Author: Saurabh Luthra (India)
Co-authors: Shrutanjoy Das, Shrey Maheshwari, Shweta Parakh, Gaurav Luthra, Mahesh Luthra, Sangeet Mittal
To evaluate modifications of fovea-sparing ILM peeling in the management of optic disc pit maculopathy.
Consecutive patients with optic disc pit maculopathy attending the Retina Service at Drishti Eye Institute, Dehradun, India
Preoperative best corrected visual acuity (BCVA), fundus photographs & Spectral Domain (SD-OCT) were recorded. Patients underwent intravitreal triamcinoone acetonide (IVTA) assisted 25G vitrectomy; Brilliant Blue G (BBG) dye assisted juxtapapillary (fovea-sparing) ILM peeling with either: 1. removal of peeled ILM, or 2. stuffing of peeled ILM into the optic pit, or 3. 41G cannula drainage of macular neurosensory detachment (NSD) with stuffing of peeled ILM into pit, or 4. temporal ILM Flap fashioning and apposition over pit; and air fluid exchange with C3F8 gas tamponade followed by postoperative positioning.
All patients achieved closure of optic disc pit. The patients with ILM flap removal, ILM flap stuffing and ILM flap stuffing with retinal fenestration showed complete resolution of macular NSD and retinoschisis at 10 months, 18 months and 17 months follow-up respectively with the BCVA improved to 6/6, 6/9, and 6/9 respectively. At last follow up at 6 months, the patient with temporal ILM Flap apposition showed significant resolution of NSD and retinoschisis with BCVA improved to 6/18p.
All four modifications of fovea-sparing ILM peeling successfully achieved closure of optic disc pit with resolution of maculopathy and good visual outcome. Epilogue: A 17 year old boy with optic pit maculopathy and gross NSD underwent 25G vitrectomy. During PVD induction, initially there was poor staining of preretinal cortical vitreous at posterior pole. During subsequent restaining with IVTA, there was inadvertent submacular triamcinolone injection. Majority of the submacular IVTA was successfully aspirated out of the pit with soft tip extrusion. Post air-fluid exchange, part of the residual submacular IVTA was gently massaged out through the pit into the optic cup with 25G loop. Juxtapapillary ILM was peeled after staining with BBG dye and apposed onto the pit. At last followup at 10 weeks, BCVA improved to 6/36, optic pit was closed with resolved macular NSD, with shallow subretinal fluid temporally, resolving hyperreflective dots in outer subfoveal retina with speckled hyperautofluorescence. This case shows that in certain anomalous variants of optic disc pit maculopathy, one may preempt the complication of submacular migration of IVTA and which may warrant cautious limited induction of PVD, leaving some vitreous attached over the optic pit to prevent the complication.