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PHOTO ESSAY
Year : 2019  |  Volume : 67  |  Issue : 7  |  Page : 1173-1174

Multimodal imaging to differentiate myopic macular pit and localized deep staphyloma in high myopia


Sri Bhagwan Mahavir Vitreoretinal Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India

Date of Submission17-Sep-2018
Date of Acceptance22-Feb-2019
Date of Web Publication25-Jun-2019

Correspondence Address:
Dr. Jaya Prakash Vadivelu
Sri Bhagwan Mahavir Vitreoretinal Services, Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1577_18

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Keywords: Localised deep staphyloma, myopic macular degeneration, myopic macular pit


How to cite this article:
Vadivelu JP, Shah A, Khetan V, Lingam G. Multimodal imaging to differentiate myopic macular pit and localized deep staphyloma in high myopia. Indian J Ophthalmol 2019;67:1173-4

How to cite this URL:
Vadivelu JP, Shah A, Khetan V, Lingam G. Multimodal imaging to differentiate myopic macular pit and localized deep staphyloma in high myopia. Indian J Ophthalmol [serial online] 2019 [cited 2019 Jul 16];67:1173-4. Available from: http://www.ijo.in/text.asp?2019/67/7/1173/260997



High myopia is linked to pathological changes, such as posterior staphyloma, optic disc changes and myopic macular degeneration (MMD) including chorioretinal atrophy (CRA), lacquer cracks, choroidal neovascular membrane (CNVM), and Foster-Fuchs spots.[1],[2]

The swept-source optical coherence tomography (SS-OCT) uses longer wavelength which penetrates deeper than conventional OCT.[3] With advent of such enhanced depth imaging and improved resolution of deeper structures, various lesions in the thinned out choroid and sclera of highly myopic eyes, namely peripapillary pits, macular intrachoroidal cavitation and myopic macular pits (MMP) have been described.[4] The extrascleral soft tissues can also be imaged in areas of severe CRA.

The MMPs are focal areas of absence of retinal and choroidal tissue at macula with alteration in the scleral curve in highly myopic fundus. Multimodal imaging helps in evaluation of MMPs and we present two similar appearing cases, one an MMP and another a localized deep staphyloma.


  Case Reports Top


Case 1

A 57-year-old high myopic lady with MMD and scarred CNVM had best corrected vision (BCVA) of 2/60 in both her eyes. In the left eye, there was a yellowish-brown oval depressed lesion, measuring 0.58 × 0.53 mm, inferior to fovea, within an area of patchy CRA. A retinal vessel dipped in, branched and continued along the superotemporal margin. MMP was suspected and confirmed on multimodal imaging [Figure 1].
Figure 1: (a) Fundus photograph of Case 1 shows oval pit (arrow) traversed by a retinal vessel within area of chorioretinal atrophy (CRA) (arrowheads). (b) Red-free image shows an oval area of low reflectance corresponding to the lesion (arrow). (c) Autofluoroscence shows an area of hypoautofluoroscence corresponding to CRA within which there was an area of lower autofluoroscence corresponding to the lesion (arrow). (d) SS OCT (TOPCON DRI Atlantis) shows loss of retina, RPE and choroid and scleral outpouching inferior to fovea, 902 microns deep and 397 microns wide. Extrascleral tissue can also be imaged in few areas

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Case 2

A 69-year-old high myopic gentleman had BCVA of 3/60, N12 in right eye and 2/60, N24 in left eye. Axial length was 31 mm bilaterally. Fundus was similar to case-1 but right eye had macular hole with schisis and a round well-defined dark-brown excavated area, inferior to fovea, measuring 1.21 × 1.15 mm, with pigmentation in superior part. [Figure 2] Inner retinal layers were intact over this excavation. The indocyanine green angiography (ICGA) revealed cilioretinal artery arising more nasally, branching, dipping and reemerging along the margins. Hence, this was just a localized deep posterior staphyloma and not an MMP as in the first case.
Figure 2: (a) Fundus photograph of Case 2 shows oval area (arrow) within CRA (arrowheads). (b) Red-free image of same. (c) Autofluoroscence shows hypoautofluoroscence at CRA with lower autofluoroscence at lesion (arrow) and pigmentation superiorly. (d and e) Fluorescein and indocyanine green angiography show cilioretinal artery branching nasally, dipping in and emerging from temporal margin. (f and g) SS OCT shows myopic foveoschisis, full thickness macular hole and thinning and outpouching of outer retina, RPE, choroid and sclera, 1249 microns deep and 1084 microns wide with intact inner retina

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  Discussion Top


Not much is known about the pathogenesis of MMPs.[4],[5] In a previous reported case,[4] scleral dehiscence was suspected but could not be demonstrated on OCT due to shadowing from pigmentation. ICGA showed that MMPs existed at sites of emissary canals of short posterior ciliary arteries.[4] The continuous mechanical tension onto macular CRA may also lead to MMPs and this may explain why MMPs occur only within areas of CRA.[4]

They are at risk of perforation during retrobulbar block and maybe sensitive to intraocular pressure fluctuations during intravitreal injections and surgery.

Further studies using multimodal imaging would shed light on pathogenesis of MMPs. MMPs are rare and this photo essay illustrates the utility of multimodal imaging in evaluation of MMPs and differentiating from localized posterior staphylomas.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Saw SM, Gazzard G, Shih-Yen EC, Chua WH. Myopia and associated pathological complications. Ophthalmic Physiol Opt 2005;25:381-91.  Back to cited text no. 1
    
2.
Spaide RF, Ohno-Matsui K, Yannuzzi LA, Rashid A, Grossniklaus HE. Update on Pathology of Pathological Myopia. Pathologic Myopia. New York, NY: Springer-Verlag; 2014. p. 83-5.  Back to cited text no. 2
    
3.
Yun SH, Bouma BE. Wavelength swept lasers. In: Drexler W, Fujimoto JG, editors. Optical Coherence Tomography: Technology and Applications. New York, NY: Springer; 2008. p. 359-78.  Back to cited text no. 3
    
4.
Ohno-Matsui K, Akiba M, Moriyama M. Macular pits and scleral dehiscence in highly myopic eyes with macular chorioretinal atrophy. Retin Cases Brief Rep 2013;7:334-7.  Back to cited text no. 4
    
5.
Freitas-da-Costa P, Falcão M, Carneiro A. Infrared reflectance pattern of macular pits in pathologic myopia. JAMA Ophthalmol 2015;133:e1580.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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