Optic disc pit (ODP) is a congenital abnormality of the optic nerve head and may lead to macular detachment. In addition to the congenital type, acquired ODP secondary to glaucoma has also been described.1 Enhanced depth imaging optical coherence tomography (OCT) was recently reported to show structural abnormalities involved in optic disc development in glaucomatous eyes associated with laminar holes or lamina cribrosa defects.2 These findings suggest that subretinal fluid (SRF) due to acquired ODP originates from vitreous fluid, passing through the ODP, not from the subarachnoid space.
In recent years, implantation of a piece of sclera,3,4 internal limiting membrane (ILM) insertion into the ODP,5,6 or the inverted ILM technique for the ODP7 have been reported to achieve good results. Furthermore, transplantation methods involving the anterior or posterior capsule for refractory macular hole (MH) treatment have also been reported.8 Herein, we describe a patient with acquired ODP maculopathy who underwent anterior capsule transplantation to close the ODP.
A 70-year-old woman had first noticed visual acuity (VA) loss in the right eye (OD) 3 years prior to presentation. She became particularly aware of VA loss in November 2015. Her best-corrected VA (BCVA) at the first visit was 20/25 OD. The intraocular pressures were 12 mm Hg OD and 13 mm Hg in the left eye (OS). Cataracts (Emery-Little grade 2) were recognized in both eyes. Fundus examination showed an ODP in the lower part of the OD optic disc and a nerve fiber defect at the same site as the ODP (Figure 1A). This corresponded to a visual field defect on Humphrey visual field testing. OCT indicated retinoschisis and a retinal detachment extending from the optic disc to the macula (Figures 1B and 1C). ODP was confirmed by OCT and angio-OCT three-dimensional images (Figures 1B and 1D). Her BCVA OD deteriorated to 20/32, necessitating 27-gauge vitrectomy.
Preoperative color photograph and optical coherence tomography (OCT) image in Case 1. (A) Right fundus of a 70-year-old woman shows an optic disc pit in the lower part of the optic disc (arrowhead) and a nerve fiber defect (arrows). (B) Optic disc OCT scan of the right eye including the optic pit shows a deep, slit-like cavity (arrows). The OCT image also indicates retinoschisis from the disc (asterisk). (C) The OCT image shows a retinal detachment extending from the optic disc to the macula (asterisk). (D) En face view of the optic disc of the angio-OCT image shows the pit at the lower pole of the optic disc (arrowhead).
Prior to vitrectomy, the patients underwent cataract surgery and anterior capsulorhexis was performed with anterior capsular forceps. The anterior capsule was removed from the eye and stained with 0.0625% Brilliant Blue G to avoid misplacing it. The capsule was then temporarily stored in a petri dish with BSS PLUS solution (Alcon, Fort Worth, TX). Then, 27-gauge vitrectomy was performed. Posterior vitreous detachment (PVD) was confirmed by visualizing the vitreous body with triamcinolone during vitreous surgery to have already been present. As fine residual vitreous cortex was observed, it was removed with a diamond dust eraser and a soft-tip endo-drainage cannula. After peripheral vitreous shaving with indentation of the sclera, dispersive ophthalmic viscoelastic substance (Viscoat; Alcon, Fort Worth, TX) was applied to the optic disc as an alternative to glue. Then, one piece of the anterior capsule dyed with Brilliant Blue G was introduced into the eye with vitreous forceps and gently placed on the ODP. Additional viscoelastic material was applied to the anterior capsule to achieve further stabilization. During this series of maneuvers, the infusion tube was clamped to facilitate stabilization of the anterior capsule. Fluid-air exchange was conducted gently to assure that the transplanted anterior capsule did not move from the optic pit area. Then, 9% C3F8 gas tamponade was provided. Endolaser photocoagulation to the ODP was not conducted. (Supplemental video available below).
As soon as the surgery had been completed, the patient was asked to assume the prone position, moving from a surgical bed to a stretcher. She remained in the prone position for 24 hours. During the next 24 hours, she stayed in the sitting position or in the left and right lateral positions until the gas had been reduced by half.
At 1 month postoperatively, when the gas had largely disappeared, detailed examinations demonstrated only slight persistent retinal detachment, and the anterior capsule showed satisfactory fixation to the optic disc on OCT (Figures 2A and 2B). BCVA was improved to 20/25 OD at 2 months postoperatively, and the retinal detachment had completely disappeared (Figure 2C). BCVA was improved to 20/20 OD at 1 year postoperatively. No visual field defect progression was recognized after surgery.
Postoperative optical coherence tomography (OCT) image in Case 1. (A, B) The anterior capsule shows that satisfactory fixation onto the optic disc has been achieved, based on vertical and horizontal swept-source OCT scans (arrows). (C) Complete disappearance of retinal detachment 2 months postoperatively.
Closure of the ODP in eyes with ODP maculopathy by applying an inverted ILM flap is thought to be the simplest technique currently available.7 However, nerve fiber defects associated with the ODP may develop. Such nerve fiber defects are often associated with visual field defects. Therefore, worsening of visual field defects is a concern when performing ILM peeling,9 especially for acquired ODP maculopathy secondary to glaucoma. Notably, this case was also thought to have had the complication of glaucoma. Performing this technique without ILM peeling may have several benefits, in terms of preventing postoperative exacerbation of visual field defects. In fact, this patient showed no visual field defect progression after surgery. Furthermore, MH formation after vitreous surgery accompanied by ILM peeling in eyes with ODP maculopathy has been reported.10,11 ILM peeling including the fovea allows MH formation to progress. The fovea-sparing method is preferable in terms of preventing MH formation. However, the optic nerve might be large in patients with congenital ODP maculopathy. In such cases, pit closure by the fovea sparing method may not be possible due to insufficient inversion of the ILM. Anterior capsule transplantation would be useful for such cases.
In our present patient, postoperative OCT showed complete closure of the optic pit. In addition, the existence of PVD was confirmed by intraoperatively visualizing the vitreous body with triamcinolone. The results indicated that there was no vitreous cortex with retinal traction. Therefore, we considered complete ODP closure to have resulted in prompt absorption of SRF, indicating ODP closure, in itself, to be a useful and effective procedure.
Further accumulation of similar cases is needed to confirm our observations. Anterior capsule closure by this method has limitations due to the difficulties of handling the anterior capsule in the eye and overall lack of experience with this technique. Furthermore, the mechanism of ODP maculopathy is complex and not fully understood for either the congenital or the acquired form. Thus, ODP closure might be ineffective in cases with fluid originating in the subarachnoid space. However, anterior capsule transplantation is minimally invasive as compared to other techniques, including the inverted ILM flap technique, for achieving ODP closure. Our technique holds promise as an initial treatment for ODP maculopathy.
In eyes that have previously undergone cataract surgery, if a second surgery becomes necessary, the posterior capsule can be used as an alternative.
To our knowledge, this is the first report describing application of the anterior capsule to treating acquired ODP maculopathy.
- Radius RL, Maumenee AE, Green WR. Pit-like changes of the optic nerve head in open-angle glaucoma. Br J Ophthalmol. 1978;62(6):389–393. https://doi.org/10.1136/bjo.62.6.389 PMID: doi:10.1136/bjo.62.6.389 [CrossRef]666988
- Yoshitake T, Nakanishi H, Setoguchi Y, et al. Bilateral papillomacular retinoschisis and macular detachment accompanied by focal lamina cribrosa defect in glaucomatous eyes. Jpn J Ophthalmol. 2014;58(5):435–442. https://doi.org/10.1007/s10384-014-0330-8 PMID: doi:10.1007/s10384-014-0330-8 [CrossRef]24931650
- Shah PK, Karandikar SS, Narendran V. Scleral Autograft for Optic Nerve Head Pit Associated Chronic Maculopathy. Ophthalmic Surg Lasers Imaging Retina. 2017;48(3):251–254. https://doi.org/10.3928/23258160-20170301-09 PMID: doi:10.3928/23258160-20170301-09 [CrossRef]28297038
- Travassos AS, Regadas I, Alfaiate M, Silva ED, Proença R, Travassos A. Optic pit: novel surgical management of complicated cases. Retina. 2013;33(8):1708–1714. https://doi.org/10.1097/IAE.0b013e31828e699c PMID: doi:10.1097/IAE.0b013e31828e699c [CrossRef]23644559
- Nawrocki J, Bonińska K, Michalewska Z. Managing Optic Pit. The Right Stuff!Retina. 2016;36(12):2430–2432. https://doi.org/10.1097/IAE.0000000000001218 PMID: doi:10.1097/IAE.0000000000001218 [CrossRef]27471828
- 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. https://doi.org/10.3928/23258160-20170329-11 PMID: doi:10.3928/23258160-20170329-11 [CrossRef]28419402
- 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. https://doi.org/10.4103/0974-9233.120008 PMID: doi:10.4103/0974-9233.120008 [CrossRef]24339690
- Chen S-N, Yang C-M. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies. Retina. 2016;36(1):163–170. https://doi.org/10.1097/IAE.0000000000000674 PMID: doi:10.1097/IAE.0000000000000674 [CrossRef]
- Tsuchiya S, Higashide T, Sugiyama K. Visual field changes after vitrectomy with internal limiting membrane peeling for epiretinal membrane or macular hole in glaucomatous eyes. PLoS One. 2017;12(5):e0177526. https://doi.org/10.1371/journal.pone.0177526 PMID: doi:10.1371/journal.pone.0177526 [CrossRef]28542230
- Yoshikawa T, Yamanaka C, Kinoshita T, Morikawa S, Ogata N. Macular retinoschisis in eyes with glaucomatous optic neuropathy: vitrectomy and natural course. Graefes Arch Clin Exp Ophthalmol. 2018;256(2):281–288. https://doi.org/10.1007/s00417-017-3855-y PMID: doi:10.1007/s00417-017-3855-y [CrossRef]
- Haruta M, Kamada R, Umeno Y, Yamakawa R. Vitrectomy for optic disc pit-associated maculopathy with or without preoperative posterior vitreous detachment. Clin Ophthalmol. 2012;6:1361–1364. https://doi.org/10.2147/OPTH.S34962 PMID: doi:10.2147/OPTH.S34962 [CrossRef]22973089