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BJO Online First, published on June 30, 2015 as 10.1136/bjophthalmol-2015-306628 Clinical science
Radius of curvature changes in spontaneous improvement of foveoschisis in highly myopic eyes Quan V Hoang,1 Ching-Lung Chen,1,2 Jose Garcia-Arumi,3 Pamela R Sherwood,1 Stanley Chang1,4 1
Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, New York, USA 2 Department of Ophthalmology, Chang Gung Memorial Hospital, Chiayi, Taiwan 3 Department of Ophthalmology, Hospital Universitario Vall d’Hebrón, Barcelona, Spain Correspondence to Sr Stanley Chang, Edward S. Harkness Eye Institute, Department of Ophthalmology, Columbia University Medical Center, 635 West 165th Street, New York, NY 10032, USA; [email protected] Received 26 January 2015 Revised 24 April 2015 Accepted 11 June 2015
ABSTRACT Background Myopic foveoschisis is the splitting of retinal layers overlying staphyloma in highly myopic patients that can lead to vision loss. We assess possible contributing mechanisms to the formation of foveoschisis by examining two cases of spontaneous improvement of myopic foveoschisis and employ a radius of curvature (ROC) measure to track posterior scleral curvature over time. Methods A retrospective, non-comparative case series was performed and optical coherence tomography images were analysed. Retinal pigment epithelial layer ROC was calculated from manually segmented images through the posterior scleral curvature apex. Results Two cases of myopic foveoschisis with foveal detachments in the left eye (OS) were studied. Both patients had high myopia (either 30 mm in axial length). One case occurred in a treatment-naive patient who improved after 4 months of observation. On initial presentation, OS posterior scleral ROC was 12.35 mm and decreased to 12.15 mm at the time of resolution. The other case occurred in a patient who was followed for 7 years, had previously underwent pars plana vitrectomy and removal of epiretinal membrane, experienced recurrence of foveoschisis and then spontaneously improved without further posterior segment surgery. There was an uncomplicated cataract extraction in the interim. Posterior scleral ROC was 4.05 mm on presentation, 4.10 during recurrence, 3.55 mm after cataract extraction and 3.75 mm at resolution. Conclusions Spontaneous improvement of myopic foveoschisis may be due to changes in tractional forces from the internal limiting membrane, cortical vitreous or staphyloma or, alternatively, from a delayed or fluctuant recovery course after intervention.
INTRODUCTION
To cite: Hoang QV, Chen C-L, Garcia-Arumi J, et al. Br J Ophthalmol Published Online First: [please include Day Month Year] doi:10.1136/ bjophthalmol-2015-306628
Myopic foveoschisis (MF), or myopic traction maculopathy, is a disorder of the vitreoretinal interface, characterised by retinoschisis of the posterior retina in highly myopic patients with posterior staphyloma.1–3 There are two subclasses described: a foveoschisis subclass in which the photoreceptor layer remains attached to retinal pigment epithelium (RPE) and the foveal detachment subclass in which the photoreceptor layer detaches from the RPE. MF occurs in 9–34% of highly myopic eyes with posterior staphyloma,1 2 4 5 and macular retinal detachment (RD) has a prevalence of 1.6–5.2%.2 5 The pathogenesis of MF remains unclear; however, several etiological factors have been suggested, including tangential traction in the inner retina exerted by an epiretinal membrane
(ERM) or residual vitreous cortex, rigidity of internal limiting membrane (ILM), thinning of the retina, stiffness of retinal vessels and scleral curvature changes within the posterior staphyloma.4–10 Optical coherence tomography (OCT) studies have depicted characteristic features of MF and the frequent association with other anomalies such as foveal detachment and macular holes (MH) with or without associated RD.1 6 11–13 In general, 1/3 of the MF cases remain stable while 2/3 progress to MH with or without RD. Pars plana vitrectomy (PPV), a procedure that removes cortical vitreous from the posterior pole in combination with ILM peeling and gas tamponade, has become the standard of care for managing visually significant MF with or without an associated MH.3 6 10 14–19 Here, we assess possible contributing mechanisms to the formation of foveoschisis by examining two cases of spontaneous resolution of MF and employ a radius of curvature (ROC) measure to track the posterior scleral curvature over time. One occurred in a treatment-naive patient and the other in a patient who had previously underwent PPV and membranectomy, experienced recurrence of foveoschisis and then spontaneous resolution without further posterior segment surgery.
METHODS A retrospective, non-comparative case series was performed. At every clinic visit, Snellen best corrected visual acuity (BCVA), slit-lamp examination and funduscopic examination were recorded. Colour fundus photographs and time-domain OCT (Zeiss Stratus, for visits prior to 2007) or spectraldomain OCT (Zeiss Cirrus) imaging of the macula were retrospectively reviewed and analysed from key time points during each patient’s history. Horizontal and vertical images through the posterior scleral curvature apex were manually segmented with photo editing software (ImageJ, Bethesda, Maryland) to focus on the RPE layer, which was then best-fit in MATLAB to calculate the ROC and root mean square error (RMSE) deviation (example shown in figure 3E, F). Horizontal and vertical scans through the posterior scleral curvature apex were averaged to arrive at the posterior scleral ROC. RMSE deviation for all curve fits was
BJO Online First, published on June 30, 2015 as 10.1136/bjophthalmol-2015-306628 Clinical science
Radius of curvature changes in spontaneous improvement of foveoschisis in highly myopic eyes Quan V Hoang,1 Ching-Lung Chen,1,2 Jose Garcia-Arumi,3 Pamela R Sherwood,1 Stanley Chang1,4 1
Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University College of Physicians and Surgeons, New York, New York, USA 2 Department of Ophthalmology, Chang Gung Memorial Hospital, Chiayi, Taiwan 3 Department of Ophthalmology, Hospital Universitario Vall d’Hebrón, Barcelona, Spain Correspondence to Sr Stanley Chang, Edward S. Harkness Eye Institute, Department of Ophthalmology, Columbia University Medical Center, 635 West 165th Street, New York, NY 10032, USA; [email protected] Received 26 January 2015 Revised 24 April 2015 Accepted 11 June 2015
ABSTRACT Background Myopic foveoschisis is the splitting of retinal layers overlying staphyloma in highly myopic patients that can lead to vision loss. We assess possible contributing mechanisms to the formation of foveoschisis by examining two cases of spontaneous improvement of myopic foveoschisis and employ a radius of curvature (ROC) measure to track posterior scleral curvature over time. Methods A retrospective, non-comparative case series was performed and optical coherence tomography images were analysed. Retinal pigment epithelial layer ROC was calculated from manually segmented images through the posterior scleral curvature apex. Results Two cases of myopic foveoschisis with foveal detachments in the left eye (OS) were studied. Both patients had high myopia (either 30 mm in axial length). One case occurred in a treatment-naive patient who improved after 4 months of observation. On initial presentation, OS posterior scleral ROC was 12.35 mm and decreased to 12.15 mm at the time of resolution. The other case occurred in a patient who was followed for 7 years, had previously underwent pars plana vitrectomy and removal of epiretinal membrane, experienced recurrence of foveoschisis and then spontaneously improved without further posterior segment surgery. There was an uncomplicated cataract extraction in the interim. Posterior scleral ROC was 4.05 mm on presentation, 4.10 during recurrence, 3.55 mm after cataract extraction and 3.75 mm at resolution. Conclusions Spontaneous improvement of myopic foveoschisis may be due to changes in tractional forces from the internal limiting membrane, cortical vitreous or staphyloma or, alternatively, from a delayed or fluctuant recovery course after intervention.
INTRODUCTION
To cite: Hoang QV, Chen C-L, Garcia-Arumi J, et al. Br J Ophthalmol Published Online First: [please include Day Month Year] doi:10.1136/ bjophthalmol-2015-306628
Myopic foveoschisis (MF), or myopic traction maculopathy, is a disorder of the vitreoretinal interface, characterised by retinoschisis of the posterior retina in highly myopic patients with posterior staphyloma.1–3 There are two subclasses described: a foveoschisis subclass in which the photoreceptor layer remains attached to retinal pigment epithelium (RPE) and the foveal detachment subclass in which the photoreceptor layer detaches from the RPE. MF occurs in 9–34% of highly myopic eyes with posterior staphyloma,1 2 4 5 and macular retinal detachment (RD) has a prevalence of 1.6–5.2%.2 5 The pathogenesis of MF remains unclear; however, several etiological factors have been suggested, including tangential traction in the inner retina exerted by an epiretinal membrane
(ERM) or residual vitreous cortex, rigidity of internal limiting membrane (ILM), thinning of the retina, stiffness of retinal vessels and scleral curvature changes within the posterior staphyloma.4–10 Optical coherence tomography (OCT) studies have depicted characteristic features of MF and the frequent association with other anomalies such as foveal detachment and macular holes (MH) with or without associated RD.1 6 11–13 In general, 1/3 of the MF cases remain stable while 2/3 progress to MH with or without RD. Pars plana vitrectomy (PPV), a procedure that removes cortical vitreous from the posterior pole in combination with ILM peeling and gas tamponade, has become the standard of care for managing visually significant MF with or without an associated MH.3 6 10 14–19 Here, we assess possible contributing mechanisms to the formation of foveoschisis by examining two cases of spontaneous resolution of MF and employ a radius of curvature (ROC) measure to track the posterior scleral curvature over time. One occurred in a treatment-naive patient and the other in a patient who had previously underwent PPV and membranectomy, experienced recurrence of foveoschisis and then spontaneous resolution without further posterior segment surgery.
METHODS A retrospective, non-comparative case series was performed. At every clinic visit, Snellen best corrected visual acuity (BCVA), slit-lamp examination and funduscopic examination were recorded. Colour fundus photographs and time-domain OCT (Zeiss Stratus, for visits prior to 2007) or spectraldomain OCT (Zeiss Cirrus) imaging of the macula were retrospectively reviewed and analysed from key time points during each patient’s history. Horizontal and vertical images through the posterior scleral curvature apex were manually segmented with photo editing software (ImageJ, Bethesda, Maryland) to focus on the RPE layer, which was then best-fit in MATLAB to calculate the ROC and root mean square error (RMSE) deviation (example shown in figure 3E, F). Horizontal and vertical scans through the posterior scleral curvature apex were averaged to arrive at the posterior scleral ROC. RMSE deviation for all curve fits was
