Case Report: “Beyond the Obvious: The Use of Optical Coherence Tomography(OCT) in Management of Peripheral Retinoschisis”

Nikki Yee, OD VA Connecticut, 950 Campbell Ave, West Haven, CT

Robert Benjamin Meade, OD VA Connecticut, 950 Campbell Ave, West Haven, CT

Andrew Lindell, OD VA Connecticut, 950 Campbell Ave, West Haven, CT

Stacy Byron, OD VA Connecticut, 950 Campbell Ave, West Haven, CT

Nancy Shenouda-Awad, OD, FAAO VA Connecticut, 950 Campbell Ave, West Haven, CT

ABSTRACT: Retinoschisis is a benign neurosensory retinal splitting that rarely results in if outer layer break is present. This case demonstrates the use of Optical Coherence Tomography (OCT) to aid in diagnosis and management.

Then follow with the details as listed below. I. Case History • 63 year old Caucasian male • Chief complaint: o Diabetic eye exam • Ocular history: o No history of diabetic o Primary Open Angle suspect OD>OS secondary to moderate cupping OU o Early o Dry eyes • Medical history: o Type II Diabetes Mellitus since Feb 2010 o Hypertension o Hyperlipidemia o Chronic Obstructive Pulmonary Disease o Obesity o Rosacea o Post-traumatic Stress Disorder o Smoker • Medications o Citalopram hydrobromide 40 mg tab QD o Ipratropium Bromide 17mcg 200D inhaler, 2 puffs QID o Lisinopril 5mg tab QD o Metformin HCl 500 mg tab BID o Metoprolol tartrate 25 mg tab BID o Metronidazole 0.75% topical gel BID o Nitroglycerin 0.4mg sublingual tab PRN o Simvastatin 40 mg tab QD o Sulfacetamide Na/Sulfur 5% lotion QD

• Other salient information o No history of flashes//veil/curtain.

II. Pertinent findings • Clinical o Best corrected VA 20/20- OU o Dilated fundus examination: § No § OD: Inferotemporal shallow retinoschisis with possible outer layer break and pigmentation at demarcation line § OS: inferotemporal shallow retinoschisis, no break appreciated o Optical Coherence Tomography (OCT): § OD: Peripheral line scan showing splitting of neurosensory , with distinct outer layer break but intact edges without retinal detachment or fluid • Physical o BP 102/65 • Laboratory studies o Last HbA1c: 6.9%

III. Differential diagnosis • Primary/leading: o Retinoschisis • Others: o Cystoid degeneration o Retinal detachment o Chorioretinal atrophy

IV. Diagnosis and discussion • This is a case of newly diagnosed asymptomatic, bilateral retinoschisis • Diagnosis was made ophthalmoscopically, but OCT has provided information at a micron level with extensive evaluation of the outer layer break • Retinoschisis with an outer layer break carries the potential risk of evolving into a retinal detachment but can be very hard to visualize with indirect ophthalmoscopy • Thus, it is imperative to confirm presence of such risk factors and rule out shallow, subclinical retinal detachment • With the micron level evaluation of the splitting and the characteristic of the break, OCT allowed us to be able to just monitor this patient with serial OCTs for any minute change

V. Treatment, management • The patient was educated regarding the risks, benefits, and alternatives of close monitoring versus prophylactic laser • Due to the confirmation of no shallow retinal detachment or subretinal fluid with OCT, and the fact that the patient was asymptomatic no treatment was deemed necessary • Patient will be monitored closely without treatment and will have repeated OCT scans to monitor any further progression that warrants laser intervention

VI. Conclusion • While OCT is typically used for the diagnosis and management of posterior pole disease, it can also be successfully used to assess peripheral retinal disease • OCT is essential in cases such as this one when micron evaluation of retinal structure is necessary to rule out shallow retinal detachment or subclinical fluid that may increase the risk • As retinoschisis is not always benign, it is essential to determine the type/location of the break (inner versus outer versus both) to guide treatment recommendations • Retinoschisis with outer layer breaks, large in size, superior location, and/or non-pigmented may be treated with prophylactic laser photocoagulation to reduce the risk of retinal detachment • Case study will include review and comparison of OCT scans of cystoid degeneration, inner break retinoschisis, outer break retinoschisis, and retinal detachment