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Different Fundus Autofluorescence Patterns of Retinoschisis and Macular Hole Retinal Detachment in High Myopia
type 2A idiopathic juxtafoveolar retinal telangiectasis. Am J Ophthalmol 2004;137:812– 819. 6. De Lahitte GD, Cohen SY, Gaudric A. Lack of apparent short-term benefit of photodynamic therapy in bilateral, acquired, parafoveal telangiectasis without subretinal neovascularization. Am J Ophthalmol 2004;138:892– 894. 7. Eandi CM, Ober MD, Freund KB, Klais CM, Slakter JS, Sorenson JA, et al. Anecortave acetate for the treatment of idiopathic perifoveal telangiectasia: a Pilot Study. Retina 2006;26:780 –785.
Different Fundus Autofluorescence Patterns of Retinoschisis and Macular Hole Retinal Detachment in High Myopia Kaori Sayanagi, Yasushi Ikuno, and Yasuo Tano PURPOSE: To report difference in fundus autofluorescence (FAF) results between macular hole retinal detachAccepted for publication Mar 30, 2007. From the Department of Ophthalmology, Osaka University Medical School, Osaka, Japan. Inquiries to Yasushi Ikuno, Department of Ophthalmology E7, Osaka University Medical School, 2-2 Yamadaoka, Suita 565-0871, Japan; e-mail: [email protected]
ment (MHRD) and myopic foveoschisis (MF) in highly myopic eyes. DESIGN: Observational case reports. METHODS: Total of 20 highly myopic eyes were included in this study (MHRD, six eyes; MF with macular hole [MH], three eyes; MF without MH, 11 eyes). The authors observed both standard and nearinfrared FAF images using the Heidelberg Retina Angiograph 2 (HRA2; Heidelberg Engineering, Heidelberg, Germany). RESULTS: MHRD typically showed extensive hypo-FAF and foveal hyper-FAF. Hypo-FAF and hyper-FAF seemed to account for RD area and MH, respectively. Some cases of MF had almost normal results, except for a subtle mottled pattern of hyper-FAF. CONCLUSIONS: MHRD and MF showed different patterns of FAF, and this fact could be helpful in diagnosing MHRD from MF. Hyperviscous subretinal fluid might have blocked FAF signal in MHRD, but not in MF. (Am J Ophthalmol 2007;144:299 –301. © 2007 by Elsevier Inc. All rights reserved.)
M
ACULAR HOLE RETINAL DETACHMENT (MHRD) AND
myopic foveoschisis (MF) are common in high myopia.1,2 Because of myopic chorioretinal atrophy, they
FIGURE 1. Fundus photographs, optical coherence tomography (OCT) results, and standard and near-infrared fundus autofluorescence (FAF) images of two cases of macular hole retinal detachment (MHRD). (Top and Bottom left) Fundus photographs and OCT results show MHRD. (Top and Bottom center and right) Posterior round and extensive hypo-FAF (arrowheads) is seen, with foveal hyper-FAF presumably corresponding to the MH (arrows). The area of hypo-FAF corresponds to the RD.
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FIGURE 2. Fundus photographs, optical coherence tomography (OCT) results, and standard and near-infrared fundus autofluorescence (FAF) images of two cases of myopic foveoschisis (MF) without a macular hole (MH). (Top and Bottom left) Fundus photographs show only the choroidal vessel pattern; however, the OCT results show typical MF in both cases. (Top and Bottom center) Standard FAF images showing almost normal posterior pole with a mottled FAF pattern in the area of the fovea (arrows). (Top center) Slightly hypo-FAF area resulting from vitreous opacity is observed in one eye (arrowheads). (Top and Bottom right) No FAF is detected in near-infrared FAF images.
observed inside the temporal arcade vessels in both cases. Both showed extensive hypo-FAF at the posterior pole in the FAF images, with hyper-FAF probably corresponding to a MH. The hypo-FAF seemed to correspond to the area of the retinal detachment. Figure 2 shows the typical appearance of MF but without a MH. OCT showed MF without a MH, and the photograph showed only atrophy. Standard FAF images showed an almost normal posterior pole with mottled hyper-FAF at the fovea. Vitreous opacity was seen as dark FAF. No abnormality was observed in near-infrared FAF images. Figure 3 shows two eyes with both MF and a MH. OCT and fundus photographs showed MF with a MH. One case had a circular hypo-FAF area with a hyper-FAF area at the MH bed in both FAF images. The other case, in which the area of the retinal detachment was limited, had a hyperFAF area at the MH bed and a relatively dark area; however, this was not as dense in standard FAF images. Spotty atrophy also was observed. No abnormality was detected in the near-infrared FAF image. The presence or absence of round and extensive hypoFAF areas was one of the most distinctive FAF patterns in MHRD and MF. This may have resulted from hyperviscous subretinal fluid that blocked the FAF from the retinal
are difficult to observe two dimensionally, such as in a fundus photograph. Optical coherence tomography (OCT) is useful; however, conventional OCT provides only cross-sectional images, not 2-dimensional information. The Heidelberg Retina Angiograph 2 (HRA2; Heidelberg Engineering, Heidelberg, Germany) provides two types of fundus autofluorescence (FAF) images. We report the ability to diagnose MHRD and MF from an FAF image. Twenty eyes of 19 patients with MHRD or MF with and without a macular hole (MH) in a high myopia clinic were included in this study. Eyes with severe chorioretinal atrophy were excluded. We obtained standard and nearinfrared FAF images at every visit. To obtain clear images, we averaged images from the original (range, eight to 12 images) using the compute mean mode after obtaining multiple images. Color fundus photographs and OCT images also were obtained simultaneously. Informed consent was obtained from all patients, although HRA2 is a noninvasive examination. Six eyes had MHRD, 11 eyes had MF without a MH, and three eyes had both MF and MH. The mean axial length was 28.57 mm, and the mean patient age was 63.4 years. Figure 1 shows a typical fundus photograph, OCT results, and FAF images of eyes with MHRD. MHRD was 300
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FIGURE 3. Fundus photographs, optical coherence tomography (OCT) images, and standard and near-infrared fundus autofluorescence (FAF) images of two cases of myopic foveoschisis (MF) with a macular hole (MH). (Top and Bottom left) OCT images showing MF with a MH, although the fundus photographs demonstrate only a choroidal vessel pattern. In one case, the FAF images show almost the same image as that of MH retinal detachment (Figure 1). (Top center and right) Standard and near-infrared FAF images showing posterior hypo-FAF (arrowheads) with foveal hyper-FAF corresponding to a MH (arrows). (Bottom center) In the second case, there is a relatively dark area around the macula in the standard FAF image outside of the retinal detachment with an area of foveal hyper-FAF (white arrows), but the hypo-FAF is not as dense as a typical case with a retinal detachment and its margin is unclear (arrowheads). Spotty atrophy shows hypo-FAF (black arrows). (Bottom right) No abnormal FAF signal is detected on near-infrared FAF image in this case.
pigment epithelium (RPE). Subretinal fluid in MHRD is extremely viscous because of the pump function of RPE and could be more viscous than intraretinal fluid. This hypothesis is also related to the natural resolution of retinoschisis and consequent development of a retinal detachment.3 The FAF in MF varied. Some cases showed a hypermottled pattern of FAF, some had slight hypo-FAF, and others were almost normal. Cases with MF with a MH showed both components depending on the area of the retinal detachment. When the retinal detachment was extensive, the appearance was similar to MHRD. However, if the retinal detachment was limited, the appearance was similar to that of MF. Hyper-FAF at the MH bed has been reported.4 It is sometimes difficult to detect the presence of a MH in highly myopic eyes with OCT, because a fixation point can shift from the anatomic fovea. Foveal hyper-FAF images may be helpful to confirm the MH, which is predictive of poor anatomic and functional surgical outcomes.5 In summary, FAF is useful for diagnosing MHRD and MF. VOL. 144, NO. 2
THIS STUDY WAS SUPPORTED BY GRANT NO. 16591750 from the Japan Society for the Promotion of Science, Tokyo, Japan. The authors indicate no financial conflict of interest. Involved in design and conduct of study (K.S., Y.I.); collection, management, analysis, and interpretation of the data (K.S.); and preparation, review, or the approval of the manuscript (K.S., Y.I., Y.T). The approval of the Institutional Review Board was not required for this study. REFERENCES
1. Siam A. Macular hole with central retinal detachment in high myopia with posterior staphyloma. Br J Ophthalmol 1969;53:62–63. 2. Phillips CI. Retinal detachment at the posterior pole. Br J Ophthalmol 1958;42:749 –753. 3. Sayanagi K, Ikuno Y, Tano Y. Spontaneous resolution of retinoschisis and consequent development of retinal detachment in highly myopic eye. Br J Ophthalmol 2006;90:652–653. 4. von Ruckmann A, Fitzke FW, Gregor ZJ. Fundus autofluorescence in patients with macular holes imaged with a laser scanning ophthalmoscope. Br J Ophthalmol 1998;82:346–351. 5. Ikuno Y, Tano Y. Vitrectomy for macular holes associated with myopic foveoschisis. Am J Ophthalmol 2006;141:774 – 776.
BRIEF REPORTS
301
Different Fundus Autofluorescence Patterns of Retinoschisis and Macular Hole Retinal Detachment in High Myopia Kaori Sayanagi, Yasushi Ikuno, and Yasuo Tano PURPOSE: To report difference in fundus autofluorescence (FAF) results between macular hole retinal detachAccepted for publication Mar 30, 2007. From the Department of Ophthalmology, Osaka University Medical School, Osaka, Japan. Inquiries to Yasushi Ikuno, Department of Ophthalmology E7, Osaka University Medical School, 2-2 Yamadaoka, Suita 565-0871, Japan; e-mail: [email protected]
ment (MHRD) and myopic foveoschisis (MF) in highly myopic eyes. DESIGN: Observational case reports. METHODS: Total of 20 highly myopic eyes were included in this study (MHRD, six eyes; MF with macular hole [MH], three eyes; MF without MH, 11 eyes). The authors observed both standard and nearinfrared FAF images using the Heidelberg Retina Angiograph 2 (HRA2; Heidelberg Engineering, Heidelberg, Germany). RESULTS: MHRD typically showed extensive hypo-FAF and foveal hyper-FAF. Hypo-FAF and hyper-FAF seemed to account for RD area and MH, respectively. Some cases of MF had almost normal results, except for a subtle mottled pattern of hyper-FAF. CONCLUSIONS: MHRD and MF showed different patterns of FAF, and this fact could be helpful in diagnosing MHRD from MF. Hyperviscous subretinal fluid might have blocked FAF signal in MHRD, but not in MF. (Am J Ophthalmol 2007;144:299 –301. © 2007 by Elsevier Inc. All rights reserved.)
M
ACULAR HOLE RETINAL DETACHMENT (MHRD) AND
myopic foveoschisis (MF) are common in high myopia.1,2 Because of myopic chorioretinal atrophy, they
FIGURE 1. Fundus photographs, optical coherence tomography (OCT) results, and standard and near-infrared fundus autofluorescence (FAF) images of two cases of macular hole retinal detachment (MHRD). (Top and Bottom left) Fundus photographs and OCT results show MHRD. (Top and Bottom center and right) Posterior round and extensive hypo-FAF (arrowheads) is seen, with foveal hyper-FAF presumably corresponding to the MH (arrows). The area of hypo-FAF corresponds to the RD.
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FIGURE 2. Fundus photographs, optical coherence tomography (OCT) results, and standard and near-infrared fundus autofluorescence (FAF) images of two cases of myopic foveoschisis (MF) without a macular hole (MH). (Top and Bottom left) Fundus photographs show only the choroidal vessel pattern; however, the OCT results show typical MF in both cases. (Top and Bottom center) Standard FAF images showing almost normal posterior pole with a mottled FAF pattern in the area of the fovea (arrows). (Top center) Slightly hypo-FAF area resulting from vitreous opacity is observed in one eye (arrowheads). (Top and Bottom right) No FAF is detected in near-infrared FAF images.
observed inside the temporal arcade vessels in both cases. Both showed extensive hypo-FAF at the posterior pole in the FAF images, with hyper-FAF probably corresponding to a MH. The hypo-FAF seemed to correspond to the area of the retinal detachment. Figure 2 shows the typical appearance of MF but without a MH. OCT showed MF without a MH, and the photograph showed only atrophy. Standard FAF images showed an almost normal posterior pole with mottled hyper-FAF at the fovea. Vitreous opacity was seen as dark FAF. No abnormality was observed in near-infrared FAF images. Figure 3 shows two eyes with both MF and a MH. OCT and fundus photographs showed MF with a MH. One case had a circular hypo-FAF area with a hyper-FAF area at the MH bed in both FAF images. The other case, in which the area of the retinal detachment was limited, had a hyperFAF area at the MH bed and a relatively dark area; however, this was not as dense in standard FAF images. Spotty atrophy also was observed. No abnormality was detected in the near-infrared FAF image. The presence or absence of round and extensive hypoFAF areas was one of the most distinctive FAF patterns in MHRD and MF. This may have resulted from hyperviscous subretinal fluid that blocked the FAF from the retinal
are difficult to observe two dimensionally, such as in a fundus photograph. Optical coherence tomography (OCT) is useful; however, conventional OCT provides only cross-sectional images, not 2-dimensional information. The Heidelberg Retina Angiograph 2 (HRA2; Heidelberg Engineering, Heidelberg, Germany) provides two types of fundus autofluorescence (FAF) images. We report the ability to diagnose MHRD and MF from an FAF image. Twenty eyes of 19 patients with MHRD or MF with and without a macular hole (MH) in a high myopia clinic were included in this study. Eyes with severe chorioretinal atrophy were excluded. We obtained standard and nearinfrared FAF images at every visit. To obtain clear images, we averaged images from the original (range, eight to 12 images) using the compute mean mode after obtaining multiple images. Color fundus photographs and OCT images also were obtained simultaneously. Informed consent was obtained from all patients, although HRA2 is a noninvasive examination. Six eyes had MHRD, 11 eyes had MF without a MH, and three eyes had both MF and MH. The mean axial length was 28.57 mm, and the mean patient age was 63.4 years. Figure 1 shows a typical fundus photograph, OCT results, and FAF images of eyes with MHRD. MHRD was 300
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OPHTHALMOLOGY
AUGUST 2007
FIGURE 3. Fundus photographs, optical coherence tomography (OCT) images, and standard and near-infrared fundus autofluorescence (FAF) images of two cases of myopic foveoschisis (MF) with a macular hole (MH). (Top and Bottom left) OCT images showing MF with a MH, although the fundus photographs demonstrate only a choroidal vessel pattern. In one case, the FAF images show almost the same image as that of MH retinal detachment (Figure 1). (Top center and right) Standard and near-infrared FAF images showing posterior hypo-FAF (arrowheads) with foveal hyper-FAF corresponding to a MH (arrows). (Bottom center) In the second case, there is a relatively dark area around the macula in the standard FAF image outside of the retinal detachment with an area of foveal hyper-FAF (white arrows), but the hypo-FAF is not as dense as a typical case with a retinal detachment and its margin is unclear (arrowheads). Spotty atrophy shows hypo-FAF (black arrows). (Bottom right) No abnormal FAF signal is detected on near-infrared FAF image in this case.
pigment epithelium (RPE). Subretinal fluid in MHRD is extremely viscous because of the pump function of RPE and could be more viscous than intraretinal fluid. This hypothesis is also related to the natural resolution of retinoschisis and consequent development of a retinal detachment.3 The FAF in MF varied. Some cases showed a hypermottled pattern of FAF, some had slight hypo-FAF, and others were almost normal. Cases with MF with a MH showed both components depending on the area of the retinal detachment. When the retinal detachment was extensive, the appearance was similar to MHRD. However, if the retinal detachment was limited, the appearance was similar to that of MF. Hyper-FAF at the MH bed has been reported.4 It is sometimes difficult to detect the presence of a MH in highly myopic eyes with OCT, because a fixation point can shift from the anatomic fovea. Foveal hyper-FAF images may be helpful to confirm the MH, which is predictive of poor anatomic and functional surgical outcomes.5 In summary, FAF is useful for diagnosing MHRD and MF. VOL. 144, NO. 2
THIS STUDY WAS SUPPORTED BY GRANT NO. 16591750 from the Japan Society for the Promotion of Science, Tokyo, Japan. The authors indicate no financial conflict of interest. Involved in design and conduct of study (K.S., Y.I.); collection, management, analysis, and interpretation of the data (K.S.); and preparation, review, or the approval of the manuscript (K.S., Y.I., Y.T). The approval of the Institutional Review Board was not required for this study. REFERENCES
1. Siam A. Macular hole with central retinal detachment in high myopia with posterior staphyloma. Br J Ophthalmol 1969;53:62–63. 2. Phillips CI. Retinal detachment at the posterior pole. Br J Ophthalmol 1958;42:749 –753. 3. Sayanagi K, Ikuno Y, Tano Y. Spontaneous resolution of retinoschisis and consequent development of retinal detachment in highly myopic eye. Br J Ophthalmol 2006;90:652–653. 4. von Ruckmann A, Fitzke FW, Gregor ZJ. Fundus autofluorescence in patients with macular holes imaged with a laser scanning ophthalmoscope. Br J Ophthalmol 1998;82:346–351. 5. Ikuno Y, Tano Y. Vitrectomy for macular holes associated with myopic foveoschisis. Am J Ophthalmol 2006;141:774 – 776.
BRIEF REPORTS
301