|Year : 2016 | Volume
| Issue : 2 | Page : 131-132
Innovations in management of optic nerve head pit associated maculopathy
Smita S Karandikar, Parag K Shah
Department of Pediatric Retina and Ocular Oncology, Aravind Eye Hospital & Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India
|Date of Web Publication||20-Mar-2017|
Parag K Shah
Department of Pediatric Retina & Ocular Oncology, Aravind Eye Hospital, Avinashi Road, Coimbatore - 641 014, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Management of chronic macular edema following optic nerve head pit has always been challenging. There are many treatment options available but none are universally accepted. In this article we present the newer techniques available for management of this disease.
Keywords: Optic nerve head pit, macular edema, recent advances
|How to cite this article:|
Karandikar SS, Shah PK. Innovations in management of optic nerve head pit associated maculopathy. Kerala J Ophthalmol 2016;28:131-2
It is very aptly said that necessity is the mother of all inventions. Retina medicine has emerged as an ever evolving field due to the constant need for better treatment options and outcomes. Optic nerve head (ONH) pit maculopathy is a congenital cavitary pathology of the ONH  whose management has significantly evolved from laser photocoagulation to microinvasive vitreoretinal surgeries.
Serous macular elevations have been estimated to develop in 25–75% of eyes with ONH pit,, and are known to become symptomatic by early adulthood. Laser photocoagulation to block the flow of fluid from the pit to the macula has been largely unsuccessful, perhaps owing to the inability of photocoagulation to seal a retinoschisis cavity., The possible sources for accumulation of serous fluid could be the vitreous cavity via the pit, subarachnoid space, blood vessels at the base of the pit, or the orbital space surrounding the dura.,, Just observation, systemic steroids, optic nerve sheath decompression, and scleral buckling procedures have not been demonstrated to be very effective treatment options to seal off this fluid.,
Recent innovations in management of ONH pit associated maculopathy are directed towards removal of vitreous source for serous fluid and its traction over ONH. Vitrectomy with induction of posterior vitreous detachment (PVD) at optic disc without gas tamponade or laser photocoagulation is thought to be an effective method of managing macular detachment resulting from ONH pits, especially when ocular coherence tomography (OCT) suggests peripapillary vitreous traction. Spaide et al. in 2006 reported a novel management technique to create half-thickness cuts into the retina with the use of a bent 25-gauge needle. Vitrectromy was also combined along with this maneuver to allow intraretinal and subretinal fluid to escape. Tamponade with intraocular gas was, however, avoided to prevent premature closure of the surgical fenestrations and the posterior hyaloid was left intact. A similar procedure was described by Schaal et al. to make three-quarter depth cuts into the retina with the use of a 27-gauge cannula in combination with a limited preretinal vitrectomy.
With advancement in knowledge regarding the disease pathology, vitrectomy with complete PVD induction is routinely performed when surgically intervened. A landmark innovation involves use of some material to plug the ONH pit to permanently seal it after vitrectomy and complete PVD induction. Two graft tissues are being extensively used and analyzed in recent times, namely the internal limiting membrane (ILM) graft recovered by intraoperative ILM peeling from same eye and the autologous scleral graft. Autologous platelet rich plasma is also being tried to seal the pit,, however, it is a temporary plug.
The ILM is a very thin, acellular, and transparent membrane on the inner surface of the retina. Although it plays a pivotal role in the early stages of retinal development, its function in adults is poorly understood. Pars plana vitrectomy (PPV), induction of PVD, peeling of the ILM, and gas tamponade have shown to help in complete resolution of intraretinal and subretinal fluid within a few months after surgery. In addition, a free flap may be plugged into the ONH pit to provide a mechanical obstruction to the fluid flow between the ONH pit and the intraretinal and subretinal space. On a similar footing, a triangular approximately 0.5 × 0.5 mm partial thickness scleral graft can be harvested from the same eye to be inserted into the ONH pit and plug it. This technique was initially described by Travassos et al. ILM or the scleral tissue provide a long-term alternative to anatomically seal the ONH pit by being nonabsorbable. Under physiological conditions, sclera is intimately related to the ONH, and thus, appears to be a safe and effective graft option. Inverse ILM flap technique to plug the pit-like large macular holes also offer a permanent solution to optic disc pit associated maculopathy. A long-term comparative study with a significant sample size should be undertaken to establish more concrete results.
It is, thus, amply evident that the advancing surgical techniques for management of ONH pit associated maculopathy present a variety of novel and innovative therapeutic options. Further studies are, however, needed to evaluate the efficacy of these techniques, although implementation of large series studies remains a challenge due to the rarity of cases with optic disc maculopathy.
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Conflicts of interest
There are no conflicts of interest.
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