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Split Down the Middle of the Fovea

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 50s with hypertension who was otherwise in good health presented for new ophthalmologic evaluation in the setting of mild, long-standing blurred vision with slight metamorphopsia in the right eye. She had a history of high myopia (approximately 9 diopters [D] OD; 8 D OS). Examination revealed an otherwise normal left eye with 20/20 best-corrected visual acuity (BCVA). The right eye demonstrated a BCVA of 20/25 and normal anterior segment, including lenticular examination. Dilated fundus examination showed wrinkling of the neurosensory retina at the fovea (Figure 1A) without posterior vitreous detachment. Spectral-domain optical coherence tomography revealed hyperreflective layering on the foveal surface consistent with epiretinal membrane, as well as splitting of the outer plexiform layer with hyporeflective cavities (Figure 1B).

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Foveal retinoschisis with epiretinal membrane in the setting of pathologic myopia

D. Observation without considering intervention unless visual acuity deterioration is found

A diagnostic explanation for retinal splitting, hyporeflective spaces, or cystoid abnormalities is necessary when evaluating retinal problems with optical coherence tomography, which sometimes can be multifactorial. The differential diagnosis for these findings in the macula includes inherited retinal disorders (eg, X-linked juvenile retinoschisis, Goldmann-Favre syndrome), medications (eg, antimicrotubular agents), vascular insults (eg, retinal vein occlusion), and trauma. In this case, the presence of an epiretinal membrane with pathologic myopia was suggestive of foveoschisis. Visualization can be supplemented by en face images and vitreoretinal interface segmentation. Myopic foveoschisis, typically with associated features, including staphyloma,1 can be associated with substantial visual acuity loss that may not always be correctable with surgical intervention. These problems are often compounded by other visual acuity loss from pathologic myopia, such as myopic degeneration in the posterior pole, in addition to epiretinal proliferation or dense remnants of cortical vitreous following posterior vitreous detachment. Foveoschisis does not always have to be accompanied by epiretinal membrane, and the causative mechanism of myopic foveoschisis remains unknown.1

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Article Information

Corresponding Author: Stanley Chang, MD, Department of Ophthalmology, Edward S. Harkness Eye Institute, NewYork–Presbyterian Hospital, Columbia University Irving Medical Center, 635 W 165th St, New York, NY 10032 (sc434@cumc.columbia.edu).

Published Online: July 8, 2021. doi:10.1001/jamaophthalmol.2020.6869

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Hoang  QV , Chen  CL , Garcia-Arumi  J , Sherwood  PR , Chang  S .  Radius of curvature changes in spontaneous improvement of foveoschisis in highly myopic eyes.   Br J Ophthalmol. 2016;100(2):222-226. doi:10.1136/bjophthalmol-2015-306628PubMedGoogle ScholarCrossref
2.
Sepúlveda  G , Chang  S , Freund  KB , Park  S , Hoang  QV .  Late recurrence of myopic foveoschisis after successful repair with primary vitrectomy and incomplete membrane peeling.   Retina. 2014;34(9):1841-1847. doi:10.1097/IAE.0000000000000156PubMedGoogle ScholarCrossref
3.
Ono  T , Terada  Y , Mori  Y , Kataoka  Y , Nakahara  M , Miyata  K .  Spontaneous resolution of myopic foveoschisis and a macular hole with retinal detachment.   Am J Ophthalmol Case Rep. 2019;13:143-146. doi:10.1016/j.ajoc.2019.01.002PubMedGoogle ScholarCrossref
4.
Lai  TT , Ho  TC , Yang  CM .  Spontaneous resolution of foveal detachment in traction maculopathy in high myopia unrelated to posterior vitreous detachment.   BMC Ophthalmol. 2016;16:18. doi:10.1186/s12886-016-0195-3PubMedGoogle ScholarCrossref
5.
Paulus  YM , Bressler  NM .  Spontaneous improvement in myopic foveoschisis.   Eye (Lond). 2014;28(12):1519-1520. doi:10.1038/eye.2014.203PubMedGoogle ScholarCrossref
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Breazzano  MP , Fang  H , Robinson  MR , Abraham  JL , Barker-Griffith  AE .  Vitreomacular attachment ultrastructure and histopathological correlation.   Curr Eye Res. 2015;18:1-7.PubMedGoogle Scholar
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