Optic disc pits (ODPs) have long been recognized as congenital abnormalities of the optic nerve head.1 Macular changes can occur in the context of an ODP (optic disc pit maculopathy [ODP-M]) and include intraretinal or subretinal fluid accumulation and retinal pigment changes.2 Although some reports describe spontaneous resolution of the subretinal fluid with improved vision, most eyes lose vision within the first 6 months with final visual acuity (VA) of 20/200 or worse.1
The predominant approach for the treatment of ODP-M is pars plana vitrectomy (PPV) with induction of posterior vitreous detachment, internal limiting membrane (ILM) peeling, peripapillary laser, fluid-air exchange, and gas or silicone oil tamponade.2–4 An alternative technique with macular buckling, active drainage of subretinal fluid with a small gauge cannula has been described, but it is rarely used.3 Other techniques designed to seal the ODP include inverting peeled ILM into the ODP5 and using Tisseel fibrin sealant (Baxter Healthcare, Deerfield, IL).6
In June 2016, a 27-year-old male was referred to our retinal clinic in Florence, Italy, with a serous macular detachment related to optic pit in the right eye. In 2007, the patient underwent vitrectomy with induced posterior hyaloid detachment, ILM peeling, peripapillary laser, and gas tamponade, but he developed subretinal fluid and his VA was worse a few years after surgery (Figure 1).
Intraoperative photograph of the patient affected by optic disc pit showing serous macular detachment and peripapillary laser scars temporal to the disc.
He was phakic with clear lens status and his VA was 20/50 with no refractive errors in both eyes. Fundus examination showed a serous macular detachment with an optic nerve coloboma. There was peripapillary atrophy due to the previous laser treatment. Optical coherence tomography confirmed the status of the macular detachment. We performed a lens-sparing 27-gauge PPV. The status of the posterior hyaloid was checked by staining the vitreous with triamcinolone acetonide. The posterior hyaloid was removed all over the posterior pole as far as the vascular arcades. With the vitrectomy probe, we extended the posterior hyaloid detachment to the medium retinal periphery. We used MembraneBlue-Dual (Brilliant Blue G + Trypan Blue; D.O.R.C., Zuidland, The Netherlands) to stain the ILM remnants in the posterior pole. All the ILM on the posterior pole had already been peeled, and we had to harvest the ILM beyond the vascular arcades. Holding the ILM with the vitreal forceps, we injected a bubble of perfluorocarbon liquids (PFCL) over the optic nerve head to better manipulate the plug of ILM, then the plug was placed inside the optic pit. PFCL was removed by tilting the eye bulb to dislocate the PFCL bubble upward in order to avoid accidentally aspirating the ILM plug from the optic nerve pit (Figure 3). Finally, fluid-air exchange and an injection of sulfur hexafluoride (SF6) gas at 20% were performed (See Supplemental Video below). The patient was positioned face-down for the first week after surgery. The subretinal fluid gradually resolved during 10 months of follow-up, and VA improved to 20/20 at the tenth month after surgery (Figure 2).
Optical coherence tomography (OCT) shows serous macular detachment with overlying retinoschisis and the connection to the subretinal fluid in the macula (A). OCT shows the internal limiting membrane plug inside the optic pit 1 month after surgery (B). Spectral-domain OCT demonstrates partial resolution of submacular fluid at the third month (C) and complete resolution at the tenth month after surgery (D).
Internal limiting membrane (ILM) plug inside the optic nerve pit during surgery. The arrow delineates the ILM graft.
Serous retinal detachment is a frequent complication of the optic pit (25% to 75%) associated with a bad VA prognosis. Many surgical approaches have been proposed, but none with a 100% retinal detachment resolution. In a recent multicenter study, a complete retinal reattachment was reported in 86.3% of the cases treated with PPV in a mean period of 7 months.7 To operate on a recurring retinal detachment associated with an optic pit that has undergone a full spectrum of intraoperative maneuvers such as ILM peeling, posterior vitreous detachment, peripapillary laser treatment, and intraocular tamponade could be considered a tough challenge. The use of autologous platelet-rich plasma to repair a recurring retinal detachment associated with optic pit has recently been described for a patient who had already undergone pars plana vitrectomy, peripapillary laser treatment, and gas tamponade with a resolution of the retinal detachment 8 months after surgery and good VA recovery.8 The inverted flap technique and ILM autologous transplantation to close macular holes in myopic eyes and to resolve a retinal detachment caused by a myopic macular hole have improved the success rate of surgery.9 It has recently been described that ILM transplants can create a physical barrier to avoid the infiltration of fluid through the break in order to seal posterior retinal breaks over chorioretinal atrophy areas.10 Inverted ILM flap technique has already been used to close the optic nerve pit, with resolution of the retinal detachment in only 1 month and good visual recovery 3 months after surgery.5 A case of ODP sealed with autologous free ILM flap, harvested from the posterior pole, was described with a similar technique explained earlier to create a barrier to stop further fluid accumulation.11 Differently from the previous technique our case had already been operated, peripapillary laser treatment had already been applied without success, and there was no residual ILM at posterior pole to carry out an optic pit inverted flap or a free ILM flap technique. We thought that a plug of ILM could work to seal the optic pit as it seals the retinal breaks in highly myopic eyes. The ILM was harvested on the edge of the previous peeling, which was over the temporal vascular arcades. In the autologous transplantation of the ILM to seal a recurring macular hole we use PFCL to manipulate the thin plug of ILM harvested beyond the posterior pole. The difficulty in this case was not to aspirate the PFCL bubble over the optic disc so as not to remove the ILM plug accidentally with the final residue of PFCL. We avoided this problem by tilting the eye bulb to dislocate the PFCL bubble upward and far from the optic disc. The colored ILM plug can be visualized inside the optic pit during all the phases of surgery to check the right positioning, even during fluid-air exchange and the first days after surgery. We did not observe a recurrence of subretinal fluid during the 14 months of follow-up.
We consider that autologous transplantation of the ILM may be effective to repair recurring optic disc pit maculopathy. Nevertheless, only one patient with surgical success does not prove the efficacy of the surgical technique. Studies with a higher number of patients affected by recurrent optic disc pit maculopathy would be useful to assess this technique and confirm our data.
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- Georgalas I, Ladas I, Georgopoulos G, Petrou P. Optic disc pit: A review. Graefes Arch Clin Exp Ophthalmol. 2011;249(8):1113–1122. doi:10.1007/s00417-011-1698-5 [CrossRef]
- Sobol WM, Blodi CF, Folk JC, Weingeist TA. Long-term visual outcome in patients with optic nerve pit and serous retinal detachment of the macula. Ophthalmology. 1990;97(11):1539–1542. doi:10.1016/S0161-6420(90)32380-1 [CrossRef]
- Moisseiev E, Moisseiev J, Loewenstein A. Optic disc pit maculopathy: When and how to treat? A review of the pathogenesis and treatment options. Int J Retina Vitreous. 2015;1:1–9. doi:10.1186/s40942-015-0013-8 [CrossRef]
- Mohammed OA, Pai A. Inverted autologous internal limiting membrane for management of optic disc pit with macular detachment. Middle East Afr J Ophthalmol. 2013;20(4):357–359. doi:10.4103/0974-9233.120008 [CrossRef]
- Al Sabti K, Kumar N, Chow DR, Kapusta MA. Management of optic disk pit-associated macular detachment with tisseel fibrin sealant. Retin Cases Brief Rep. 2008;2(4):274–277. doi:10.1097/ICB.0b013e3180eaa21b [CrossRef]
- Avci R, Kapran Z, Ozdek Ş, et al. Multicenter study of pars plana vitrectomy for optic disc pit maculopathy: MACPIT study. Eye (Lond). 2017;31(9):1266–1273. doi:10.1038/eye.2017.142 [CrossRef]
- Todorich B, Sharma S, Vajzovic L. Successful repair of recurrent optic disk pit maculopathy with autologous platelet rich plasma: Report of a surgical technique. Retin Cases Brief Rep. 2017;11(1):15–17. doi:10.1097/ICB.0000000000000276 [CrossRef]
- Okuda T. Macular hole closure over residual subretinal fluid by an inverted internal limiting membrane flap technique in patients with macular hole retinal detachment in high myopia. Retin Cases Brief Rep. 2016;10(2):140–144. doi:10.1097/ICB.0000000000000205 [CrossRef]
- Rizzo S, Tartaro R, Barca F, et al. Autologous internal limiting membrane fragment transplantation for rhegmatogenous retinal detachment due to paravascular or juxtapapillary retinal breaks over patchy chorioretinal atrophy in pathologic myopia. Retina. 2018;38(1):198–202. doi:10.1097/IAE.0000000000001636 [CrossRef]
- D'Souza P, Babu U, Narendran V. Autologous free internal limiting membrane flap for optic nerve head pit with maculopathy. Ophthalmic Surg Lasers Imaging Retina. 2017;48(4):350–353. doi:10.3928/23258160-20170329-11 [CrossRef]