Case report:
History:
19 yr old Caucasian male seen in the vitreo-retinal clinic at APH June 2000
HPC: LE blurring vision for one year
POHx: Nil. Nil Hx. of Trauma
PMHx: Nil.

Ocular Examination
BCVA: 6/5 RE; 3/60 LE
No RAPD
Anterior Segment: Normal
IOP 14mmHg BE
Clear medium BE

Fundus of the RE
Normal Optic Disc
Normal macula
Fundus of the LE ( see picture)

what is the diagnosis ?
your proposed investigations ?
any treatment based on your diagnosis ?

I will post the diagnosis and outcome of treatment with discussion next weekend.

［打包下载］　　　［引用该文］　　　［发表评论］　　　［转寄该文］　　　［关闭窗口］

此文章相关评论:

该文章有13个相关评论如下：(点这儿论坛方式查看)

2002yxy	发表于： 2003/11/01 03:04pm
	[这个贴子最后由2002yxy在 2003/11/01 11:10am 编辑] imp: optic disc pit (os) 依据:1.19 yr old     2.ffa:早期病变处荧光缺如,晚期显高荧光,后极部有渗漏,来源于视乳头     3.眼底:大片环状的后极部浆液性视网膜上皮脱离,似与视乳头相连. 治疗:    本病重要的是早期诊断;现在效果较好的治疗是: vitrectomy +gas tamponade + photocoagulation     拙见,请指教!
顶部

毛进	发表于： 2003/11/02 03:53am
	支持楼上的意见。
顶部

shuandai	发表于： 2003/11/02 09:12pm 相关图片如下：
	Very good indeed. I agree with your suggested treatment. I also have some things to surprise you. I will post the result of this patient's treatment here. We also have the second case who had the above treatment done in India a few years ago with 6/60 vision. We use the new treatment as I will describe here, he now sees 6/18 even after 5 years of poor vision. "Peeling of Internal Limiting Membrane" -new approach to this problem Under GA Standard Pars Plana three-port vitrectomy Induction of PVD 4x4 DD area of ILM was peeled off over macula Air-fluid exchange Intra-vitreous injection of 12% C3F8 No Peripapillary laser photocoagulation Face down posture for 10 days postoperatively Result(post-op): Day 1 VA: HM, retina appeared to be flat One week:VA:6/60,flat retina Two months post –op.: VA:LE 6/12 unaided Flat retina Six months post –op.: VA:LE 6/7.5 unaided Flat retina Last seen in March 2001 Discussion Congenital optic disc pit – 1 per 12,000 Serous macula detachment: 40% ~70% Pathogenesis unclear Management Approaches Peri-papillary laser photocoagulation Higher failure rate Poor functional result Laser + vitrectomy + gas tamponade Improved reattachment rate Variable functional results Overall disappointing outcome New concept Lincoff first demonstrated by using OCT Schisis cavities within the inner retinal layers over the macula Communication from pit to schisis cavities Macula detachment is a secondary change Other studies confirmed the above findings Our hypothesis: Vitro-retinal interface (ILM) contributes to macula detachment associated with disc pit Significant vitreous–retinal traction needed for macula detachment to occur Vitreo-retinal traction creates negative pressure within the schisis cavities – fluid drawn in – macula detachment Anatomically, ILM peel permanently abolishes vitreo-retinal adhesion/ or traction Summaries: ILM plays a significant role in induction of macula detachment in optic pit ILM peel + vitrectomy + gas tamponade results in rapid retinal reattachment and recovery of macula function Peripapillary laser not required ILM peel has implication for Rx of other macula schisis More cases are needed to confirm our observations
顶部

罗岩	发表于： 2003/11/03 02:32am
	抱歉，这些代码的具体意思是什么？请指教。 HPC: LE blurring vision for one year POHx: Nil. Nil Hx. of Trauma PMHx: Nil. we only do peri-papillary laser photocoagulation in our hospital, and I have never heard of your method in china. Maybe we should try it.But how long have you followed your patient after the operation.
顶部

2002yxy	发表于： 2003/11/03 08:25pm
	疑问:    ILM peel + vitrectomy + gas tamponade 确实在回复后极部脱离和视功能方面有很大优点.不过由于只是对征治疗,因此可能会出现以下两种情况:    1 手术时或术后可能会出现gas进入subretinal or retinal schisis 使手术失败      2由于没有彻底阻断viteous fluid/CSF--pit--subretinal or retinal schisis通道,所以仍然存在复发的解剖基础.    不知shuandai 如何看待此问题?请指教!
顶部

shuandai	发表于： 2003/11/04 08:39pm
	HPC: history of present complaint POHx: past ophthalmic history PMHx: past medical history Nil: no Parapapillary laser is the first reported treatment for congenital disc pit. very higher failure rate due to frequent recurrence and repeated laser almost needed for all reported cases underwent such treatment.this repeated laser treatment resulted in poor vision in cases did achieved anatomical retina reattached because laser damage to the maculapapillary bundle of the optic nerve fibres. Reason for few new treatment for such condition is due to our poor understanding of the pathogenesis of the process. With OCT and recent findings we have better understanding of the mechanism of the serous macular detachment in this disease, We beilieve it is the vitreoretinal traction which causes the fluid flow and serous macular detachment.As you will find from the literature and perhaps your own experience that the macular detachment occurs in 20 or 30 year of age not immediately after birth despite the pit is congenital. there are also reported cases of spontaneous reattachment after posterior vitreous detachment. Please see more details on my paper in "Clinical and Experienmental Ophthalmology, vol 31,Number3,June 2003,page272-5.
顶部

shuandai	发表于： 2003/11/04 08:47pm
	answer to question one: It is impossible for gas to go through the schisis as it is not a full thickness break. answer to question two; the mechanism of serous macular detachment is not the mere prescence of the pit, it is the vitreous retinal traction causes the fliud flow,as you would know not every one has a pit will have macular detachment. please refer to my answer to the previous question for more details. we have so far had three cases done this way all successful, obvious it requires more cases treated this way to confirm the effectiveness of our treatment.
顶部

deyongdeng	发表于： 2003/11/04 10:31pm
	Thank you,shuandai!!!it is good done!!! I have some questions:   1.the Pit is not full break,but why it is appeared as so seriously serous detachment?   2.In my mind,laser coagulation+Vitrectomy +gas is a good measures to the problem,but I learn your new proach is better.since ILM peel + Vitrectomy +gas can lead the detachment retina attachment,have you any measures only by drugs? I will be grateful for your answer!!!!!!!!!
顶部

罗岩	发表于： 2003/11/04 10:56pm
	也就是说，你认为，pit是发育上的一个解剖缺陷，但是玻璃体视网膜的牵拉才是发生脱离的必要条件。
顶部

shuandai	发表于： 2003/11/06 03:05pm
	The serous detachment of macular is due to fluid buildup within the inner retinal layers, then further vitreoretinal traction causes outer retinal break,then serous macular detachment. there are disputes from where the fluid enters the retinal causing macular detachment. I think there are two potential means for fluid to enter the macular area. 1) transvitreo-retinal interface via microchannels. 2) via the pit by some valve mechanisms as others proposed. both will require vitreo-retinal traction to facilitate the inflow of fluid. we can not confirm those theories by histology for obvious reasons, recent evidence on OCT and increasing good results from ILM peel for chronic diabetic macular ecema all support the role of vitreoretinal traction in the formation of serous macular edema laser photocoagulation is the traditional way we deal with this problem but evidence told us it is not effective. I am not aware that any drug can treat disc pit associated macular edema.
顶部

shuandai	发表于： 2003/11/06 03:07pm
	Yes, you are right.
顶部

2002yxy	发表于： 2003/11/06 10:39pm
	to shuandai   国内与optic disc pit相关研究确实很少.新的理论总会面临很多疑惑,我想问一下按照你的理论Peeling of Internal Limiting Membrane后,是不是本病基本不可能复发?还有,你们ILM peel + vitrectomy + gas tamponade 做了多少病人?术后观察多长时间?  请指教!
顶部

shuandai	发表于： 2003/11/07 09:16am
	This is a rare condition. we have done three, the longest followup is two and half years, the shortest 6 months, so far no recurrence.