintained the modest improvement, and his macular schisis progressively resolved (Fig. 2B). The central retina thickness decreased from 598 to 218 μm. Outer nuclear thinning and loss of the subfoveal ellipsoid zone was observed on SD-OCT (Fig. 2B). The hyaloid was no longer adherent to the retinal surface on OCT evaluation.
      The pathophysiology of ODP-M continues to be debated in the literature. The fluid dissecting into and under the retina is argued to derive from either the vitreous or, alternatively, the cerebrospinal fluid. Less well-accepted theories involve fluid leakage from the retinal vasculature, choroidal circulation, or orbital tissues.
      • Jain N.
      • Johnson M.W.
      Pathogenesis and treatment of maculopathy associated with cavitary optic disc anomalies.
      Management options include observation, laser photocoagulation, gas injection, macular buckling surgery, and vitrectomy surgery. A variety of approaches have been advocated for vitrectomy surgery, including the variable use of laser, internal limiting membrane peeling, inner retinal fenestration, and/or gas tamponade.
      • Ooto S.
      • Mittra R.A.
      • Ridley M.E.
      • Spaide R.F.
      Vitrectomy with inner retinal fenestration for optic disc pit maculopathy.
      Johnson et al.
      • Jain N.
      • Johnson M.W.
      Pathogenesis and treatment of maculopathy associated with cavitary optic disc anomalies.
      subscribe to the concept that differential pressures between the intraocular pressure and the intracranial pressure drive fluid through an anomalous passage, resulting from the ODP, into and under the retina. Conversely, other authors believe that the vitreous and its attachments at the optic nerve play an integral role in the development of ODP-M, possibly as a result of tractional forces.
      • Georgalas I.
      • Ladas I.
      • Georgopoulos G.
      • Petrou P.
      Optic disc pit: a review.
      • Haruta M.
      • Kamada R.
      • Umeno Y.
      • Yamakawa R.
      Vitrectomy for optic disc pit-associated maculopathy with or without preoperative posterior vitreous detachment.
      • Hirakata A.
      • Okada A.A.
      • Hida T.
      Long-term results of vitrectomy without laser treatment for macular detachment associated with an optic disc pit.
      • Ohno-Matsui K.
      • Hirakata A.
      • Inoue M.
      • Akiba M.
      • Ishibashi T.
      Evaluation of congenital optic disc pits and optic disc colobomas by swept-source optical coherence tomography.
      • Georgalas I.
      • Petrou P.
      • Koutsandrea C.
      • Papaconstadinou D.
      • Ladas I.
      • Gotzaridis E.
      Optic disc pit maculopathy treated with vitrectomy, internal limiting membrane peeling, and gas tamponade: a report of two cases.
      Hence, the creation of a PVD is believed by some to be key in ODP-M management. Hirakata et al.
      • Hirakata A.
      • Inoue M.
      • Hiraoka T.
      • McCuen 2nd, B.W.
      Vitrectomy without laser treatment or gas tamponade for macular detachment associated with an optic disc pit.
      published a series of 8 patients with ODP-M and no preoperative evidence of PVD, in which 7 had resolution of ODP-M with time, after vitrectomy without laser photocoagulation or gas tamponade. Simple induction of a PVD resulted in resolution of ODP-M.
      It is not known exactly how PVD, either surgically induced or nonsurgical and spontaneous, may achieve improvement of ODP-M. Possible mechanisms include altering pressure gradients, releasing subtle traction, and stimulating scarring within the ODP.
      • Jain N.
      • Johnson M.W.
      Pathogenesis and treatment of maculopathy associated with cavitary optic disc anomalies.
      Resolution of ODP-M with nonsurgical spontaneous PVD has previously been described clinically in 2 patients by Bonnet.
      • Bonnet M.
      Serous macular detachment associated with optic nerve pits.
      Our case is the first report of EDI-OCT images before and after spontaneous nonsurgical PVD in a patient with ODP-M, whose maculopathy subsequently resolved. This lends support to the perspective that the vitreous and its peripapillary adhesions may be integral to the pathogenesis and management of ODP-M. Interestingly, a recent publication by Rayat et al.
      • Rayat J.S.
      • Rudnisky C.J.
      • Waite C.
      • et al.
      Long-term outcomes for optic disc pit maculopathy after vitrectomy.
      found that the final visual outcome in eyes followed without surgical intervention was, on average, worse than others that underwent surgical intervention, and that increased baseline central retinal thickness was found to be a poor prognostic factor.

      References

        • Georgalas I.
        • Ladas I.
        • Georgopoulos G.
        • Petrou P.
        Optic disc pit: a review.
        Graefes Arch Clin Exp Ophthalmol. 2011; 249: 1113-1122
        • Jain N.
        • Johnson M.W.
        Pathogenesis and treatment of maculopathy associated with cavitary optic disc anomalies.
        Am J Ophthalmol. 2014; 158: 423-435
        • Haruta M.
        • Kamada R.
        • Umeno Y.
        • Yamakawa R.
        Vitrectomy for optic disc pit-associated maculopathy with or without preoperative posterior vitreous detachment.
        Clin Ophthalmol. 2012; 6: 1361-1364
        • Hirakata A.
        • Okada A.A.
        • Hida T.
        Long-term results of vitrectomy without laser treatment for macular detachment associated with an optic disc pit.
        Ophthalmology. 2005; 112: 1430-1435
        • Ohno-Matsui K.
        • Hirakata A.
        • Inoue M.
        • Akiba M.
        • Ishibashi T.
        Evaluation of congenital optic disc pits and optic disc colobomas by swept-source optical coherence tomography.
        Invest Ophthalmol Vis Sci. 2013; 54: 7769-7778
        • Georgalas I.
        • Petrou P.
        • Koutsandrea C.
        • Papaconstadinou D.
        • Ladas I.
        • Gotzaridis E.
        Optic disc pit maculopathy treated with vitrectomy, internal limiting membrane peeling, and gas tamponade: a report of two cases.
        Eur J Ophthalmol. 2009; 19: 324-326
        • Hirakata A.
        • Inoue M.
        • Hiraoka T.
        • McCuen 2nd, B.W.
        Vitrectomy without laser treatment or gas tamponade for macular detachment associated with an optic disc pit.
        Ophthalmology. 2012; 119: 810-818
        • Ooto S.
        • Mittra R.A.
        • Ridley M.E.
        • Spaide R.F.
        Vitrectomy with inner retinal fenestration for optic disc pit maculopathy.
        Ophthalmology. 2014; 121: 1727-1733
        • Bonnet M.
        Serous macular detachment associated with optic nerve pits.
        Graefes Arch Clin Exp Ophthalmol. 1991; 229: 526-532
        • Rayat J.S.
        • Rudnisky C.J.
        • Waite C.
        • et al.
        Long-term outcomes for optic disc pit maculopathy after vitrectomy.
        Retina. 2015; 35: 2011-2017