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Arch Ophthalmol. 2005;123:1449-1450.

A 34-year-old Japanese woman suspected of having glaucoma by a local physician visited us for a consultation. The patient had not previously undergone intraocular surgery. Her corrected visual acuity was 20/20 OD with –9.5 diopter sphere (DS) and 20/20 OS with –9.0 DS. Her intraocular pressures were 11 mm Hg OD and 8 mm Hg OS. Color and red-free fundus photographs showed multiple, spindle-shaped retinal cleavages around blood vessels in both eyes. Small bundles of nerve fiber were seen passing across the cleavages, and the optic discs appeared normal (Figure 1). Optical coherence tomography showed a clear profile of the inner retinal cleavages (Figure 2). The mean ± SD thickness of the retina at the site of the cleavages was 106.4 ± 17.7 m and that of the adjacent unaffected retina was 254.2 ± 25.8 m. The mean thickness of the retina at the site of the cleavages was significantly thinner than that of the adjacent unaffected retina (P<.001, Mann-Whitney U test). The fluorescein angiograms showed no abnormalities. The results of standard automated perimetry (Humphrey Field Analyzer 30-2 program; Carl Zeiss Meditec, Dublin, Calif) were normal, but microperimetry with a scanning laser ophthalmoscope (Scotometry program, version 3.0; Rodenstock Instruments, Ottobrunn, Germany) revealed a relative scotoma in the area of the retinal cleavages (Figure 3).¹ No retinal cleavage was found in her parents or her elder brother.

View larger version (64K): [in this window] [in a new window] Figure 1. Color (A) and red-free (B) fundus photographs of the right eye showing multiple, spindle-shaped retinal cleavages around blood vessels. Small nerve fiber bundles can be seen passing across the cleavages. The optic disc appears normal.

View larger version (110K): [in this window] [in a new window] Figure 2. Optical coherence tomographic image of the right eye corresponding to the scan line indicated by the arrow. Some of the outer retinal layers other than the nerve fiber layer appear to be absent in the areas of the cleavages.

View larger version (93K): [in this window] [in a new window] Figure 3. Microperimetry of the right eye with a scanning laser ophthalmoscope. (size, Goldmann I; brightness, –15 dB; background, 10 candelas/m2). The patient did not recognize the stimulus at the positions indicated by the red Ps.

Comments
Chihara and Chilhara² reported a cleavage of the retinal nerve fiber layer in eyes with high myopia, but there has been only 1 report of retinal cleavages around blood vessels in highly myopic eyes. They used the term "cleavage" to distinguish the cleavages from the "defect" seen in glaucomatous eyes.

It is clinically important to differentiate the cleavage from the retinal nerve fiber layer (RNFL) defect. The cleavage is often spindle shaped and we can sometimes see small bundles of nerve fiber passing across the cleavage, whereas the RNFL defect is wedge shaped and we never see small bundles of nerve fiber passing across the RNFL defect. However, there should be many cases in which we cannot make a clear distinction between them just by fundoscopic appearance. Optical coherence tomographic imaging should be very useful in such cases in making a correct diagnosis.

The optical coherence tomographic images showed the cleavages clearly along with the possibility that these cleavages extended deeper than the nerve fiber layer. Although Chihara and Chilhara² reported that the retinal sensitivity in the area of the cleavage was not depressed, we detected a relative scotoma in that area in our case. These findings indicated there may be some abnormalities in nerve conduction in the area of the cleavage.

AUTHOR INFORMATION
Correspondence: Dr Komeima, De partment of Ophthalmology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan (kkome{at}med.nagoya-u.ac.jp).

Financial Disclosure: None.

Keiichi Komeima, MD, PhD; Masato Kikuchi, MD; Yasuki Ito, MD, PhD; Hiroko Terasaki, MD, PhD; Yozo Miyake, MD, PhD

REFERENCES
1. Timberlake GT, Mainster MA, Webb RH, Hughes GW, Trempe CL. Retinal localization of scotomata by scanning laser ophthalmoscopy. Invest Ophthalmol Vis Sci. 1982;22:91-97. FREE FULL TEXT 2. Chihara E, Chihara K. Apparent cleavage of the retinal nerve fiber layer in asymptomatic eyes with high myopia. Graefes Arch Clin Exp Ophthalmol. 1992;230:416-420. ISI | PUBMED

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