Abstract Acquired macular retinoschisis in a highly myopic patient may be under diagnosed due to its subtle clinical presentation. Optical Coherence Tomography (OCT) is, therefore, vital in the diagnosis and management of this condition.
Title:
OCT and Funduscopic Features of Acquired Macular Retinoschisis in High Myopia
I. Case History
Patient demographics o 63 YO AA female Chief complaint o Pt c/o of the weight of the glasses being “too heavy” OD compared to OS Ocular history o Mild refractive amblyopia OD due to high myopia o Anomalous, myopic optic disc OD o Nuclear Cataracts OU o Lattice degeneration OD Medical history o Controlled, Type II Diabetic o HTN o Hyperlipidemia Medications o Ocular medication . None o Systemic medication: . HCTZ 25/Lisinopril 20mg . Metformin HCL 1000 mg . Atrovastatin calcium 80mg . Multivitmain cap/tab . Cholecalciferol (Vit D3) 1,000unit
II. Pertinent findings
Clinical o Confrontation Visual Field: full to finger count OD, OS o Extra-ocular motility: smooth full range of motion (-) pain, diplopia OU o Pupils: Equally round and reactive to light, with no afferent pupillary defect o Refraction and corresponding BVA: . OD -10.25 -3.00 x 005 20/25- (stable from prior) . OS -1.75 sph 20/20 Add: +2.25
o Slit Lamp: . Intraocular pressures: Goldman (18/18) . Internals: . C/D . OD: 0.2 titled disc/oblique insertion . myopic crescent . temporal staphyloma . OS: 0.5 flat, pink and discrete . Posterior pole: . OD: RPE pigmentation para macular with visible choroidal vasculature; bowed vessel inferior to the macula . OS : unremarkable . Periphery: . OD: inferior lattice without holes . OS: unremarkable . Additional Testing: . Macular OCT . O.D. retinal thinning, choroidal thinning, myopic retinoschisis 2 DD abutting the fovea; blunted foveal pit due to the retinal thinning. No CNVM . O.S. unremarkable
III. Differential diagnosis
Primary/leading o Myopic Macular/Paramacular Retinoschisis in the posterior pole O.D. secondary to high axial myopia Other: o Rhegmatogenous retinal detachment (RRD) o Myopic chorodial neovascular membrane (CNVM)
IV. Diagnosis and Discussion
Fundus Features of acquired retinoschisis o Typical Location . Inferior temporal o Clinical appearance . Demarcation line in peripheral retinoschisis . +/- inner/outer holes . Subtle retinal thickening in posterior pole at site of retinoschisis
OCT Features of High Myopia and Macular Retinoschisis o Retinoschisis features on OCT . OPL/IPL Splitting . Retinal thickening at site of retinoschisis o Additional Potential Retinal/OCT findings in high myopia . Staphyloma . Retinal thinning . Choroidal thinning . CNVM Pathophysiology o Multifactorial . Staphyloma progression . Vitreo macular traction . Epiretinal membrane . Retinal-vascular traction Statistics/Prevalence of Macular Retinoschisis in Myopia and that of Peripheral Retinoschisis Additional testing: o B-scan o A-scan Treatment and management o Amsler Grid o Monitor o ILM Peel/PPV in cases where indicated o Bibliography . Gerstenblith, Adam,; Rabinowitz, Micheal (2012). The Wills Eye Manual: Office and Emergency room diagnosis and treatment of eye disease 6th edition. Lippincott Williams&Wilkins. 298-300. 331-332. . Ho, Vincent Y.; Wehmeier, Jarrod M.’ Shah, Gurav. “WIDE-FIELD INFRARED IMAGING: A Descriptive Review of Characteristics of Retinoschisis, Retinal Detachment, and Schisis Detachments”. The Retina Institute. 36.8 (2016): 1439-1445. Web. . Rachitskaya, Aleksandra, et.al “Optical coherence tomography of outer retinal holes in senile retinoschisis and schisis-detachment.” Br J Ophthalmol. 2016. Web. . Qi, Yue, et.al. “Vitrectomy without inner limiting membrane peeling for macular retionoschisis in highly myopia eyes.” Beijing Institute of Ophthalmology. 36.5. (2016). 953-956. Web.
VI. Conclusion
Due to its often asymptomatic nature and subtle clinical findings, it may be beneficial to routinely obtain macular OCT imaging on all highly myopic patients due to the fact that diagnoses such as macular retinoschisis, may be undiagnosed.