Serous macular detachment is well known complication of optic disc pits,1 morning glory syndrome, disc colobomas2 and optic disc dysversions3 and can result in outer layer macular holes. We describe a similar presentation in an eye with a dysplastic disc.
A 29-year-old male presented with history of reduced visual acuity in the right eye of 18 months duration. He had been variously diagnosed as central serous retinopathy and lamellar macular hole. He had received one course of systemic steroid therapy (60 mg per day for 5 days tapered over one month period) and one course of anti tuberculous treatment elsewhere, completed 6 months ago.
At the time of presentation to us, his best-corrected visual acuity was 20/200; N18 in the right eye and 20/20; N6 in the left. His anterior segments and intraocular pressure were normal. Fundus examination of the right eye [Fig. 1] revealed subretinal fluid in the macular area with outer layer lamellar hole. The inner layers were clearly noted to be intact. Slit lamp biomicroscopy of the disc did not reveal any optic pit or coloboma. The disc was smaller than that of the left eye; had no visible cup and had a patch of gliosis on surface. Fundus fluorescein angiography showed an area of late staining on the temporal part of the disc shaped like a vertical band [Fig. 2] and window defects in macular area due to retinal pigment epithelial defects.
Intravitreal gas (0.2 cc of C3F8) was injected via the pars plana and the patient was encouraged to lie prone (or keep the head down while sitting) for at least 16 hours a day. The aim of this exercise was to displace the subretinal fluid from the peripapillary area to facilitate early photocoagulation. Two days later, the peripapillary area was found to be relatively dry. The retina along the temporal border of the disc was treated with diode laser of 200-micron spot size and 0.25 mw power. By one month, significant reduction in subretinal fluid was noted as evaluated by slit lamp biomicroscopy, but the vision remained 20/200. At 1 year follow up, the macula was dry and no lamellar hole was evident [Fig. 3]. However the visual acuity remained 20/200 because of the retinal pigment epithelial changes under the fovea. Unfortunately optical coherence tomography could not be done in this patient at initial visit as well as on follow up visits.
Serous macular retinal detachments with outer layer lamellar macular holes have been well described with optic pits.1 Less commonly such detachments have also been described with morning glory syndromes, optic disc colobomas2 and tilted disc syndrome.3 The present case had serous macular detachment similar to what was described in these entities. However, the disc did not have a visible pathology that could be identified as coloboma, pit or tilted disc. The disc could be labelled dysplastic, since it did not fit into any of the other well-defined congenital abnormalities.4 Fluorescein angiography revealed a vertical band of hyperfluorescence, the significance of which is uncertain. One may not be wrong in presuming that the dysplastic disc led to the macular condition similar to the mechanism described in cases of optic pit. Presumably any anomalous optic disc could potentially lead to a macular serous retinal detachment and outer layer lamellar hole formation. While treating the retina beyond the border of disc, diode laser is the preferred modality. The burns are deeper than with green laser and hence the risk of nerve fiber layer damage is minimised. This brief report describes an association of serous macular retinal detachment with dysplastic optic disc even in the absence of visible pit or coloboma.
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4. Brodsky MCMiller NR, Newman NJ. Congenital anomalies of the optic disc in ‘Walsh and Hoyt’s clinical neuro ophthalmology 1998 Baltimore Williams and Wilkins:794