COMBINED RETINOSCHISIS– DETACHMENT INVOLVING THE FOVEA MANAGED WITH OBSERVATION Ali Zaidi, MD, Brandon Lujan, MD
Purpose: To report a case of a combined retinoschisis–detachment progressing to foveal involvement managed by observation. Methods: This is a case report with a 19-month follow-up period. Clinical examination, fundus photography, and optical coherence tomography were used to follow the retinal findings over time. Results: A 61-year-old man presented with 20/20 vision with a retinoschisis–detachment. The detachment progressed to involve the fovea, and the vision declined to 20/40. The patient was observed for 14 months, and his vision remained 20/40. Optical coherence tomography demonstrated a stable detachment. Conclusion: Retinal detachment may occur within retinoschisis. Despite foveal detachment, patients may maintain good vision without surgical intervention. RETINAL CASES & BRIEF REPORTS 8:254–256, 2014
identify any peripheral retinal breaks. Optical coherence tomography (OCT) of the macula of the left eye demonstrated a neurosensory retinal detachment sparing the fovea with intraretinal cysts (Figure 2). Optical coherence tomography of the inferotemporal periphery of the right eye also demonstrated a neurosensory detachment (Figure 3). The patient was observed and returned after 3 months complaining of blurry vision in the left eye. The visual acuity measured 20/40 in the left eye. Clinical examination revealed subretinal fluid under the fovea. No inner or outer retinal holes were identified in the periphery. Optical coherence tomography demonstrated
From the Retina and Macula Specialists, Tacoma, Washington.
A
cquired (senile) retinoschisis is an abnormal splitting of the retinal layers. Progression to a symptomatic retinal detachment involving the macula is very rare.1 This article describes a case of a retinoschisis–detachment that progressed to involve the fovea. Despite a foveal detachment, the patient maintained good visual acuity with observation alone.
Case Report A 61-year-old man was referred for retinal elevation in the left eye. He denied visual symptoms. His visual acuity measured 20/20 in each eye. His anterior segment examination demonstrated 1+ nuclear sclerosis in each eye but was otherwise unremarkable. Posterior segment examination revealed bilateral areas of smooth dome-shaped retinal elevation in the inferotemporal periphery of both eyes. In the left eye, there was a well-circumscribed circular area of elevation that extended inside the inferior arcade concerning for subretinal fluid (Figure 1). The fovea was flat. Slit-lamp biomicroscopy with both a noncontact and a contact lens did not identify an outer or inner retinal hole. Indirect ophthalmoscopy with scleral depression also did not Presented at the Pacific Retina Club Meeting, Los Angeles, CA, April 2013. The author has no financial/conflicting interests to disclose. Reprint requests: Ali Zaidi, MD, Retina and Macula Specialists, Tacoma, Washington 98409; e-mail: [email protected]
Fig. 1. Color fundus photograph showing dome-shaped retinal elevation in the inferotemporal macula.
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Fig. 2. Spectral domain-OCT showing neurosensory retinal detachment sparing the fovea in the left eye.
Fig. 4. Spectral domain-OCT showing progression of the retinal detachment in the left eye.
progression of the neurosensory retinal detachment into the fovea and persistent intraretinal cysts (Figure 4). Peripheral OCT demonstrated tissue along the surface of the retinal pigment epithelium, suggesting schisis rather than a neurosensory retinal detachment (Figure 5). After discussion of the options with the patient, including observation versus surgery, he elected for observation. The patient has subsequently been observed for 19 months. At his most recent visit, the visual acuity remained stable at 20/20 in the right eye and 20/40 in the left eye. His clinical examination was stable without progression of the retinal detachment in either eye. Repeat OCT scans demonstrated stable neurosensory retinal detachments in both eyes. Optical coherence tomography of the left eye showed that the intraretinal cysts have resolved over time (Figure 6). The patient has elected for continued observation.
Watzke et al2 reported the long-term findings of acquired retinoschisis involving the fovea in 7 patients. In the two patients in whom the retinoschisis alone involved the fovea, good vision was still possible. However, when the retinal detachment
involved the fovea, each of the patients had severe vision loss. All cases of retinal detachment in the study had visible outer layer holes. Most of the patients in the study were followed before the advent of OCT, therefore it may have been difficult to be certain if the fovea was elevated because of schisis versus detachment. This report describes a case of a retinoschisis– detachment that progressed to involve the fovea as confirmed by OCT. Despite a neurosensory retinal detachment of the fovea, the patient maintained good vision. The mechanism for maintaining good vision is unclear, but may be due to the volume and composition of fluid within the schisis cavity rather than the vitreous fluid. Presumably, the intraretinal fluid within the schisis cavity dissected under the retina rather than vitreous fluid because of the absence of retinal breaks. The limited volume of schisis fluid under the retina may have restricted progression of the detachment. Vitreous fluid may also be more viscous than intraretinal fluid and may contain factors that damage the photoreceptors.
Fig. 3. Spectral domain-OCT showing neurosensory retinal detachment sparing the fovea in the right eye.
Fig. 5. Spectral domain-OCT of the peripheral retina in the left eye showing tissue on the surface of the retinal pigment epithelium.
Discussion
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causes severe vision loss. This case describes a patient with a foveal detachment that was managed by observation alone and maintained good vision. This report suggests that not all cases of retinoschisis– detachment involving the fovea may require surgical intervention. Key words: retinoschisis, macular schisis, retinal detachment. Fig. 6. Spectral domain-OCT showing stable retinal detachment in the left eye. Cystoid macular edema is now resolved.
Conclusion Retinoschisis–detachment may progress to involve the fovea in rare cases. Foveal detachment typically
References 1. Byer NE. Long-term natural history study of senile retinoschisis with implications for management. Ophthalmology 1986;93: 1127–1137. 2. Watzke RC, Folk JC, Lauer AK. Foveal involvement by acquired retinoschisis: long-term visual outcomes. Retina 2013;33:606–612.
Purpose: To report a case of a combined retinoschisis–detachment progressing to foveal involvement managed by observation. Methods: This is a case report with a 19-month follow-up period. Clinical examination, fundus photography, and optical coherence tomography were used to follow the retinal findings over time. Results: A 61-year-old man presented with 20/20 vision with a retinoschisis–detachment. The detachment progressed to involve the fovea, and the vision declined to 20/40. The patient was observed for 14 months, and his vision remained 20/40. Optical coherence tomography demonstrated a stable detachment. Conclusion: Retinal detachment may occur within retinoschisis. Despite foveal detachment, patients may maintain good vision without surgical intervention. RETINAL CASES & BRIEF REPORTS 8:254–256, 2014
identify any peripheral retinal breaks. Optical coherence tomography (OCT) of the macula of the left eye demonstrated a neurosensory retinal detachment sparing the fovea with intraretinal cysts (Figure 2). Optical coherence tomography of the inferotemporal periphery of the right eye also demonstrated a neurosensory detachment (Figure 3). The patient was observed and returned after 3 months complaining of blurry vision in the left eye. The visual acuity measured 20/40 in the left eye. Clinical examination revealed subretinal fluid under the fovea. No inner or outer retinal holes were identified in the periphery. Optical coherence tomography demonstrated
From the Retina and Macula Specialists, Tacoma, Washington.
A
cquired (senile) retinoschisis is an abnormal splitting of the retinal layers. Progression to a symptomatic retinal detachment involving the macula is very rare.1 This article describes a case of a retinoschisis–detachment that progressed to involve the fovea. Despite a foveal detachment, the patient maintained good visual acuity with observation alone.
Case Report A 61-year-old man was referred for retinal elevation in the left eye. He denied visual symptoms. His visual acuity measured 20/20 in each eye. His anterior segment examination demonstrated 1+ nuclear sclerosis in each eye but was otherwise unremarkable. Posterior segment examination revealed bilateral areas of smooth dome-shaped retinal elevation in the inferotemporal periphery of both eyes. In the left eye, there was a well-circumscribed circular area of elevation that extended inside the inferior arcade concerning for subretinal fluid (Figure 1). The fovea was flat. Slit-lamp biomicroscopy with both a noncontact and a contact lens did not identify an outer or inner retinal hole. Indirect ophthalmoscopy with scleral depression also did not Presented at the Pacific Retina Club Meeting, Los Angeles, CA, April 2013. The author has no financial/conflicting interests to disclose. Reprint requests: Ali Zaidi, MD, Retina and Macula Specialists, Tacoma, Washington 98409; e-mail: [email protected]
Fig. 1. Color fundus photograph showing dome-shaped retinal elevation in the inferotemporal macula.
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Fig. 2. Spectral domain-OCT showing neurosensory retinal detachment sparing the fovea in the left eye.
Fig. 4. Spectral domain-OCT showing progression of the retinal detachment in the left eye.
progression of the neurosensory retinal detachment into the fovea and persistent intraretinal cysts (Figure 4). Peripheral OCT demonstrated tissue along the surface of the retinal pigment epithelium, suggesting schisis rather than a neurosensory retinal detachment (Figure 5). After discussion of the options with the patient, including observation versus surgery, he elected for observation. The patient has subsequently been observed for 19 months. At his most recent visit, the visual acuity remained stable at 20/20 in the right eye and 20/40 in the left eye. His clinical examination was stable without progression of the retinal detachment in either eye. Repeat OCT scans demonstrated stable neurosensory retinal detachments in both eyes. Optical coherence tomography of the left eye showed that the intraretinal cysts have resolved over time (Figure 6). The patient has elected for continued observation.
Watzke et al2 reported the long-term findings of acquired retinoschisis involving the fovea in 7 patients. In the two patients in whom the retinoschisis alone involved the fovea, good vision was still possible. However, when the retinal detachment
involved the fovea, each of the patients had severe vision loss. All cases of retinal detachment in the study had visible outer layer holes. Most of the patients in the study were followed before the advent of OCT, therefore it may have been difficult to be certain if the fovea was elevated because of schisis versus detachment. This report describes a case of a retinoschisis– detachment that progressed to involve the fovea as confirmed by OCT. Despite a neurosensory retinal detachment of the fovea, the patient maintained good vision. The mechanism for maintaining good vision is unclear, but may be due to the volume and composition of fluid within the schisis cavity rather than the vitreous fluid. Presumably, the intraretinal fluid within the schisis cavity dissected under the retina rather than vitreous fluid because of the absence of retinal breaks. The limited volume of schisis fluid under the retina may have restricted progression of the detachment. Vitreous fluid may also be more viscous than intraretinal fluid and may contain factors that damage the photoreceptors.
Fig. 3. Spectral domain-OCT showing neurosensory retinal detachment sparing the fovea in the right eye.
Fig. 5. Spectral domain-OCT of the peripheral retina in the left eye showing tissue on the surface of the retinal pigment epithelium.
Discussion
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causes severe vision loss. This case describes a patient with a foveal detachment that was managed by observation alone and maintained good vision. This report suggests that not all cases of retinoschisis– detachment involving the fovea may require surgical intervention. Key words: retinoschisis, macular schisis, retinal detachment. Fig. 6. Spectral domain-OCT showing stable retinal detachment in the left eye. Cystoid macular edema is now resolved.
Conclusion Retinoschisis–detachment may progress to involve the fovea in rare cases. Foveal detachment typically
References 1. Byer NE. Long-term natural history study of senile retinoschisis with implications for management. Ophthalmology 1986;93: 1127–1137. 2. Watzke RC, Folk JC, Lauer AK. Foveal involvement by acquired retinoschisis: long-term visual outcomes. Retina 2013;33:606–612.
