Sir,

Congenital optic disc pit (ODP) with associated maculopathy is a rare anomaly with unknown pathogenesis. However, since the remarkable observations of Lincoff, it is widely accepted that fluid originating from ODP creates a schisis-like separation of the neuroretina and subsequently breaks through into the subretinal space.1

We report successful surgical management of this pathology with emphasis on drainage of subretinal fluid.

Case report

A 35-year-old woman was referred for left ODP maculopathy with reduced visual acuity to counting finger of 6 months duration. Fundus examination and Optical Coherence Tomography (OCT) confirmed the diagnosis (Figures 1 and 2).

Figure 1
figure 1

Fundus photograph shows temporally located optic disc pit with associated maculopathy.

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Figure 2
figure 2

−5 degree 10 mm single line time-domain (OCT) through optic nerve head and fovea (asterisk) shows schisis-like separation of the neuroretina (long arrows) and subretinal space (short arrow).

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Parsplana vitrectomy (PPV) with induction of vitreous detachment was carried out. Subretinal fluid only was internally drained. Argon endolaser was applied to retinotomy sites only. Internal tamponade was achieved with C3 F8 14%. Ten days face-down posturing was instructed.

Postoperatively, visual acuity improved to 6/18. Macula was flat on biomicroscopy with no recurrence and stable vision after 26 months (Figure 3).

Figure 3
figure 3

Post-operative fundus photograph and OCT scan show the recovery of foveal depression and flat looking macula on biomicroscopy. Subfoveal hyporeflectivity (arrow) could be caused by shallow residual subretinal fluid or schisis.

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Comment

The unfavourable natural history of this pathology has encouraged ophthalmologists to use a combination of techniques such as PPV, laser photocoagulation to the temporal margin of the optic disc, internal tamponade, macular scleral buckling procedure, and internal drainage of submacular fluid.2, 3, 4 However, the success rate is variable and optimal treatment is controversial.

Laser photocoagulation alone to the temporal margin of the disc does not generally yield promising results.5 The reason could be that laser energy that is absorbed by retinal pigment epithelium creates a deep scar, while the primary pathology is more superficial.6 It can also be destructive to the important structures adjacent to the disc.

Tangential vitreous traction is thought to be important in the pathogenesis. Vitrectomy with removal of posterior hyaloid combined with internal compression with or without laser treatment has successfully reattached the macula in several reports but has usually required a few months before complete disappearance of fluid.7, 8

The viscous nature of the fluid prompted the surgeon (PES) to attempt active internal drainage of subretinal fluid intraoperatively, which resulted in faster visual recovery in this patient. This is the first report that demonstrates inducing PVD with drainage of subretinal fluid could be as effective as applying laser to the temporal margin of the disc without its associated complications.