Purpose
To evaluate the clinical outcomes of 23 gauge vitrectomy, endolaser, and gas tamponade vs vitrectomy alone for the management of serous macular detachment associated with optic disc pits.
Design
Retrospective, comparative case series.
Methods
Seventeen eyes of 16 patients who underwent 23 gauge transconjunctival sutureless pars plana vitrectomy (PPV) for serous macular detachment associated with optic disc pits were evaluated in this study. Complete ophthalmologic examinations including optical coherence tomography (OCT) and fundus autofluorescence were evaluated at the baseline and during the postoperative follow-up period. Ten eyes of 9 cases that underwent 23 gauge PPV, endolaser, and gas tamponade were allocated to Group 1, and 7 eyes of 7 cases that underwent 23 gauge PPV alone were allocated to Group 2.
Results
There were 6 male and 3 female patients in Group 1, and the average age of patients was 24.7 years. There were 5 male and 2 female patients in Group 2 and the average age of patients was 22.1 years. There was no difference in the postoperative visual acuity ( P = .7) and postoperative central foveal thickness ( P = .5) between the 2 groups. The mean time of the subretinal fluid resolution was significantly shorter in Group 1 than in Group 2. OCT showed the inner layer separation improved before than serous retinal detachment. Preoperative features of the inner/outer segment junction correlate well with improvement of postoperative visual acuity.
Conclusions
Vitrectomy alone without gas tamponade and laser photocoagulation is a safe and effective method for management of serous macular detachment resulting from optic disc pits as well as combined surgery.
Optic disc pits are a rare congenital anomaly with a reported incidence of 1 in 11 000 patients. They are predominantly unilateral, with estimates of bilaterality ranging from 10% to 28%. Some investigators had considered optic disc pit to represent small colobomatous defects of the optic disc arising from incomplete closure of the ocular fetal fissure in the region of the optic disc. Among the approximately 40%–66% of eyes with optic disc pits, the associated nonrhegmatogenous, serous retinal detachment or signs suggestive of earlier detachment can be seen, most commonly in the second or third decade. The precipitant is probably vitreous traction, and the risk is greatest if the pit is temporal. The origin of the macular fluid continues to be a controversial subject, with reports that the fluid is of cerebrospinal origin through the peripapillary subarachnoid space, derived from the vitreous cavity or arising from the orbit. The proposed mechanism for such retinal detachments is that fluid enters the optic disc pit and causes retinal schisis between the inner and outer retina. The fact is that macular detachments can be schisis or full-thickness sensory retinal detachment, or both. Optical coherence tomography (OCT) is an important imaging technique for the evaluation of optic disc pit maculopathy. OCT has demonstrated the inner and outer layer of retinal schisis and retinal detachment in optic disc pit maculopathy. Fundus autofluorescence (FAF) imaging can be used to monitor the level of lipofuscin that has accumulated in the subretinal space and in the retinal pigment epithelium. An accumulation of intensely autofluorescent subretinal deposits in the area of a serous retinal detachment has been reported in the FAF images of eyes with optic disc pit maculopathy.
Pars plana vitrectomy (PPV) with the creation of a posterior vitreous detachment (PVD) and gas tamponade with laser treatment had been reported to lead to a complete reattachment of the retina and resolution of the retinal schisis. However, it required approximately 1 year for the reattachment and the reason for the long recovery period and the appearance of the retina during the course of the recovery has not been reported.
The aim of this study was to assess the clinical outcomes of 23 gauge PPV, endolaser, and gas tamponade vs vitrectomy alone for serous macular detachment associated with optic disc pit.
Methods
Seventeen eyes of 16 patients who underwent 23 gauge transconjunctival sutureless PPV for serous macular detachment associated with optic disc pit and were followed up in Ulucanlar Eye Education and Research Hospital between January 2008 and December 2014 were evaluated in this study. All of the study procedures were conducted in accordance with the Declaration of Helsinki, and informed consents were taken from all of the participants after approval from the Institutional Review Board. This study was approved by The Ethical Committee of Diskapi Training and Research Hospital. All patients were white Turkish individuals. Patients with a history of prior PPV surgery and any corneal pathology were excluded from the study. Complete ophthalmologic examinations including best-corrected visual acuity (BCVA), intraocular pressure (IOP) with applanation tonometry, slit-lamp biomicroscopy, dilated fundus examination, OCT, and FAF were evaluated at the baseline and during the postoperative follow-up period. Patients were followed up monthly. BCVA was measured with the Snellen chart. For statistical analysis, Snellen values were converted to the logarithm of the minimal angle of resolution (logMAR) chart. The intraocular pressure was measured by using the Goldmann applanation tonometer. The spectral-domain optical coherence tomography (SD OCT) volume scan (20 × 20 degrees with 49 horizontal sections, ART 15) including en face images and macular mapping image obtained with HRA2 (Heidelberg Retina Angiograph-Optical Coherence Tomography; Heidelberg Engineering, Heidelberg, Germany) was performed for each study eye. FAF images were obtained with a confocal scanning laser ophthalmoscope with scanning fields of 50 degrees. For the FAF images, a wavelength of 488 nm was used for excitation with an observation filter passing wavelengths >500 nm. For FAF images, 9 images (8.8 frames per second) were averaged with the Automatic Real Time composite mode of the instrument to obtain high-quality images.
Ten eyes of 9 cases that underwent 23 gauge PPV, endolaser, and gas tamponade were allocated to Group 1, and 7 eyes of 7 cases that underwent 23 gauge vitrectomy alone were allocated to Group 2. Nine consecutive cases underwent combined surgery, followed by 7 consecutive cases that underwent vitrectomy alone. All cases were phakic and had serous retinal detachment. All surgery was performed by 1 surgeon (M.Y.T.). The OCT and FAF were examined by a retina specialist (M.C.) who was masked to the patient and visual acuity outcomes.
All surgeries were performed under local anesthesia by retrobulbar injection. The Dutch Ophthalmic Research Company (DORC, Zuidland, Netherlands) 23 gauge system was used in all cases. Transscleral cannulas were placed through the pars plana in the superonasal, superotemporal, and inferotemporal quadrants, per standard vitrectomy protocol. A 23 gauge PPV with triamcinolone-assisted removal of the posterior hyaloid interface was performed. Fluid-air exchange and endodrainage through the pit using silicone-tipped extrusion cannula was performed; no additional drainage retinotomies were created. Endodrainage was considered successful if flattening of macular elevation was observed intraoperatively. In Group 2, the operation was finalized. Additionally, peripapillary endolaser barrage photocoagulation was performed using frequency-doubled neodymium–yttrium-aluminum-garnet laser (532 nm) temporally, and air-gas exchange was performed with 16% perfluoropropane (C3F8) gas in Group 1. Three rows of 100 mm spot size burns were placed temporal and adjacent to the optic nerve to span the juxtapapillary border of the retinal detachment and the superior and inferior margins of the detached retina. After surgery, the patients were instructed to maintain a facedown position for 1 week in Group 1. Postoperative facedown positioning was not suggested in Group 2.
All statistics in this study were analyzed using SPSS for Windows (SPSS Inc, Chicago, Illinois, USA). Differences between the 2 groups for retinal thickness parameters were evaluated using t test analysis, where applicable. The level of significance was set at <.05.
This study is registered as an International Standard Randomized Controlled Trial, number ISRCTN 3759180.
Results
There were 6 male and 3 female patients in Group 1, and the average age of patients was 24.7 years. In Group 2 there were 5 male and 2 female patients, and the average age of patients was 22.1 years. Seventeen eyes of 16 patients were involved. The duration of symptoms ranged from 6 to 60 months (12.4 ± 7.9 months). Neither PVD nor vitreomacular or vitreopapillary traction was observed in any eyes preoperatively. No patients had received any prior treatment. None of the affected eyes had severe refractive errors (±3 diopters). Optic disc pit was located temporally in all patients. Vitrectomy was performed. The attachment of the posterior hyaloid to the dome-shaped inner limiting membrane (ILM) was confirmed, and the posterior hyaloid membrane was separated from the ILM. Removal of the posterior hyaloid was created with difficulty. ILM peeling was not performed in any cases. At the same time, very taut ILM was observed. For 11 of 17 eyes (64.7%), condensed vitreous or glial tissue was seen within the pit intraoperatively. In all of the cases, no intraoperative complications occurred including vitreous prolapses, bleeding in the sclerotomy site, and contact to the lens. Through the follow-up visit, none of the 17 eyes developed endophthalmitis. The mean follow-up period was 31 months (22–56 months). There were no significant differences between the 2 groups with respect to age ( P = .6), sex ( P = .6), preoperative logMAR BCVA ( P = .2), and preoperative central foveal thickness (CFT) ( P = .5).
In Group 1, the average age of the patients (mean ± SD) was 24.7 ± 10.9 years (8–39 years). The mean preoperative BCVA was 1.08 ± 0.44 (0.52–1.59) logMAR (Snellen equivalents, mean 20/240, range 20/780–20/66). Mean overall postoperative BCVA was 0.71 ± 0.42 (0.15–1.30) logMAR at last visit (Snellen equivalents, mean 20/100, range 20/400–20/28). Statistically significant improvement in BCVA was established at the last visits compared to the preoperative BCVA ( P = .009). Six eyes in Group1 gained 3 or more lines. The mean overall preoperative IOP (mean ± SD) was 13.20 ± 1.93 mm Hg (range, 10–16 mm Hg). Mean overall postoperative IOP was 13.30 ± 2.86 mm Hg (range, 10–18 mm Hg) at last visit. The intraocular pressure of all eyes remained in normal limits through the postoperative period (range, 10–18 mm Hg). There were no statistically significant changes of intraocular pressure in the postoperative period ( P = .09). The CFT was reduced from a preoperative value of 709.70 ± 205.72 μm to a postoperative value of 163.20 ± 20.19 μm ( P = .0001) ( Figure 1 ).
In Group 2, the average age of the patients (mean ± SD) was 22.1 ± 9.3 years (11–34 years). The mean preoperative BCVA was 1.30 ± 0.22 (1.00–1.52) logMAR (Snellen equivalents, mean 20/400, range 20/600–20/200). Mean overall postoperative BCVA was 0.65 ± 0.27 (0.30–1.00) logMAR at last visit (Snellen equivalents, mean 20/90, range 20/200–20/40). Statistically significant improvement in BCVA was established at the last visits compared to the preoperative BCVA ( P = .003). Four eyes in Group 2 gained 3 or more lines. The mean overall preoperative IOP (mean ± SD) was 14.28 ± 3.49 mm Hg (range, 10–19 mm Hg). Mean overall postoperative IOP was 13.71 ± 2.36 mm Hg (range, 11–18 mm Hg) at last visit. The intraocular pressure of all eyes remained in normal limits through the postoperative period (range, 11–18 mm Hg). There were no statistically significant changes of intraocular pressure in the postoperative period ( P = .17). The CFT was reduced from a preoperative value of 759.00 ± 101.48 μm to a postoperative value of 170.71 ± 25.86 μm ( P = .0001) ( Figure 2 ).
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