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Ingrid U. Scott, MD, MPH; Andrew A. Moshfeghi, MD; Harry W. Flynn, Jr, MD

Arch Ophthalmol. 2006;124:1197-1199.

Macular retinoschisis is an uncommon complication of high myopia. Limited data are available on surgical management of macular retinoschisis in high myopia, and these reports involve patients with concurrent localized retinal detachment.^1-2 We describe visual acuity and optical coherence tomography (OCT) outcomes following surgical management of macular retinoschisis (without retinal detachment) associated with high myopia.

Report of Cases
Case 1

A 53-year-old man with 14 diopters (D) of myopia experienced progressive visual loss over 2 years in the left eye, from best-corrected visual acuity (BCVA) of 20/30 to BCVA of 20/200, due to progressive macular retinoschisis. Fluorescein angiography showed no retinal vascular leakage or cystoid macular edema. Optical coherence tomography showed macular retinoschisis with outer retinal cystic spaces and a macular pseudohole. The central foveal thickness measured 519 µm (Figure 1A); there was no retinal detachment. Eight months after pars plana vitrectomy, removal of the posterior hyaloid, internal limiting membrane peeling, and fluid-gas exchange using 16% perfluoropropane gas, BCVA was 20/80⁺¹ and OCT showed resolution of the macular retinoschisis and a central foveal thickness of 151 µm (Figure 1B).

View larger version (52K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. Optical coherence tomography showing macular retinoschisis. A, Outer retinal cystic spaces and a macular pseudohole are shown. Increased choroidal penetrance of the optical coherence tomography signal appears as an area of enhanced reflectivity directly beneath the foveal center. Reduced reflective areas are evident posterior to the retinal pigment epithelium and are of undetermined significance. The central foveal thickness is 519 µm. B, Resolution of the macular retinoschisis with a central foveal thickness of 151 µm is shown.

Case 2

A 31-year-old woman with 18 D of myopia (axial length, 32.6 mm) experienced progressive visual loss over 18 months in the right eye, from BCVA of 20/30 to BCVA of 20/200, due to progressive macular retinoschisis. Fluorescein angiography showed no retinal vascular leakage or cystoid macular edema. Optical coherence tomography showed macular retinoschisis with outer retinal cystic spaces, traction from an attached posterior hyaloid, and a pocket of subfoveal fluid. The central foveal thickness measured 517 µm (Figure 2A). Seven months after pars plana vitrectomy, removal of the posterior hyaloid, and fluid-gas exchange using 16% perfluoropropane gas, BCVA was 20/40 and OCT showed improved macular retinoschisis, an absence of vitreomacular traction, and a small amount of subretinal fluid. The central foveal thickness measured 229 µm (Figure 2B).

View larger version (56K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. Optical coherence tomographic images. A, Macular retinoschisis with outer retinal cystic spaces and elongated retinal pillars is shown. There is traction from an attached posterior hyaloid and a pocket of subfoveal fluid. There are focal areas of reduced reflectivity posterior to the retinal pigment epithelium. The central foveal thickness is 517 µm. B, Improved macular retinoschisis is shown, and vitreomacular traction is absent. A small pocket of subfoveal fluid remains. Increased choroidal penetrance of the optical coherence tomography signal is evident as a broad area of enhanced reflectivity posterior to the retinal pigment epithelium. The central foveal thickness is 229 µm.

Case 3

A 69-year-old woman with 17 D of myopia experienced progressive visual loss in the left eye over the previous year. During the previous 4 months, BCVA decreased from 20/50 to 20/400 OS due to progressive macular retinoschisis. Fluorescein angiography showed no vascular leakage or cystoid macular edema. Optical coherence tomography showed macular retinoschisis, tenting of the fovea as a result of vitreomacular traction centrally, and no subfoveal fluid. The central foveal thickness measured 577 µm (Figure 3A). One month following pars plana vitrectomy, removal of the posterior hyaloid, internal limiting membrane peeling, and fluid-gas exchange using 16% perfluoropropane gas, BCVA was 20/50. Optical coherence tomography showed an improved foveal contour and absent vitreomacular traction, but there was residual macular retinoschisis. The central foveal thickness measured 279 µm (Figure 3B).

View larger version (54K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 3. Optical coherence tomographic images. A, Macular retinoschisis and tenting of the fovea due to vitreomacular traction are shown. Increased choroidal penetrance of the optical coherence tomography signal is evident as an area of enhanced reflectivity. The central foveal thickness is 577 µm. B, Improved macular retinoschisis is shown, and vitreomacular traction is absent. Increased choroidal reflectivity is still evident, and the central foveal thickness is 279 µm.

Comment
The existence of macular retinoschisis in highly myopic eyes has been described previously.^1-3 In 2 of these articles^1-2 including OCT evaluations, macular retinoschisis was accompanied by foveal detachment; also, treatment with pars plana vitrectomy, removal of the posterior hyaloid, internal limiting membrane peeling, and gas tamponade was associated with improved visual acuity and resolution of the foveal detachment. The only published study³ of the natural history of macular retinoschisis in high myopia included 21 eyes, 13 of which were followed up for 12 or more months. In the latter study, macular retinoschisis was found to be fairly stable in terms of visual acuity and retinal thickness; however, in 2 of the 4 eyes with foveal traction (presumably from the posterior hyaloid), a full-thickness macular hole developed.

Eyes with pathologic myopia may have multiple causes of poor vision, including choroidal neovascularization, lacquer cracks, geographic atrophy of the retinal pigment epithelium, macular hole, and posterior staphyloma. In addition to macular hole, macular retinoschisis represents another category of maculopathy in these eyes that may be amenable to surgical management. As with macular hole, visual acuity outcomes are limited by the complex pathology in these highly myopic eyes.^4-5

In our study, surgical management of macular retinoschisis without retinal detachment was associated with improved visual acuity and full or partial resolution of the macular retinoschisis. The patients described in this series had progressive vision loss over 12 to 24 months preoperatively; visual acuity and OCT changes improved postoperatively.

AUTHOR INFORMATION
Correspondence: Dr Scott, Department of Ophthalmology, Penn State College of Medicine, 500 University Dr, HU19, Hershey, PA 17033-0850 (iscott{at}psu.edu).

Financial Disclosure: None reported.

REFERENCES
1. Kobayashi H, Kishi S. Vitreous surgery for highly myopic eyes with foveal detachment and retinoschisis. Ophthalmology. 2003;110:1702-1707. FULL TEXT | WEB OF SCIENCE 2. Ikuno Y, Sayanagi K, Ohji M, et al. Vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Am J Ophthalmol. 2004;137:719-724. WEB OF SCIENCE | PUBMED 3. Benhamou N, Massin P, Haouchine B, et al. Macular retinoschisis in highly myopic eyes. Am J Ophthalmol. 2002;133:794-800. FULL TEXT | WEB OF SCIENCE | PUBMED 4. Sulkes DJ, Smiddy WE, Flynn HW Jr, Feuer W. Outcomes of macular hole surgery in severely myopic eyes: a case-control study. Am J Ophthalmol. 2000;130:335-339. FULL TEXT | WEB OF SCIENCE | PUBMED 5. Garcia-Arumi J, Martinez V, Puig K, Corcostegui B. The role of vitreoretinal surgery in the management of myopic macular hole without retinal detachment. Retina. 2001;21:332-338. FULL TEXT | WEB OF SCIENCE | PUBMED

SECTION EDITOR: W. RICHARD GREEN, MD

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