Optic Pit: How to Deal with a Stubborn ILM Flap?


EDITED FILM


ABSTRACT

Introduction:

Optic pits (OP) are congenital defects in the development of the primitive papilla, that course with macular edema in 25-75% of cases. This results from liquid evading the vitreous or subarachnoid space, through the pit and into the macula. Vitreous traction also plays a major role in the pathogenesis of OP-related maculopathy. Vitrectomy with posterior hyaloid stripping and peeling of the internal limiting membrane (ILM) has been the preferred treatment for many years. Most recently reported techniques involve bending the ILM flap over the optic disc to block the fenestrated pit wall and stop fluid flow between vitreous and macula. Our purpose is to present a successful surgical approach of an OP-related maculopathy in which the ILM flap was bent over the optic disc.

Methods:

Clinical case review of a 74-year-old male patient who presented with right eye (RE) progressive visual acuity decrease. He was submitted to complete ophthalmological examination, including best corrected visual acuity (BCVA), biomicroscopy, tonometry and fundus observation. RE initial BCVA was 20/60 and slit-lamp examination was unremarkable apart from an optic pit with accompanying macular edema noticed on fundoscopy. Complementary macular optical coherence tomography (OCT) confirmed the presence of macular edema with disruption of the outer retinal layers and baseline central macular thickness (CMT) of 570μm. Surgical treatment was proposed.

Results:

Surgery started with 23-gauge pars plana vitrectomy followed by triamcinolone injection and careful mechanic elevation of the posterior hyaloid. Trypan-blue dye was then used to stain the ILM. During ILM peeling a flap was created and several unsuccessful attempts were made to bend it over the optic disc. Cohesive viscoelastic material was then used but the flap always regained its original position. The flap was finally stabilized using a dispersive viscoelastic device. After fluid-air change and sclerotomies’ suture, the vitreous cavity was tamponed with 20% SF6. 2 weeks after surgery, BCVA had improved to 20/50 and reabsorption of macular fluid was observed. After a two-year follow-up the patient remains stable presenting a BCVA 20/30 and residual subfoveal fluid. Normalization of retinal anatomy with reconstruction of the outer layers was noticed.

Conclusion:

Optic pits often require challenging surgical procedures. Classic approaches address vitreous traction solely, but novel techniques step forward into the pathogenesis of the macular edema. The method used solved both vitreous traction and leakage of fluid from the vitreous into the retina, with favorable long-term anatomic and functional results.


CONTACT DETAILS

Filipe Henriques
Coimbra, Portugal
Email : filh1967@gmail.com
Cell Phone: +351918362497
Work Phone: +351916191052