Photo Essay

Edited by Cynthia A. Toth with Eric W. Schneider and Francisco A. Folgar

Idiopathic Internal Limiting Membrane Detachment Fig. 1. Photograph showing internal limiting membrane detachment around the macula in the right eye. A. Fundus photograph revealing a shallow thickened ILM elevation accompanied with some deposits visible as yellowish spots distributing underneath it in the posterior pole. B. Infrared image showing an ellipsoid lesion appearing hyporeflective around the macula which corresponds to the ILM elevation area shown in (A) and the deposits appears dark. C. Corresponding horizontal OCT scan through fovea demonstrating the hyperreflective, convex configuration of the ILM detachment with sub-ILM deposits (arrow) as well as the separation of hyaloids from ILM and foveal tenting (asterisk). Mild opacities were noted within the vitreous cavity (arrowhead). D. Another OCT scan showing the domeshaped inner retinal cyst and a tethered ILM attachment at the fovea (arrow). The strand and area surrounding its ILM attachment appears thick (arrowhead), suggesting glial hyperplasia. OCT, optical coherence tomography.

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was noted around the macula with some yellowish deposits distributing underneath the ILM (Figure 1A). Infrared image showed a distinct hyporeflective lesion around the macula, and the deposits appeared dark (Figure 1B). Corresponding horizontal optical coherence tomography macular scan revealed the separation of hyaloids from ILM and the dome-shaped ILM detachment with deposits on internal surface (Figure 1C). Tenting of the fovea is obviously seen. The vitreoretinal interface showed mild vitreous opacities but no evidence of obvious traction over the ILM (Figure 1C). A cut from a different angle demonstrated an elongated lesion extending from fovea to the highly elevated ILM (Figure 1D), suggesting an impending macular hole.4 The patient had no spontaneous improvement in vision at 1 month after the onset. Vitrectomy with

nternal limiting membrane (ILM) detachment has been reported to occur in Valsalva retinopathy1 and vitreomacular traction.2,3 We describe an interesting case of idiopathic ILM detachment in a 39-yearold woman presenting with a 1-month history of blurred vision in right eye. She had no history of any ocular or systemic problems. Her visual acuity was 20/200 in the right eye and 20/20 in the left eye. On fundus photography, an ellipsoid area of ILM elevation approximately 4 to 5 disk diameters From the Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, China. None of the authors have any financial/conflicting interests to disclose. Reprint requests: Luosheng Tang, MD, PhD, The Second Xiangya Hospital, No. 139, Middle Renmin Road, Changsha 410011, China; e-mail: [email protected]

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PHOTO ESSAY

Key words: internal limiting membrane, optical coherence tomography, vitrectomy. HUILING LI, MD, PHD XIAOJIAN GUO, MD, PHD LUOSHENG TANG, MD, PHD References

Fig. 2. Horizontal optical coherence tomography scans through fovea confirming restoration of foveal architecture 12 days after vitrectomy. A dissociated optic nerve fiber layer appearance is clearly seen in the temporal macula (arrowheads). Mildly decreased thickness of outer nuclear layer and irregular IS/OS junction of the photoreceptors around the fovea are visible.

ILM removal was performed and 12 days later, optical coherence tomographic scan through fovea demonstrated the disappearance of any hyperreflective signal at the vitreoretinal interface and yielding a relatively normal foveal appearance, which explains why visual acuity was partially preserved to 8/20. Small depressions in the contour of the inner retina were visible temporally (Figure 2). IS/OS junction of the photoreceptors was lightly irregular around the fovea, and mean fovea thickness was 130 mm. A tentative diagnosis of idiopathic ILM detachment was made on this case because a dissociated optic nerve fiber layer appearance which occurred only in eyes that had internal limiting membrane peeling5 are visible in the temporal macula, indicating this cyst is roofed by ILM. In addition, the ILM detachment was not associated with any predisposing factors, such as vitreoretinal traction, trauma, or hemorrhage. Given Nd:YAG laser hyaloidectomy would damage the retina without a predilection from hemorrhage, and there were mild vitreous opacities, and vitrectomy was justified and the vision substantially improved to 20/25 six months later.

1. Zou M, Gao S, Zhang J, Zhang M. Persistent unsealed internal limiting membrane after Nd:YAG laser treatment for valsalva retinopathy. BMC Ophthalmol 2013;13:15. 2. Figus M, Carpineto P, Romagnoli M, et al. Optical coherence tomography findings of incomplete posterior vitreoschisis with vitreomacular traction syndrome and impending macular hole: a case report. Eur J Ophthalmol 2008;18:147–149. 3. Sayanagi K, Ikuno Y, Tano Y. Tractional internal limiting membrane detachment in highly myopic eyes. Am J Ophthalmol 2006;142:850–852. 4. Smiddy WE, Flynn HW Jr. Pathogenesis of macular holes and therapeutic implications. Am J Ophthalmol 2004;137: 525–537. 5. Spaide RF. “Dissociated optic nerve fiber layer appearance” after internal limiting membrane removal is inner retinal dimpling. Retina 2012;32:1719–1726.

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