|Year : 2023 | Volume
| Issue : 1 | Page : 165-169
Surgical treatment of a chronic foveal retinal detachment combined with staphyloma, foveoschisis, and macular hole
Efthymios Karmiris1, Evangelia Chalkiadaki1, Ourania Fydanaki1, Michael Apostolopoulos2
1 Department of Ophthalmology, 251 Hellenic Airforce General Hospital, Athens, Greece
2 Department of Eye, University of Athens, Athens, Greece
|Date of Submission||26-Jul-2022|
|Date of Acceptance||28-Dec-2022|
|Date of Web Publication||21-Feb-2023|
3 P. Kanellopoulou Street, Attica 11527
Source of Support: None, Conflict of Interest: None
| Abstract|| |
To present a case of anatomical success and visual improvement after the treatment of a long-standing foveal retinal detachment in a staphylomatous myopic eye with foveoschisis and macular hole. A 60-year-old woman with high myopia presented with foveoschisis and a lamellar macular hole in her right eye. After 2 years of follow-up without deterioration, her eye developed a full-thickness macular hole and a foveal retinal detachment which caused a severe reduction in visual acuity. However, the patient had no surgical treatment for her condition at that time. Vitrectomy was performed 2 years after the retinal detachment formation. Regardless of the longstanding detachment, anatomical success, and visual improvement were evident after the surgery. Despite a 2-year longstanding foveal detachment on a highly myopic eye with foveoschisis and macular hole, surgical repair could still be satisfactory.
Keywords: Chronic foveal detachment, foveoschisis, macular hole, staphyloma
|How to cite this article:|
Karmiris E, Chalkiadaki E, Fydanaki O, Apostolopoulos M. Surgical treatment of a chronic foveal retinal detachment combined with staphyloma, foveoschisis, and macular hole. Oman J Ophthalmol 2023;16:165-9
|How to cite this URL:|
Karmiris E, Chalkiadaki E, Fydanaki O, Apostolopoulos M. Surgical treatment of a chronic foveal retinal detachment combined with staphyloma, foveoschisis, and macular hole. Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 27];16:165-9. Available from: https://www.ojoonline.org/text.asp?2023/16/1/165/370040
| Introduction|| |
Highly myopic staphylomatous eyes are susceptible to developing different and combined deformities at the posterior pole. Myopic foveoschisis is presented in these eyes up to 34%. Foveoschisis can be stable for years and may not reduce significantly the best corrected visual acuity (BCVA). However, the myopic foveoschisis can trigger the formation of macular hole, lamellar macular hole, epiretinal membrane (ERM), and foveal retinal detachment, which usually are responsible for a dramatical deterioration of patient's BCVA. Optical coherence tomography (OCT) is an indispensable tool for diagnosis as it can depict the macular and premacular deformities in detail. Using OCT, myopic foveoschisis is observed as the splitting of the inner retina from the outer retinal layers, with multiple columnar structures connecting the split retinal layers. Herein, we observed anatomical success and visual improvement in a case of myopic foveoschisis and macular hole with foveal retinal detachment that was treated 2 years after the diagnosis. The anatomical restoration of the fovea and the quality of vision remained stable postoperatively through 3 years of follow-up.
| Case Report|| |
A 60-year-old Caucasian woman presented with a reduction in the BCVA of her right eye, complaining also for metamorphopsia for the last 6 months. At the initial presentation, her BCVA was 6/9 in the right eye and 6/6 in the left eye. The mean spherical equivalent was − 12.25 diopters in her right eye and − 10.75 diopters in her left eye. She had no history of trauma, inflammation, infection, or surgery. The anterior segment was deep, and no inflammation was observed. The intraocular pressure (IOP) was 13 mmHg bilaterally. The Amsler Grid test of the right eye detected metamorphopsia, while it appeared normal when the left eye was examined. The OCT revealed a posterior staphyloma with foveoschisis, ERM, and a lamellar macular hole in her right eye [Figure 1]a. Her left eye was also staphylomatous but the anatomy of the macula was not disturbed [Figure 1]b. There was no retinal detachment in her right eye at that point.
|Figure 1: (a) OCT of the right eye at the initial visit. SD-OCT revealed a posterior staphyloma with foveoschisis, ERM and a lamellar macular hole in the patient's right eye, (b) OCT of the left eye at the initial visit. SD-OCT revealed a posterior staphyloma, but the anatomy of the fovea was not disturbed. SD-OCT: Spectral domain-Optical coherence tomography|
Click here to view
As visual acuity was remaining fairly good, an observation period was suggested with close monitoring. Through a 2-year regular follow-up period, the condition of both of the eyes remained stable, without deterioration of the clinical symptoms of the patient.
Two years after her first visit, our patient presented complaining of a severe reduction in her right eye BCVA and worsening of her right eye metamorphopsia. The Snellen visual acuity of the right eye deteriorated to 6/126, while the BCVA of the left eye remained unchanged at 6/6. IOP was 14 mmHg and 15 mmHg in the right and left eye, respectively. The anterior segment examination of both eyes was unremarkable. The OCT examination of the right eye showed a full-thickness macular hole that was classified into stage 4 according to Gass classification and a foveal retinal detachment [Figure 2].
|Figure 2: The SD-OCT examination of the right eye 2 years after the first visit showed a full-thickness macular hole that was classified into stage 4 according to Gass classification and a foveal retinal detachment. SD-OCT: Spectral domain-Optical coherence tomography|
Click here to view
Despite the fact that surgical treatment was recommended at that time, the patient refused to undergo any surgery until 2 years later. During that observation period, the OCT findings remained the same, however, metamorphopsia seriously worsened, affecting the quality of life of the patient.
Micro-incision vitrectomy surgery by a 23-gauge pars plana vitrectomy system was conducted with ERM and internal limiting membrane (ILM) peeling and subsequent gas tamponade with C3F8. The patient maintained face-down positioning for 2 weeks after the surgery. Anatomical success was achieved postoperatively, and it was still evident 3 months later. The BCVA of the right eye improved to 6/60, whist metamorphopsia alleviated to the predetachment level. Postoperative OCT showed a central atrophic area under the fovea of the right eye [Figure 3].
|Figure 3: Postoperative SD-OCT of the right eye showing full reattachment of the retina and central chorioretinal atrophy. SD-OCT: Spectral domain-Optical coherence tomography|
Click here to view
Three-year follow-up of the patient showed no recurrence of the foveal retinal detachment or any of the patient's previous macular pathology. Her BCVA remained 6/60, and the patient was not complaining of metamorphopsia anymore.
| Discussion|| |
Myopic foveoschisis is a clinical deformity directly related to highly myopic eyes, which are characterized by an elongation of their axial length. It is increasingly being recognized as one of the major causes of visual loss in highly myopic eyes. The pathogenesis has not yet been clearly established; however, myopic foveoschisis is believed to be caused by strong vitreomacular traction on the fovea and the retinal changes correlated to this traction, poor elasticity of the ILM, inflexibility of the retinal vessels and ERM in association with axial length elongation and stretching of the retina due to a preexistent staphyloma.,,,,,,
A macular hole is also recognized as a complication of highly myopic eyes and can progress to retinal detachment, which impairs visual acuity. The pathophysiology of macular holes is not well defined, as there are many pathophysiology paths that lead to them. Some of the proposed causes are vitreoretinal traction due to posterior staphyloma or due to the contraction of the cortical vitreous or an ERM, as well as retinal epithelial atrophy that obstructs the retinal adherence to the choroid. Reportedly, most patients with myopic foveoschisis do not develop a macular hole.
The natural history of myopic foveoschisis is inactivity in most cases, with the maintenance of stable visual acuity and retinal thickness. There are ten cases described in the literature in which myopic foveoschisis spontaneously resolved,, and one case with myopic foveoschisis which was accompanied with macular hole and retinal detachment that resolved spontaneously in 3 weeks. The indications for the surgical treatment of macular foveoschisis and the combined deformities are controversial and the benefit of vitrectomy is uncertain. The type of myopic foveoschisis which is suitable for vitrectomy is uncertain, too. Rey et al. suggested that the symptomatically visual deterioration of BCVA ≤20/40 and metamorphopsia related to foveoschisis are absolute indications for a surgical intervention. Ikuno et al. suggested that only patients with symptoms should undergo surgery.
In a minority of foveoschisis cases (about 30%), progressive detachment of the fovea occurs and thus leading to decreased visual acuity or metamorphopsia. In these cases, surgery is often necessary to reattach the retina and prevent and even reverse the deterioration of visual acuity. Many surgical techniques have been suggested and performed for the treatment of myopic foveoschisis with foveal detachment. The most prominent and studied currently among these is micro-incision vitrectomy surgery by a 20 (or 23 or 25)-gauge vitrectomy system, with or without ILM peeling and gas tamponade, mostly with C3F8., Variations of the above technique use SF6 or silicone oil tamponade., Other techniques include macular buckling,,, either combined with vitrectomy or not and gas tamponade without vitrectomy.
Surgical treatment of myopic foveoschisis with or without macular holes and retinal detachment has various anatomical and visual results. Studies indicate that anatomical restoration of the macula and complete foveal reattachment in these cases approaches 75%–83%., Regarding the visual outcome after the surgery, the results differ among the researches. In some cases, there is an improvement in BCVA from 2/200 to 2/120 or more than two lines. These results are related to many factors, such as the level of fovea deformity before the surgery or the surgical method preferred. Lee et al. claimed that good preoperative visual acuity and the absence of foveal detachment before the vitrectomy are important predictors of good visual prognosis. Therefore, they suggested that timely surgical intervention before the development of macular complications may improve the visual outcome after surgical treatment with myopic foveoschisis. Kim et al., who also studied the possible prognostic factors which are related with the surgical outcome of vitrectomy in such cases, prove that more severe myopic maculopathy and the presence of foveal detachment are associated with poorer functional and anatomical outcomes of vitrectomy. Lehmann et al. found that the main factor influencing the postoperative visual acuity is the preoperative visual acuity. They concluded that the preoperative foveal anatomical status did not influence the postoperative visual acuity.
In our case study, the left eye of the patient was also staphylomatous, it was slightly less myopic, but the foveal anatomy was not disturbed. Nevertheless, the right eye of the patient was highly myopic with a posterior staphyloma and when myopic foveoschisis was first diagnosed, a lamellar macular hole and an ERM were already present. However, the BCVA of the eye was fairly good. Two years later, when a full-thickness macular hole and foveal retinal detachment were observed, the option of vitrectomy was discussed with the patient. It is worth noting that the patient did not want to proceed with the surgical treatment until 2 years later when metamorphopsia was seriously affecting her quality of life. Despite the late vitrectomy, the anatomical postoperative results were impressive, as we observed a complete foveal reattachment. The foveal structure was restored almost to normal, with a central atrophic area affecting eventually our patient's visual acuity. The central chorioretinal atrophy probably developed due to the degenerative changes found in our patient's highly myopic eye. Posterior staphyloma and increased axial length could cause the obliteration of the choriocapillaris and a reduction of retinal blood flow, thus reducing the nutritional support for the retina, which subsequently becomes atrophic., These findings remained surprisingly stable through the 3-year follow-up period.
The improvement of the BCVA and the alleviation of metamorphopsia was another significant observation, despite the long-standing retinal detachment and the remaining central atrophic area following the surgery. Even if the patient's preoperative BCVA of the right eye was only 6/126, it reached 6/60 postoperatively, however the most important benefit, according to the patient, was the alleviation of metamorphopsia and the improvement in the quality of her binocular vision. This is a significant amelioration in a patient with low visual acuity. This indicates that even if the retinal deformations and the structural features of myopic maculopathy had been altering the morphology of the fovea for at least 4 years since the first diagnosis of foveoschisis, there were not settled macular deformities in the patient's eye. It is also worth mentioning that the patient had a foveal retinal detachment for 2 years and that the surprisingly good postoperative results did not relapse through the 3-year postoperative period.
This report showed that despite the late surgical treatment in a highly myopic eye with preexisting foveoschisis, ERM, macular hole, and foveal retinal detachment, the postoperative anatomical and functional benefits were surprisingly satisfactory. This implies that surgical treatment of such cases can be beneficial and should be tried even when foveal retinal detachment has become chronic.
Ethical approval was not sought for the present study as our institution does not require approval for single-patient case reports.
Statement of informed consent
Confirmation to publish these findings and images was gathered from the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hwang JU, Joe SG, Lee JY, Kim JG, Yoon YH. Microincision vitrectomy surgery for myopic foveoschisis. Br J Ophthalmol 2013;97:879-84.
Gaucher D, Haouchine B, Tadayoni R, Massin P, Erginay A, Benhamou N, et al.
Long-term follow-up of high myopic foveoschisis: Natural course and surgical outcome. Am J Ophthalmol 2007;143:455-62.
Takano M, Kishi S. Foveal retinoschisis and retinal detachment in severely myopic eyes with posterior staphyloma. Am J Ophthalmol 1999;128:472-6.
Gohil R, Sivaprasad S, Han LT, Mathew R, Kiousis G, Yang Y. Myopic foveoschisis: A clinical review. Eye (Lond) 2015;29:593-601.
Müller B, Joussen AM. Myopic traction maculopathy – Vitreoretinal traction syndrome in high myopic eyes and posterior staphyloma. Klin Monbl Augenheilkd 2011;228:771-9.
Wu PC, Chen YJ, Chen YH, Chen CH, Shin SJ, Tsai CL, et al.
Factors associated with foveoschisis and foveal detachment without macular hole in high myopia. Eye (Lond) 2009;23:356-61.
Polito A, Lanzetta P, Del Borrello M, Bandello F. Spontaneous resolution of a shallow detachment of the macula in a highly myopic eye. Am J Ophthalmol 2003;135:546-7.
Bando H, Ikuno Y, Choi JS, Tano Y, Yamanaka I, Ishibashi T. Ultrastructure of internal limiting membrane in myopic foveoschisis. Am J Ophthalmol 2005;139:197-9.
Ikuno Y, Gomi F, Tano Y. Potent retinal arteriolar traction as a possible cause of myopic foveoschisis. Am J Ophthalmol 2005;139:462-7.
Margolis R, Chang S. Treatment of retinal detachment due to macular hole. Retin Physician 2009.
Baba T, Ohno-Matsui K, Futagami S, Yoshida T, Yasuzumi K, Kojima A, et al.
Prevalence and characteristics of foveal retinal detachment without macular hole in high myopia. Am J Ophthalmol 2003;135:338-42.
Lai TT, Ho TC, Yang CM. Spontaneous resolution of foveal detachment in traction maculopathy in high myopia unrelated to posterior vitreous detachment. BMC Ophthalmol 2016;16:18.
García-Ben A, García-Campos JM, Morillo Sanchez MJ, Figueroa-Ortiz LC. Chorioretinal atrophy after spontaneous resolution of myopic foveoschisis. Case Rep Ophthalmol Med 2014;2014:825906.
Ono T, Terada Y, Mori Y, Kataoka Y, Nakahara M, Miyata K. Spontaneous resolution of myopic foveoschisis and a macular hole with retinal detachment. Am J Ophthalmol Case Rep 2019;13:143-6.
Ikuno Y, Sayanagi K, Ohji M, Kamei M, Gomi F, Harino S, et al.
Vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Am J Ophthalmol 2004;137:719-24.
Rey A, Jürgens I, Maseras X, Carbajal M. Natural course and surgical management of high myopic foveoschisis. Ophthalmologica 2014;231:45-50.
García-Layana A, García-Arumí J, Ruiz-Moreno JM, Arias-Barquet L, Cabrera-López F, Figueroa MS. A review of current management of vitreomacular traction and macular hole. J Ophthalmol 2015;2015:809640.
Dolar-Szczasny J, Święch-Zubilewicz A, Mackiewicz J. A review of current myopic foveoschisis management strategies. Semin Ophthalmol 2019;34:146-56.
Li XJ, Yang XP, Li QM, Wang YY, Wang J, Lyu XB, et al.
Posterior scleral reinforcement combined with vitrectomy for myopic foveoschisis. Int J Ophthalmol 2016;9:258-61.
Zhao X, Ma W, Lian P, Tanumiharjo S, Lin Y, Ding X, et al.
Three-year outcomes of macular buckling for macular holes and foveoschisis in highly myopic eyes. Acta Ophthalmol 2020;98:e470-8.
Wu TY, Yang CH, Yang CM. Gas tamponade for myopic foveoschisis with foveal detachment. Graefes Arch Clin Exp Ophthalmol 2013;251:1319-24.
Lee DH, Moon I, Kang HG, Choi EY, Kim SS, Byeon SH, et al.
Surgical outcome and prognostic factors influencing visual acuity in myopic foveoschisis patients. Eye (Lond) 2019;33:1642-8.
Kim CY, Kim MS, Kim KL, Woo SJ, Park KH. Prognostic factors related with surgical outcome of vitrectomy in myopic traction maculopathy. Korean J Ophthalmol 2020;34:67-75.
Lehmann M, Devin F, Rothschild PR, Gaucher D, Morin B, Philippakis E, et al.
Preoperative factors influencing visual recovery after vitrectomy for myopic foveoschisis. Retina 2019;39:594-600.
Shimada N, Ohno-Matsui K, Harino S, Yoshida T, Yasuzumi K, Kojima A, et al.
Reduction of retinal blood flow in high myopia. Graefes Arch Clin Exp Ophthalmol 2004;242:284-8.
Benavente-Pérez A, Hosking SL, Logan NS, Broadway DC. Ocular blood flow measurements in healthy human myopic eyes. Graefes Arch Clin Exp Ophthalmol 2010;248:1587-94.
[Figure 1], [Figure 2], [Figure 3]