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Ophthalmology

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

JAMA Ophthalmology

Published Online: July 8, 2021

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Mark P. Breazzano, MD^1,2;

Stanley Chang, MD¹

Author Affiliations

¹Edward S. Harkness Eye Institute, NewYork–Presbyterian Hospital, Columbia University Irving Medical Center, New York
²Wilmer Eye Institute, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland

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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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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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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

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-2015-306628 PubMed Google Scholar Crossref

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.0000000000000156 PubMed Google Scholar Crossref

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.2019.01.002 PubMed Google Scholar Crossref

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/s12886-016-0195-3 PubMed Google Scholar Crossref

Paulus YM , Bressler NM . Spontaneous improvement in myopic foveoschisis. Eye (Lond). 2014;28(12):1519-1520. doi:10.1038/eye.2014.203 PubMed Google Scholar Crossref

Breazzano MP , Fang H , Robinson MR , Abraham JL , Barker-Griffith AE . Vitreomacular attachment ultrastructure and histopathological correlation. Curr Eye Res. 2015;18:1-7.PubMed Google Scholar

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.