High myopia can be associated with a range of pathologic changes within the macula that are now easily appreciated with optical coherence tomography. In the setting of high myopia and a macular traction retinal detachment, the expectation is for progressive worsening over time, and surgical intervention is often undertaken early. The authors present a case of spontaneous improvement of myopic macular detachment, which illustrates the potential value of an initial period of observation in this clinical setting.
[Ophthalmic Surg Lasers Imaging Retina. 2013;44:497–498.]
From the Department of Ophthalmology, New England Eye Center, Tufts Medical Center and Ophthalmic Consultants of Boston, Massachusetts.
Supported in part by an unrestricted award to the New England Eye Center, Department of Ophthalmology, Tufts University School of Medicine from Research to Prevent Blindness and by the Massachusetts Lions.
The authors have no financial or proprietary interest in the materials presented herein.
Dr. Duker did not participate in the editorial review of this manuscript.
Address correspondence to Jay S. Duker, MD, Department of Ophthalmology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111; email:
Received: March 10, 2013
Accepted: June 02, 2013
In some eyes, high myopia results in a spectrum of macular changes (myopic traction maculopathy) that include schisis and retinal detachment.1–3 Both macular schisis and retinal detachment were not well recognized prior to the advent of optical coherence tomography (OCT). In the OCT era, the prevalence of macular retinoschisis in highly myopic eyes has been shown to be as high as 20%2 and that of macular retinal detachment to be 1.6% to 5.2%.2,4 The natural clinical course of macular retinal detachment in the setting of high myopia and foveal schisis is typically that of progressive worsening.1,3 In such eyes, surgical intervention with core vitrectomy, induction of a posterior vitreous detachment, and peeling of the internal limiting membrane has been shown to be effective and has been suggested to prevent macular hole formation.5 Therefore, in the setting of high myopia and progressive macular retinal detachment, surgical intervention is often advocated early to maximize visual outcome. We present a case illustrating spontaneous improvement of myopic macular detachment.
A 60-year-old highly myopic woman with a history of complex retinal detachment repair in the right eye presented complaining of decreased visual acuity and seeing a yellow spot in the left eye for the prior 5 days. Her visual acuity measured counting fingers in the right eye and 20/70 in the left eye. Examination revealed a macular scar in the right eye and a posterior staphyloma with focal retinal detachment involving the fovea of the left eye (Figure 1, top). OCT confirmed the presence of a focal macular detachment and macular schisis (Figure 1, bottom). There was no evidence of dome-shaped macula on a vertical OCT section. Fluorescein angiography revealed no evidence of choroidal neovascularization. Surgery with vitrectomy and membrane peeling was considered, but given the relatively intact vision and monocular status, the patient elected for initial observation. Two weeks later, the patient returned, reporting a spontaneous improvement in visual acuity in the left eye, which measured 20/40. Examination and OCT revealed a reduction in submacular fluid. Six weeks after initial presentation, continued improvement in visual acuity (to 20/30) and nearly resolved submacular fluid (Figure 2) were observed, both of which remained after 1 year.
Figure 1. Fundus photograph of the left eye at presentation shows tilted disc, peripapillary atrophy, and posterior staphyloma consistent with degree of high myopia (top). Within the arcades, just inferior to an atrophic lesion, is a retinal detachment (white arrowheads) correlating to area of thickening on corresponding OCT map image (inset). OCT shows vitreomacular traction, macular schisis, and subretinal fluid in the macula (bottom).
Figure 2. Six weeks after presentation, the retinal detachment is barely perceptible (top), and the corresponding OCT map image (inset) shows a significant reduction in thickening inferiorly. OCT shows continued persistent vitreomacular traction, near resolution of subretinal fluid, and schisis-like changes in the fovea (bottom).
This case represents an unusual course of untreated myopic macular retinal detachment in that spontaneous improvement occurred over time without surgical intervention. It has been suggested that myopic retinal detachment with schisis is due to abnormal vitreoretinal tractional forces,1,6 an idea that is supported by the efficacy of vitrectomy surgery to repair these abnormalities. In the case presented here, there is a broad vitreoretinal adhesion over the nasal part of the macula, which does not appear to change following resolution of the detachment. To explain the spontaneous improvement in the macular contour, there may have been an anterior vitreous adhesion outside of the imaging field that spontaneously released. This observation brings into question the validity of vitreoretinal traction over the macula as the only or major pathophysiologic mechanism that is implicated, and further research in this area would be insightful. In a patient who presents with a localized macular retinal detachment in the setting of high myopia without a macular hole, an initial observation period should be considered prior to surgical intervention.
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