- Email: [email protected]
En Face Optical Coherence Tomography of the Posterior Pole in High Myopia
En Face Optical Coherence Tomography of the Posterior Pole in High Myopia RAIMONDO FORTE, GILDA CENNAMO, FABRIZIA PASCOTTO, AND GIUSEPPE DE CRECCHIO ● PURPOSE:
To evaluate a large series of patients affected by high myopia using multiplanar imaging provided by en face optical coherence tomography (OCT). ● DESIGN: Observational cross-sectional study. ● METHODS: En face OCT longitudinal cross-sectional B scans and coronal C scans were obtained in 200 eyes of 100 patients with myopia greater than – 6 diopters and evidence of posterior staphyloma at fundus examination and at ultrasound B-scan evaluation. ● RESULTS: A macular hole was present in three eyes (1.5%). We detected posterior retinal detachment in 37 cases (18.5%). In 15 eyes (7.5%) detachment was associated with a macular hole. In the remaining 22 eyes (11%), the detachment was located in the area of the staphyloma, and was associated with vitreoretinal traction in four eyes (18.2%) of 22 eyes. There was evidence of detachment of the internal limiting membrane (ILM) in 12 eyes (6%) and retinoschisis in 27 (13.5%) of 200 eyes. Retinal vascular microfolds were detected in 40 eyes (20%), and occurred in all cases of peripapillary retinal detachment, ILM detachment, and retinoschisis. Paravascular microcysts occurred in three eyes (1.5%), and peripapillary detachment of the pigment epithelium in 10 eyes (5%). ● CONCLUSIONS: En face OCT provides accurate imaging of retinal abnormalities in high myopia and allows width measurement and point-to-point localization of alterations. Thus, it can represent a noninvasive way to detect minimal changes during follow-up. Posterior detachment in the absence of a macular hole seems to be related to vitreoretinal traction, staphyloma, and inward forces exerted by rigid retinal vessels and ILM. En face OCT-assisted surgery of macular holes could help to plan removal of premacular tractional structures. (Am J Ophthalmol 2008;145: 281–288. © 2008 by Elsevier Inc. All rights reserved.)
D
EGENERATIVE MYOPIA, ALSO CALLED PATHO-
logic or high myopia, is defined as a myopic refractive error of more than 6 diopters (D) associated with degenerative fundus changes. The main feature of degenerative myopia is congenital scleral weak-
Accepted for publication Sep 10, 2007. From the Eye Department, University Federico II, Naples, Italy (R.F., G.C., G.d.C.); and the Eye Department, Seconda Università, Naples, Italy (F.P.). Inquiries to Raimondo Forte, Dipartimento di Scienze Oftalmologiche, Università Federico II, Via Pansini 5, 80131 Naples, Italy; e-mail: [email protected] 0002-9394/08/$34.00 doi:10.1016/j.ajo.2007.09.022
©
2008 BY
ness, leading to progressive globe enlargement, axial lengthening, and finally the formation of posterior staphyloma. Scleral stretching can lead to such degenerative changes as vitreous degeneration, progressive atrophy of the choriocapillaris and choroid, linear ruptures of the Bruch membrane (lacquer cracks), and retinal thinning. The posterior retina can be damaged by traction induced by an epiretinal membrane or residual focal vitreoretinal adhesion. The combination of retinal traction, posterior staphyloma, and progressive global scleral stretching frequently leads to macular holes,1,2 retinoschisis and posterior retinal detachment,3,4 detachment of the internal limiting membrane (ILM),5 peripapillary detachment of the pigment epithelium (PDPM),6 – 8 vascular traction with retinal microfolds, and paravascular intraretinal cysts.9 –11 We previously described several cases of retinal abnormalities associated with high myopia examined with en face optical coherence tomography (OCT).12–14 En face OCT combines OCT and confocal ophthalmoscopy, and yields longitudinal B scans and coronal C scans of the retina that correspond pixel-to-pixel with red-free images of the fundus.15 The coronal image allows prompt visualization of the lateral extent of lesions on the posterior pole. The aim of this study was to evaluate with en face OCT the incidence of retinal abnormalities in a large number of cases presenting high myopia and posterior staphyloma.
METHODS TWO HUNDRED SYMPTOMATIC AND ASYMPTOMATIC HIGHLY
myopic eyes (100 consecutive patients) examined between November 20, 2005 and June 30, 2006 at the University of Naples Federico II were studied. Inclusion criteria were myopia greater than ⫺6 D, and evidence of posterior staphyloma at fundus examination and at ultrasound Bscan evaluation. Exclusion criteria were moderate to dense lens opacities, history of intraocular inflammation such as anterior or posterior uveitis, history of peripheral retinal detachment, laser treatment for peripheral retinal diseases, diabetes, connective tissue diseases, history of ocular trauma or optic neuropathy, and other systemic or neurological diseases. All patients underwent evaluation of best-corrected visual acuity (BCVA), slit-lamp examination of the anterior segment, and ophthalmoscopy of the posterior fundus. In all cases, en face OCT of the posterior pole was performed with time domain OCT Ophthalmo-
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77 years). The mean refractive error was ⫺13.8 D (range, ⫺6 to ⫺22 D). The mean axial length was 28.9 ⫾ 2.2 mm (range, 25.8 to 35.2 mm). The results of the analyzed sample of 200 eyes are reported in Table 1. The association among the detected abnormalities is reported in Table 2.
TABLE 1. Characteristics of 200 Highly Myopic Eyes Evaluated with En Face Optical Coherence Tomography No. (%) of Eyes
Macular hole without posterior detachment Posterior retinal detachment With macular hole Without macular hole Peripapillary detachment of the pigment epithelium Retinoschisis Detachment of the internal limiting membrane Retinal vascular microfolds Paravascular microcysts
3 (1.5) 37 (18.5) 15 (7.5) 22 (11)
● MACULAR HOLE: Three eyes (1.5%) were affected by a macular hole (Figure 1) without posterior retinal detachment. Two of these eyes had a full-thickness macular hole, and the third eye had a lamellar macular hole and an epiretinal membrane.
10 (5) 27 (13.5) 12 (6) 40 (20) 3 (1.5)
● POSTERIOR RETINAL DETACHMENT: We detected posterior retinal detachment in 37 cases (18.5%). In all cases en face OCT longitudinal B scans showed the cross-sectional shape of the detachment, the neuroretinal microarchitecture, and vitreoretinal traction, if present. From the coronal C scans, we determined the lateral extent of the detachment at different depths from the vitreoretinal interface to the pigment epithelium. These scans could be overlaid on the red-free image of the fundus. Posterior detachment was associated with a macular hole in 15 (7.5%) of 200 eyes. Of these, 13 eyes with a mean BCVA of 20/50 (range, 20/30 to 20/200) had a full-thickness macular hole, whereas two eyes with a BCVA of 20/60 and 20/30 had a lamellar hole. The diameter of the hole ranged from 600 m to 900 m (mean, 700 m). An epiretinal membrane was detected in seven (46.6%) of 15 eyes. Posterior detachment was not associated with a macular hole in 22 (11%) of 200 eyes. In all these cases, detachment was located on the area of the staphyloma, and it affected the macula in 10 cases (Figure 1) and was extramacular in 12. In one of the 12 latter cases, the extramacular detachment occurred in correspondence to an inferonasal staphyloma (Figure 2), whereas in the remaining 11 (50%) of 22 eyes it occurred in correspondence to a papillary staphyloma (Figures 3 and 4). Biomicroscopic examination showed a Weiss ring detached from the optic disk in 77.3% (17/22 eyes), and there was no sign that posterior vitreous detachment had occurred in five of 22 eyes. In four (18.2%) of 22 eyes, en face OCT revealed a premacular structure constituted by an epiretinal membrane in three eyes, and posterior hyaloidal traction in one eye (Figure 3). Of the 10 eyes with macular involvement, visual acuity was 20/20 in five eyes, and ranged from 20/25 to 20/200 (mean, 20/30). We measured the thickness of the detachment in any given point, and found a low negative correlation between visual acuity and foveal thickness (Spearman r ⫽ ⫺0.529, P ⫽ .039).
scope (OTI, Toronto, Ontario, Canada) by the same examiner (R.F.). In the time domain OCT Ophthalmoscope system, the light emitted by a super luminescent diode (820 nm, 20-nm band width) is split by a partially reflecting mirror (“beam-splitter”) into two parts. One beam is transmitted to the eye and is reflected by intraocular structures at different distances, the other is reflected from a reference mirror at a known spatial position. The two backreflected optical beams are collected through an interferometer to produce the OCT signal. Two orthogonal scanners scan the eye in depth and transversally, and the scan plane obtained depends on the order in which these scans are taken and on the scanning direction associated with the line displayed in the raster of the final image delivered. The light reflected from the eye can be split and reflected in part to a separate photodetector to produce a confocal signal (scanning laser ophthalmoscopy/ OCT, SLO/OCT). Thus, the coronal C-scan corresponds pixel-to-pixel to the confocal red-free image. Scans were interpreted as described elsewhere.12–16 We use the term “retinoschisis” to indicate a separation among internal retinal layers, with persistence of an adherence between the outer layers and the retinal pigment epithelium (RPE).3 We define detachment of the ILM based on evidence of a membrane partially separated from the internal retinal surface with persisting columnar elements.5 We used the term “retinal detachment” to indicate the complete separation between the neuroepithelium and RPE, without evidence of persistent outer neuroepithelial layers.3,4,17 All data were analyzed using the statistical package of SPSS version 13.0 for Windows (SPSS Inc, Chicago, Illinois, USA). A P value less than .05 was considered statistically significant.
THE MEAN AGE OF THE PATIENTS (58 WOMEN AND 42
● DETACHMENT OF THE INTERNAL LIMITING MEMBRANE, RETINOSCHISIS, RETINAL VASCULAR MICROFOLDS, AND PARAVASCULAR MICROCYSTS: Detachment of the ILM
men) was 58.3 ⫾ 5.5 years (mean ⫾ SD) (range, 46 to
was detected in 12 (6%) of 200 eyes. In seven (58.3%)
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TABLE 2. Association (%) among Abnormalities of the Posterior Pole Detected with En Face Optical Coherence Tomography in a Series of 200 Highly Myopic Eyes
PDMH PDWMH PPRD RTS ILMD PDPM MH RVM VMT
PDMH
PDWMH
PPRD
RTS
ILMD
PDPM
MH
RVM
VMT
— — — 0 0 0 0 3 (1.5) 7 (3.5)
— — — 10 (5) 7 (3.5) 0 0 6 (3) 5 (2.5)
— — — 9 (4.5) 7 (3.5) 0 0 11 (5.5) 0
0 10 (5) 9 (4.5) — 10 (5) 1 (0.5) 1 (0.5) 27 (13.5) 21 (10.5)
0 7 (3.5) 7 (3.5) 10 (5) — 0 0 12 (6) 5 (2.5)
0 0 0 1 (0.5) 0 — 0 1 (0.5) 0
0 0 0 1 (0.5) 0 0 — 1 (0.5) 1 (0.5)
3 (1.5) 6 (3) 11 (5.5) 27 (13.5) 12 (6) 1 (0.5) 1 (0.5) — 32 (16)
7 (3.5) 5 (2.5) 0 21 (10.5) 5 (2.5) 0 1 (0.5) 32 (16) —
PDMH ⫽ posterior retinal detachment with macular hole; PDWMH ⫽ posterior retinal detachment without macular hole; PPRD ⫽ peripapillary retinal detachment; RTS ⫽ retinoschisis; ILMD ⫽ detachment of the internal limiting membrane; PDPM ⫽ peripapillary detachment of the pigment epithelium; MH ⫽ macular hole without posterior detachment; RVM ⫽ retinal vascular microfolds; VMT ⫽ vitreomacular traction.
FIGURE 1. En face optical coherence tomography (OCT) in highly myopic eyes. (Top left) Longitudinal B-scan and (Top right) coronal C-scan showing a lamellar macular hole (arrow). Refractive error is ⴚ19 diopters (D). (Second row, left) En face OCT cross-sectional B-scan showing retinoschisis with bridging elements in correspondence to a posterior staphyloma. The thickness of the schisis is 1010 m. (Second row, right) The coronal C-scan shows the lateral extent of the schisis (arrowheads). (Bottom left) En face OCT B-scan and (Bottom middle and right) consecutive antero-posterior coronal OCT C scans showing a retinal detachment without macular hole in correspondence of a posterior pole staphyloma. The thickness of the detachment is 610 m. Note the epiretinal membrane on the retinal surface (arrow). This patient had undergone photodynamic therapy for choroidal neovascularization and a columnar scar is visible in the middle of the detachment. Retinoschisis is present in its periphery. The angular size for all scans is 20 ⴛ 20 degrees.
of 12 eyes, it was associated with a papillary staphyloma and involved the peripapillary area. Retinoschisis was present in 27 (13.5%) of 200 eyes (Figures 1 and 4), and was associated with a posterior detachment without macular hole in 10 (37%) of 27 cases. Premacular traction occurred in 21 (77.7%) of 27 eyes with retinoschisis. Retinal vascular microfolds were detected in 40 VOL. 145, NO. 2
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(20%) of 200 eyes, and appeared as tent-like bending of the vessels (Figures 3 and 4). They were present in the 11 eyes with peripapillary retinal detachment, the 12 eyes with ILM detachment, and the 27 eyes with retinoschisis. Paravascular microcysts were detected in three (1.5%) of 200 eyes; they appeared as paravascular cystoid spaces in the inner retina at longitudinal B-scan IN
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FIGURE 2. Posterior detachment in high myopia. (Top left) En face OCT cross-sectional B scans showing a wide posterior detachment in correspondence of the inferonasal staphyloma in a pseudophakic patient. (Bottom left) The height of the optically empty subretinal space corresponding to the detachment is 1289 m. (Top right, middle, and bottom) Consecutive antero-posterior OCT coronal (Left) overlaid confocal red free image/coronal C scans and (Right) not overlaid C scans show the lateral extent of the detachment (arrows) and confirm its correspondence with the inferonasal staphyloma.
and coronal C-scan (Figure 4). In all cases, they were localized alongside the supero-temporal vein. In all these cases, overlaying of coronal OCT/red-free confocal images showed the exact point-to-point location of the abnormalities on the retinal surface.
staphyloma), the early stages of myopic retinal alterations can be easily underestimated by biomicroscopy, angiography, or ultrasonography, and therefore remain undiagnosed. In recent years, OCT with cross-sectional images of retinal structure has greatly facilitated the study of the posterior vitreoretinal anatomy in eyes with high myopia. It can also reveal otherwise undetectable macular changes in asymptomatic patients. The OCT ophthalmoscope produces retinal conventional longitudinal B scans and coronal C scans.12–16 Thus, it provides information not readily available with conventional imaging techniques. Whereas B scans produce cross-sectional images of retinal morphology, bearing a strong resemblance to histology, OCT C scans are represented as 2-dimensional transversal slices at any given depth through the retina, thereby enabling visualization of the lateral extent of structures. OCT C scans can be associated pixel-to-pixel and simultaneously to a confocal red-free image, which is used to identify the exact position of lesions on the posterior pole. To our knowledge, our study represents the first large cross-sectional evaluation with en face OCT of fundus alterations in high myopia. All the abnormalities identified seem to be related with the mechanical elongation forces taking place in highly myopic eyes. The stretching of retinochoroidal tissues may result from a combination of vitreoretinal adhesion,17,18 posterior staphyloma,3,4 rigidity of the ILM,5 and inflexibility of the retinal vessels.9 In our series, posterior retinal detachment (with or without macular hole) was present in 18.5% of eyes. Of these, a macular hole was present in 40.5%, and was associated with an epiretinal membrane in 46.6% of cases. As en face OCT allows visualization of the total lateral extension of vitreomacular adherences,19 and as
● PERIPAPILLARY DETACHMENT OF THE PIGMENT EPITHELIUM: Peripapillary detachment of the pigment ep-
ithelium was present in 10 (5%) of 200 eyes (Figure 5). BCVA ranged from 20/30 to 20/100 (mean, 20/40). There was no perimetric alteration in three of 10 eyes, whereas examination with the Humphrey visual field analyzer (Carl Zeiss Meditec, Dublin, California, USA) revealed glaucomatous visual field defects consisting in arcuate scotoma and nasal step in seven (70%) of 10 eyes. These defects matched the peripapillary abnormality in three (42.8%) of seven eyes. In all cases, coronal scans clearly showed the lateral extent of the PDPM, and its thickness could be measured on longitudinal scans. The thickness of the PDPM ranged from 304 m to 400 m (mean, 359 m). There was no correlation between visual acuity and PDPM thickness (Spearman r ⫽ ⫺0.134, P ⫽ .021), whereas there was a strong correlation between PDPM thickness and grade of matching between the PDPM and the visual field defects (Spearman r ⫽ 0.874, P ⫽ .028).
DISCUSSION BECAUSE OF THE CHARACTERISTIC CONFOUNDING FEA-
tures of the choroid, retina, and vitreoretinal interface in degenerative myopia (i.e., thin retina, areas of choriocapillaris atrophy, retinal pigment epithelium hypopigmentation or hyperpigmentation and posterior 284
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FIGURE 3. Vitreoretinal traction and vascular microfolds in highly myopic eyes. En face OCT (Top) longitudinal cross-sectional B-scan showing vitreoretinal tractions (arrows) and detachment of the peripapillary neuroepithelium (asterisks) at both sides of a papillary staphyloma. (Second row, left) Overlaid confocal red free image/coronal C-scan and (Second row, right) not overlaid C-scan show the lateral extent of the subneuroepithelial hyporeflective area of retinal detachment (asterisks). The refractive error was ⴚ18 D. In the left eye (Third row) OCT cross-sectional B-scan shows vitreoretinal traction in correspondence of vascular folds (arrows). (Bottom left) Overlaid confocal red free image/coronal C-scan and (Bottom right) not overlaid C-scan parallel to the internal retinal surface show the stretched hyperreflective vessel (arrowheads) in the hyporeflectivity of the vitreous.
evident in 18.2%. Vitreomacular traction has been implicated in the formation of posterior detachment in patients with pathologic myopia, and it has been reported that removal of a thin layer of adherent vitreous led to the resolution of the detachment.21,22 On the other hand, all our cases of peripapillary retinal detachment or ILM detachment were affected by retinal vascular microfolds, which are thought to be caused by the inflexibility of retinal vessels as opposed to retinal stretching.9 These data could suggest that retinal splitting at different
vitreous surgery combined with membrane peeling and use of retinal tamponade seems to be successful in achieving retinal reattachment in eyes with macular hole and posterior staphyloma,20 coronal en face OCT C scans may help in planning the best approach for removal of premacular tractional structures. A macular hole was not present in 22 of the 37 eyes (59.5%) with posterior detachment. In these 22 eyes, the detachment was localized in correspondence of the staphyloma, and tractional premacular structures were VOL. 145, NO. 2
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FIGURE 4. Retinal vascular microfolds, paravascular microcysts and retinoschisis in highly myopic eyes. (Top left) Color fundus image showing papillary staphyloma. En face OCT B scans show (Top right) detachment of the peripapillary neuroepithelium (asterisk) and (Right, second row) V-shaped bending of the vessels (arrow). (Left, second row) Longitudinal cross-sectional en face OCT B-scan showing paravascular inner retinal cysts. (Middle, third row) Overlaid confocal red free image/coronal C-scan and (Right, third row) not overlaid C-scan. The extent of the retinal cysts alongside the vessel (arrow) is visible. (Bottom left) Retinoschisis at cross-sectional B-scan, (Bottom, middle) overlaid confocal red free image/coronal C-scan and (Bottom right) not overlaid C-scan. Splitting of retinal layers is present (arrows).
correlation could be attributable to a progressive damage to the retinal nerve fiber layer that crosses the edge of the excavated myopic conus. As en face OCT coronal C scans allow visualization of the lateral extent of the PDPM, they could represent an alternative to fluorescein angiography for the detection of minimal changes of width and thickness during follow-up. In conclusion, en face OCT provides an accurate imaging of retinal changes in high myopia and allows prompt recognition of their localization. With en face OCT it is possible to identify the exact location of retinal lesions and measure their width and thickness, thus allowing a noninvasive evaluation of changes during follow-up. The high frequency of retinal abnormalities in our series suggests that myopic ocular elongation plays an important role in their development. We found a high incidence of posterior retinal detachment and stretching-related fundus abnormalities, namely, retinoschisis,
depths in high myopia could be attributable to vitreoretinal traction, to the staphyloma, and to the inward forces exerted by the rigid vessels and ILM. As reported by others,3,17,23 we found no significant correlation between foveal detachment without macular hole and visual impairment. This lack of correlation is probably due to the relative preservation of the neuroepithelium and the persistent release of nutrients from the choriocapillaris,4 which would continue for some time after detachment. However, a further reduction of visual acuity has been reported after increase in the thickness of the detachment during follow-up.17 The incidence of peripapillary detachment of the pigment epithelium in our series was similar to that reported by others, as was the high correlation of peripapillary detachment with visual field defects.6 – 8 According to our findings, PDPM thickness could be correlated with the matching of the PDPM with visual field defects. This 286
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FIGURE 5. Peripapillary detachment of the pigment epithelium in high myopia. En face OCT (Top) longitudinal B-scan, (Bottom left) overlaid confocal red free image/coronal C-scan and (Bottom right) not overlaid C-scan show a hyporeflective area under the pigment epithelium (asterisks).
ILM detachment, and vascular microfolds. Posterior detachment without macular hole was always in the area
of the staphyloma, which suggests that the staphyloma could play an important etiologic role in this condition.
THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN DESIGN AND conduct of study (R.F.); collection, management, analysis, and interpretation of the data (R.F., G.C., F.P., G.d.C.); and preparation, review, or approval of the manuscript (R.F.).Written informed consent according to the tenets of the Declaration of Helsinki was obtained from each patient included. Federico II Institutional Review Board approval was obtained. This study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
7. Toranzo J, Cohen SY, Erginay A, Gaudric A. Peripapillary intrachoroidal cavitation in myopia. Am J Ophthalmol 2005;140:731–732. 8. Shimada N, Ohno-Matsui K, Yoshida T, et al. Characteristics of peripapillary detachment in pathologic myopia. Arch Ophthalmol 2006;124:46 –52. 9. Sayanagi K, Ikuno Y, Gomi F, Tano Y. Retinal vascular microfolds in highly myopic eyes. Am J Ophthalmol 2005; 139:658 – 663. 10. Ikuno Y, Gomi F, Tano Y. Potent retinal arteriolar traction as a possible cause of myopic foveoschisis. Am J Ophthalmol 2005;139:462– 467. 11. Ohno-Matsui K, Hayashi K, Tokoro T, Mochizuki M. Detection of paravascular retinal cysts before using OCT in a highly myopic patient. Graefes Arch Clin Exp Ophthalmol 2006;244:642– 644. 12. Forte R, Pascotto F, Soreca E, Cusati G, de Crecchio G. Posterior retinal detachment without macular hole in high myopia: visualization with en face optical coherence tomography. Eye 2007;21:111–113.
REFERENCES 1. Phillips CI, Dobbie JG. Posterior staphyloma and retinal detachment. Am J Ophthalmol 1963;55:332–335. 2. Abdel-Latif S. Macular hole with central retinal detachment in high myopia with posterior staphyloma. Br J Ophthalmol 1969;53:62– 63. 3. Takano M, Kishi S. Foveal retinoschisis and retinal detachment in severely myopic eyes with posterior staphyloma. Am J Ophthalmol 1999;128:472– 476. 4. Baba T, Ohno-Matsui K, Futagami S, et al. Prevalence and characteristics of foveal retinal detachment without macular hole in high myopia. Am J Ophthalmol 2003;135: 338 –342. 5. Sayanagi K, Ikuno Y, Tano Y. Tractional internal limiting membrane detachment in highly myopic eyes. Am J Ophthalmol 2006;142:850 – 852. 6. Freund KB, Ciardella AP, Yannuzzi LA, et al. Peripapillary detachment in pathologic myopia. Arch Ophthalmol 2003; 121:197–204.
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13. Forte R, Pascotto F, Napolitano F, Cennamo G, de Crecchio G. En face optical coherence tomography of macular holes in high myopia. Eye 2007;21:436 – 437. 14. Forte R, Pascotto F, Cennamo G, de Crecchio G. Evaluation of peripapillary detachment in pathologic myopia with en face optical coherence tomography. Eye. Forthcoming. 15. van Velthoven ME, Verbraak FD, Yannuzzi LA, Rosen RB, Podoleanu AG, de Smet MD. Imaging the retina by en face optical coherence tomography. Retina 2006;26: 129 –136. 16. Lumbroso B, Brancato R, Rosen R. OCT/SLO “en face” optical coherence tomography. Rome, Italy: I.N.C. Innovation-News-Communication, 2006:1–110. 17. Gaucher D, Haouchine B, Tadayoni R, et al. Long-term follow-up of high myopic foveoschisis: natural course and surgical outcome. Am J Ophthalmol 2007;143:455– 462.
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18. Panozzo G, Mercanti A. Optical coherence tomography findings in myopic traction maculopathy. Arch Ophthalmol 2004;122:1455–1460. 19. Forte R, Pascotto F, de Crecchio G. Visualization of vitreomacular tractions with en face optical coherence tomography. Eye. Forthcoming. 20. Soheilian M, Ghaseminejad AK, Yazdani S, et al. Surgical management of retinal detachment in highly myopic eyes with macular hole. Ophthalmic Surg Lasers Imaging 2007;38:15–22. 21. Ikuno Y, Sayanagi K, Ohji M, et al. Vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Am J Ophthalmol 2004;137:719 –724. 22. Kobayashi H, Kishi S. Vitreous surgery for highly myopic eyes with foveal detachment and retinoschisis. Ophthalmology 2003;110:1702–1707. 23. Ichibe M, Baba E, Funaki S, Yoshizawa T, Abe H. Retinoschisis in a highly myopic eye without vision impairment. Retina 2004;24:331–333.
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Biosketch Raimondo Forte, MD, is currently attending a PhD Training Program at the Department of Ophthalmology at the University of Naples Federico II in Naples, Italy. Previously, Dr Forte was a fellow at the Department of Ophthalmology of the Centre Hospitalier Intercommunal of Creteil, France. He subsequently attended the St Erik Eye Hospital in Stockholm, Sweden as an observer. Dr Forte’s main research interests are medical retinal diseases and chorioretinal tumors.
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To evaluate a large series of patients affected by high myopia using multiplanar imaging provided by en face optical coherence tomography (OCT). ● DESIGN: Observational cross-sectional study. ● METHODS: En face OCT longitudinal cross-sectional B scans and coronal C scans were obtained in 200 eyes of 100 patients with myopia greater than – 6 diopters and evidence of posterior staphyloma at fundus examination and at ultrasound B-scan evaluation. ● RESULTS: A macular hole was present in three eyes (1.5%). We detected posterior retinal detachment in 37 cases (18.5%). In 15 eyes (7.5%) detachment was associated with a macular hole. In the remaining 22 eyes (11%), the detachment was located in the area of the staphyloma, and was associated with vitreoretinal traction in four eyes (18.2%) of 22 eyes. There was evidence of detachment of the internal limiting membrane (ILM) in 12 eyes (6%) and retinoschisis in 27 (13.5%) of 200 eyes. Retinal vascular microfolds were detected in 40 eyes (20%), and occurred in all cases of peripapillary retinal detachment, ILM detachment, and retinoschisis. Paravascular microcysts occurred in three eyes (1.5%), and peripapillary detachment of the pigment epithelium in 10 eyes (5%). ● CONCLUSIONS: En face OCT provides accurate imaging of retinal abnormalities in high myopia and allows width measurement and point-to-point localization of alterations. Thus, it can represent a noninvasive way to detect minimal changes during follow-up. Posterior detachment in the absence of a macular hole seems to be related to vitreoretinal traction, staphyloma, and inward forces exerted by rigid retinal vessels and ILM. En face OCT-assisted surgery of macular holes could help to plan removal of premacular tractional structures. (Am J Ophthalmol 2008;145: 281–288. © 2008 by Elsevier Inc. All rights reserved.)
D
EGENERATIVE MYOPIA, ALSO CALLED PATHO-
logic or high myopia, is defined as a myopic refractive error of more than 6 diopters (D) associated with degenerative fundus changes. The main feature of degenerative myopia is congenital scleral weak-
Accepted for publication Sep 10, 2007. From the Eye Department, University Federico II, Naples, Italy (R.F., G.C., G.d.C.); and the Eye Department, Seconda Università, Naples, Italy (F.P.). Inquiries to Raimondo Forte, Dipartimento di Scienze Oftalmologiche, Università Federico II, Via Pansini 5, 80131 Naples, Italy; e-mail: [email protected] 0002-9394/08/$34.00 doi:10.1016/j.ajo.2007.09.022
©
2008 BY
ness, leading to progressive globe enlargement, axial lengthening, and finally the formation of posterior staphyloma. Scleral stretching can lead to such degenerative changes as vitreous degeneration, progressive atrophy of the choriocapillaris and choroid, linear ruptures of the Bruch membrane (lacquer cracks), and retinal thinning. The posterior retina can be damaged by traction induced by an epiretinal membrane or residual focal vitreoretinal adhesion. The combination of retinal traction, posterior staphyloma, and progressive global scleral stretching frequently leads to macular holes,1,2 retinoschisis and posterior retinal detachment,3,4 detachment of the internal limiting membrane (ILM),5 peripapillary detachment of the pigment epithelium (PDPM),6 – 8 vascular traction with retinal microfolds, and paravascular intraretinal cysts.9 –11 We previously described several cases of retinal abnormalities associated with high myopia examined with en face optical coherence tomography (OCT).12–14 En face OCT combines OCT and confocal ophthalmoscopy, and yields longitudinal B scans and coronal C scans of the retina that correspond pixel-to-pixel with red-free images of the fundus.15 The coronal image allows prompt visualization of the lateral extent of lesions on the posterior pole. The aim of this study was to evaluate with en face OCT the incidence of retinal abnormalities in a large number of cases presenting high myopia and posterior staphyloma.
METHODS TWO HUNDRED SYMPTOMATIC AND ASYMPTOMATIC HIGHLY
myopic eyes (100 consecutive patients) examined between November 20, 2005 and June 30, 2006 at the University of Naples Federico II were studied. Inclusion criteria were myopia greater than ⫺6 D, and evidence of posterior staphyloma at fundus examination and at ultrasound Bscan evaluation. Exclusion criteria were moderate to dense lens opacities, history of intraocular inflammation such as anterior or posterior uveitis, history of peripheral retinal detachment, laser treatment for peripheral retinal diseases, diabetes, connective tissue diseases, history of ocular trauma or optic neuropathy, and other systemic or neurological diseases. All patients underwent evaluation of best-corrected visual acuity (BCVA), slit-lamp examination of the anterior segment, and ophthalmoscopy of the posterior fundus. In all cases, en face OCT of the posterior pole was performed with time domain OCT Ophthalmo-
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77 years). The mean refractive error was ⫺13.8 D (range, ⫺6 to ⫺22 D). The mean axial length was 28.9 ⫾ 2.2 mm (range, 25.8 to 35.2 mm). The results of the analyzed sample of 200 eyes are reported in Table 1. The association among the detected abnormalities is reported in Table 2.
TABLE 1. Characteristics of 200 Highly Myopic Eyes Evaluated with En Face Optical Coherence Tomography No. (%) of Eyes
Macular hole without posterior detachment Posterior retinal detachment With macular hole Without macular hole Peripapillary detachment of the pigment epithelium Retinoschisis Detachment of the internal limiting membrane Retinal vascular microfolds Paravascular microcysts
3 (1.5) 37 (18.5) 15 (7.5) 22 (11)
● MACULAR HOLE: Three eyes (1.5%) were affected by a macular hole (Figure 1) without posterior retinal detachment. Two of these eyes had a full-thickness macular hole, and the third eye had a lamellar macular hole and an epiretinal membrane.
10 (5) 27 (13.5) 12 (6) 40 (20) 3 (1.5)
● POSTERIOR RETINAL DETACHMENT: We detected posterior retinal detachment in 37 cases (18.5%). In all cases en face OCT longitudinal B scans showed the cross-sectional shape of the detachment, the neuroretinal microarchitecture, and vitreoretinal traction, if present. From the coronal C scans, we determined the lateral extent of the detachment at different depths from the vitreoretinal interface to the pigment epithelium. These scans could be overlaid on the red-free image of the fundus. Posterior detachment was associated with a macular hole in 15 (7.5%) of 200 eyes. Of these, 13 eyes with a mean BCVA of 20/50 (range, 20/30 to 20/200) had a full-thickness macular hole, whereas two eyes with a BCVA of 20/60 and 20/30 had a lamellar hole. The diameter of the hole ranged from 600 m to 900 m (mean, 700 m). An epiretinal membrane was detected in seven (46.6%) of 15 eyes. Posterior detachment was not associated with a macular hole in 22 (11%) of 200 eyes. In all these cases, detachment was located on the area of the staphyloma, and it affected the macula in 10 cases (Figure 1) and was extramacular in 12. In one of the 12 latter cases, the extramacular detachment occurred in correspondence to an inferonasal staphyloma (Figure 2), whereas in the remaining 11 (50%) of 22 eyes it occurred in correspondence to a papillary staphyloma (Figures 3 and 4). Biomicroscopic examination showed a Weiss ring detached from the optic disk in 77.3% (17/22 eyes), and there was no sign that posterior vitreous detachment had occurred in five of 22 eyes. In four (18.2%) of 22 eyes, en face OCT revealed a premacular structure constituted by an epiretinal membrane in three eyes, and posterior hyaloidal traction in one eye (Figure 3). Of the 10 eyes with macular involvement, visual acuity was 20/20 in five eyes, and ranged from 20/25 to 20/200 (mean, 20/30). We measured the thickness of the detachment in any given point, and found a low negative correlation between visual acuity and foveal thickness (Spearman r ⫽ ⫺0.529, P ⫽ .039).
scope (OTI, Toronto, Ontario, Canada) by the same examiner (R.F.). In the time domain OCT Ophthalmoscope system, the light emitted by a super luminescent diode (820 nm, 20-nm band width) is split by a partially reflecting mirror (“beam-splitter”) into two parts. One beam is transmitted to the eye and is reflected by intraocular structures at different distances, the other is reflected from a reference mirror at a known spatial position. The two backreflected optical beams are collected through an interferometer to produce the OCT signal. Two orthogonal scanners scan the eye in depth and transversally, and the scan plane obtained depends on the order in which these scans are taken and on the scanning direction associated with the line displayed in the raster of the final image delivered. The light reflected from the eye can be split and reflected in part to a separate photodetector to produce a confocal signal (scanning laser ophthalmoscopy/ OCT, SLO/OCT). Thus, the coronal C-scan corresponds pixel-to-pixel to the confocal red-free image. Scans were interpreted as described elsewhere.12–16 We use the term “retinoschisis” to indicate a separation among internal retinal layers, with persistence of an adherence between the outer layers and the retinal pigment epithelium (RPE).3 We define detachment of the ILM based on evidence of a membrane partially separated from the internal retinal surface with persisting columnar elements.5 We used the term “retinal detachment” to indicate the complete separation between the neuroepithelium and RPE, without evidence of persistent outer neuroepithelial layers.3,4,17 All data were analyzed using the statistical package of SPSS version 13.0 for Windows (SPSS Inc, Chicago, Illinois, USA). A P value less than .05 was considered statistically significant.
THE MEAN AGE OF THE PATIENTS (58 WOMEN AND 42
● DETACHMENT OF THE INTERNAL LIMITING MEMBRANE, RETINOSCHISIS, RETINAL VASCULAR MICROFOLDS, AND PARAVASCULAR MICROCYSTS: Detachment of the ILM
men) was 58.3 ⫾ 5.5 years (mean ⫾ SD) (range, 46 to
was detected in 12 (6%) of 200 eyes. In seven (58.3%)
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TABLE 2. Association (%) among Abnormalities of the Posterior Pole Detected with En Face Optical Coherence Tomography in a Series of 200 Highly Myopic Eyes
PDMH PDWMH PPRD RTS ILMD PDPM MH RVM VMT
PDMH
PDWMH
PPRD
RTS
ILMD
PDPM
MH
RVM
VMT
— — — 0 0 0 0 3 (1.5) 7 (3.5)
— — — 10 (5) 7 (3.5) 0 0 6 (3) 5 (2.5)
— — — 9 (4.5) 7 (3.5) 0 0 11 (5.5) 0
0 10 (5) 9 (4.5) — 10 (5) 1 (0.5) 1 (0.5) 27 (13.5) 21 (10.5)
0 7 (3.5) 7 (3.5) 10 (5) — 0 0 12 (6) 5 (2.5)
0 0 0 1 (0.5) 0 — 0 1 (0.5) 0
0 0 0 1 (0.5) 0 0 — 1 (0.5) 1 (0.5)
3 (1.5) 6 (3) 11 (5.5) 27 (13.5) 12 (6) 1 (0.5) 1 (0.5) — 32 (16)
7 (3.5) 5 (2.5) 0 21 (10.5) 5 (2.5) 0 1 (0.5) 32 (16) —
PDMH ⫽ posterior retinal detachment with macular hole; PDWMH ⫽ posterior retinal detachment without macular hole; PPRD ⫽ peripapillary retinal detachment; RTS ⫽ retinoschisis; ILMD ⫽ detachment of the internal limiting membrane; PDPM ⫽ peripapillary detachment of the pigment epithelium; MH ⫽ macular hole without posterior detachment; RVM ⫽ retinal vascular microfolds; VMT ⫽ vitreomacular traction.
FIGURE 1. En face optical coherence tomography (OCT) in highly myopic eyes. (Top left) Longitudinal B-scan and (Top right) coronal C-scan showing a lamellar macular hole (arrow). Refractive error is ⴚ19 diopters (D). (Second row, left) En face OCT cross-sectional B-scan showing retinoschisis with bridging elements in correspondence to a posterior staphyloma. The thickness of the schisis is 1010 m. (Second row, right) The coronal C-scan shows the lateral extent of the schisis (arrowheads). (Bottom left) En face OCT B-scan and (Bottom middle and right) consecutive antero-posterior coronal OCT C scans showing a retinal detachment without macular hole in correspondence of a posterior pole staphyloma. The thickness of the detachment is 610 m. Note the epiretinal membrane on the retinal surface (arrow). This patient had undergone photodynamic therapy for choroidal neovascularization and a columnar scar is visible in the middle of the detachment. Retinoschisis is present in its periphery. The angular size for all scans is 20 ⴛ 20 degrees.
of 12 eyes, it was associated with a papillary staphyloma and involved the peripapillary area. Retinoschisis was present in 27 (13.5%) of 200 eyes (Figures 1 and 4), and was associated with a posterior detachment without macular hole in 10 (37%) of 27 cases. Premacular traction occurred in 21 (77.7%) of 27 eyes with retinoschisis. Retinal vascular microfolds were detected in 40 VOL. 145, NO. 2
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(20%) of 200 eyes, and appeared as tent-like bending of the vessels (Figures 3 and 4). They were present in the 11 eyes with peripapillary retinal detachment, the 12 eyes with ILM detachment, and the 27 eyes with retinoschisis. Paravascular microcysts were detected in three (1.5%) of 200 eyes; they appeared as paravascular cystoid spaces in the inner retina at longitudinal B-scan IN
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FIGURE 2. Posterior detachment in high myopia. (Top left) En face OCT cross-sectional B scans showing a wide posterior detachment in correspondence of the inferonasal staphyloma in a pseudophakic patient. (Bottom left) The height of the optically empty subretinal space corresponding to the detachment is 1289 m. (Top right, middle, and bottom) Consecutive antero-posterior OCT coronal (Left) overlaid confocal red free image/coronal C scans and (Right) not overlaid C scans show the lateral extent of the detachment (arrows) and confirm its correspondence with the inferonasal staphyloma.
and coronal C-scan (Figure 4). In all cases, they were localized alongside the supero-temporal vein. In all these cases, overlaying of coronal OCT/red-free confocal images showed the exact point-to-point location of the abnormalities on the retinal surface.
staphyloma), the early stages of myopic retinal alterations can be easily underestimated by biomicroscopy, angiography, or ultrasonography, and therefore remain undiagnosed. In recent years, OCT with cross-sectional images of retinal structure has greatly facilitated the study of the posterior vitreoretinal anatomy in eyes with high myopia. It can also reveal otherwise undetectable macular changes in asymptomatic patients. The OCT ophthalmoscope produces retinal conventional longitudinal B scans and coronal C scans.12–16 Thus, it provides information not readily available with conventional imaging techniques. Whereas B scans produce cross-sectional images of retinal morphology, bearing a strong resemblance to histology, OCT C scans are represented as 2-dimensional transversal slices at any given depth through the retina, thereby enabling visualization of the lateral extent of structures. OCT C scans can be associated pixel-to-pixel and simultaneously to a confocal red-free image, which is used to identify the exact position of lesions on the posterior pole. To our knowledge, our study represents the first large cross-sectional evaluation with en face OCT of fundus alterations in high myopia. All the abnormalities identified seem to be related with the mechanical elongation forces taking place in highly myopic eyes. The stretching of retinochoroidal tissues may result from a combination of vitreoretinal adhesion,17,18 posterior staphyloma,3,4 rigidity of the ILM,5 and inflexibility of the retinal vessels.9 In our series, posterior retinal detachment (with or without macular hole) was present in 18.5% of eyes. Of these, a macular hole was present in 40.5%, and was associated with an epiretinal membrane in 46.6% of cases. As en face OCT allows visualization of the total lateral extension of vitreomacular adherences,19 and as
● PERIPAPILLARY DETACHMENT OF THE PIGMENT EPITHELIUM: Peripapillary detachment of the pigment ep-
ithelium was present in 10 (5%) of 200 eyes (Figure 5). BCVA ranged from 20/30 to 20/100 (mean, 20/40). There was no perimetric alteration in three of 10 eyes, whereas examination with the Humphrey visual field analyzer (Carl Zeiss Meditec, Dublin, California, USA) revealed glaucomatous visual field defects consisting in arcuate scotoma and nasal step in seven (70%) of 10 eyes. These defects matched the peripapillary abnormality in three (42.8%) of seven eyes. In all cases, coronal scans clearly showed the lateral extent of the PDPM, and its thickness could be measured on longitudinal scans. The thickness of the PDPM ranged from 304 m to 400 m (mean, 359 m). There was no correlation between visual acuity and PDPM thickness (Spearman r ⫽ ⫺0.134, P ⫽ .021), whereas there was a strong correlation between PDPM thickness and grade of matching between the PDPM and the visual field defects (Spearman r ⫽ 0.874, P ⫽ .028).
DISCUSSION BECAUSE OF THE CHARACTERISTIC CONFOUNDING FEA-
tures of the choroid, retina, and vitreoretinal interface in degenerative myopia (i.e., thin retina, areas of choriocapillaris atrophy, retinal pigment epithelium hypopigmentation or hyperpigmentation and posterior 284
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FIGURE 3. Vitreoretinal traction and vascular microfolds in highly myopic eyes. En face OCT (Top) longitudinal cross-sectional B-scan showing vitreoretinal tractions (arrows) and detachment of the peripapillary neuroepithelium (asterisks) at both sides of a papillary staphyloma. (Second row, left) Overlaid confocal red free image/coronal C-scan and (Second row, right) not overlaid C-scan show the lateral extent of the subneuroepithelial hyporeflective area of retinal detachment (asterisks). The refractive error was ⴚ18 D. In the left eye (Third row) OCT cross-sectional B-scan shows vitreoretinal traction in correspondence of vascular folds (arrows). (Bottom left) Overlaid confocal red free image/coronal C-scan and (Bottom right) not overlaid C-scan parallel to the internal retinal surface show the stretched hyperreflective vessel (arrowheads) in the hyporeflectivity of the vitreous.
evident in 18.2%. Vitreomacular traction has been implicated in the formation of posterior detachment in patients with pathologic myopia, and it has been reported that removal of a thin layer of adherent vitreous led to the resolution of the detachment.21,22 On the other hand, all our cases of peripapillary retinal detachment or ILM detachment were affected by retinal vascular microfolds, which are thought to be caused by the inflexibility of retinal vessels as opposed to retinal stretching.9 These data could suggest that retinal splitting at different
vitreous surgery combined with membrane peeling and use of retinal tamponade seems to be successful in achieving retinal reattachment in eyes with macular hole and posterior staphyloma,20 coronal en face OCT C scans may help in planning the best approach for removal of premacular tractional structures. A macular hole was not present in 22 of the 37 eyes (59.5%) with posterior detachment. In these 22 eyes, the detachment was localized in correspondence of the staphyloma, and tractional premacular structures were VOL. 145, NO. 2
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FIGURE 4. Retinal vascular microfolds, paravascular microcysts and retinoschisis in highly myopic eyes. (Top left) Color fundus image showing papillary staphyloma. En face OCT B scans show (Top right) detachment of the peripapillary neuroepithelium (asterisk) and (Right, second row) V-shaped bending of the vessels (arrow). (Left, second row) Longitudinal cross-sectional en face OCT B-scan showing paravascular inner retinal cysts. (Middle, third row) Overlaid confocal red free image/coronal C-scan and (Right, third row) not overlaid C-scan. The extent of the retinal cysts alongside the vessel (arrow) is visible. (Bottom left) Retinoschisis at cross-sectional B-scan, (Bottom, middle) overlaid confocal red free image/coronal C-scan and (Bottom right) not overlaid C-scan. Splitting of retinal layers is present (arrows).
correlation could be attributable to a progressive damage to the retinal nerve fiber layer that crosses the edge of the excavated myopic conus. As en face OCT coronal C scans allow visualization of the lateral extent of the PDPM, they could represent an alternative to fluorescein angiography for the detection of minimal changes of width and thickness during follow-up. In conclusion, en face OCT provides an accurate imaging of retinal changes in high myopia and allows prompt recognition of their localization. With en face OCT it is possible to identify the exact location of retinal lesions and measure their width and thickness, thus allowing a noninvasive evaluation of changes during follow-up. The high frequency of retinal abnormalities in our series suggests that myopic ocular elongation plays an important role in their development. We found a high incidence of posterior retinal detachment and stretching-related fundus abnormalities, namely, retinoschisis,
depths in high myopia could be attributable to vitreoretinal traction, to the staphyloma, and to the inward forces exerted by the rigid vessels and ILM. As reported by others,3,17,23 we found no significant correlation between foveal detachment without macular hole and visual impairment. This lack of correlation is probably due to the relative preservation of the neuroepithelium and the persistent release of nutrients from the choriocapillaris,4 which would continue for some time after detachment. However, a further reduction of visual acuity has been reported after increase in the thickness of the detachment during follow-up.17 The incidence of peripapillary detachment of the pigment epithelium in our series was similar to that reported by others, as was the high correlation of peripapillary detachment with visual field defects.6 – 8 According to our findings, PDPM thickness could be correlated with the matching of the PDPM with visual field defects. This 286
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FIGURE 5. Peripapillary detachment of the pigment epithelium in high myopia. En face OCT (Top) longitudinal B-scan, (Bottom left) overlaid confocal red free image/coronal C-scan and (Bottom right) not overlaid C-scan show a hyporeflective area under the pigment epithelium (asterisks).
ILM detachment, and vascular microfolds. Posterior detachment without macular hole was always in the area
of the staphyloma, which suggests that the staphyloma could play an important etiologic role in this condition.
THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN DESIGN AND conduct of study (R.F.); collection, management, analysis, and interpretation of the data (R.F., G.C., F.P., G.d.C.); and preparation, review, or approval of the manuscript (R.F.).Written informed consent according to the tenets of the Declaration of Helsinki was obtained from each patient included. Federico II Institutional Review Board approval was obtained. This study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
7. Toranzo J, Cohen SY, Erginay A, Gaudric A. Peripapillary intrachoroidal cavitation in myopia. Am J Ophthalmol 2005;140:731–732. 8. Shimada N, Ohno-Matsui K, Yoshida T, et al. Characteristics of peripapillary detachment in pathologic myopia. Arch Ophthalmol 2006;124:46 –52. 9. Sayanagi K, Ikuno Y, Gomi F, Tano Y. Retinal vascular microfolds in highly myopic eyes. Am J Ophthalmol 2005; 139:658 – 663. 10. Ikuno Y, Gomi F, Tano Y. Potent retinal arteriolar traction as a possible cause of myopic foveoschisis. Am J Ophthalmol 2005;139:462– 467. 11. Ohno-Matsui K, Hayashi K, Tokoro T, Mochizuki M. Detection of paravascular retinal cysts before using OCT in a highly myopic patient. Graefes Arch Clin Exp Ophthalmol 2006;244:642– 644. 12. Forte R, Pascotto F, Soreca E, Cusati G, de Crecchio G. Posterior retinal detachment without macular hole in high myopia: visualization with en face optical coherence tomography. Eye 2007;21:111–113.
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13. Forte R, Pascotto F, Napolitano F, Cennamo G, de Crecchio G. En face optical coherence tomography of macular holes in high myopia. Eye 2007;21:436 – 437. 14. Forte R, Pascotto F, Cennamo G, de Crecchio G. Evaluation of peripapillary detachment in pathologic myopia with en face optical coherence tomography. Eye. Forthcoming. 15. van Velthoven ME, Verbraak FD, Yannuzzi LA, Rosen RB, Podoleanu AG, de Smet MD. Imaging the retina by en face optical coherence tomography. Retina 2006;26: 129 –136. 16. Lumbroso B, Brancato R, Rosen R. OCT/SLO “en face” optical coherence tomography. Rome, Italy: I.N.C. Innovation-News-Communication, 2006:1–110. 17. Gaucher D, Haouchine B, Tadayoni R, et al. Long-term follow-up of high myopic foveoschisis: natural course and surgical outcome. Am J Ophthalmol 2007;143:455– 462.
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18. Panozzo G, Mercanti A. Optical coherence tomography findings in myopic traction maculopathy. Arch Ophthalmol 2004;122:1455–1460. 19. Forte R, Pascotto F, de Crecchio G. Visualization of vitreomacular tractions with en face optical coherence tomography. Eye. Forthcoming. 20. Soheilian M, Ghaseminejad AK, Yazdani S, et al. Surgical management of retinal detachment in highly myopic eyes with macular hole. Ophthalmic Surg Lasers Imaging 2007;38:15–22. 21. Ikuno Y, Sayanagi K, Ohji M, et al. Vitrectomy and internal limiting membrane peeling for myopic foveoschisis. Am J Ophthalmol 2004;137:719 –724. 22. Kobayashi H, Kishi S. Vitreous surgery for highly myopic eyes with foveal detachment and retinoschisis. Ophthalmology 2003;110:1702–1707. 23. Ichibe M, Baba E, Funaki S, Yoshizawa T, Abe H. Retinoschisis in a highly myopic eye without vision impairment. Retina 2004;24:331–333.
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Biosketch Raimondo Forte, MD, is currently attending a PhD Training Program at the Department of Ophthalmology at the University of Naples Federico II in Naples, Italy. Previously, Dr Forte was a fellow at the Department of Ophthalmology of the Centre Hospitalier Intercommunal of Creteil, France. He subsequently attended the St Erik Eye Hospital in Stockholm, Sweden as an observer. Dr Forte’s main research interests are medical retinal diseases and chorioretinal tumors.
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