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Taiwan Journal of Ophthalmology xxx (2014) 1e2

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Taiwan Journal of Ophthalmology

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Case report

Foveoschisis with focal choroidal excavation

Chih-Kang Hsu a,b,c, Chun-Cheng Liu b,d, Jiann-Torng Chen a,c, Yun-Hsiang Chang a,c,*

aDepartment of Ophthalmology, Tri-Service General Hospital, Taipei, TaiwanbDepartment of Ophthalmology, Armed Forces Tao-Yuan General Hospital, Taoyaun, TaiwancNational Defense Medical Center, Taipei, TaiwandDepartment of Optometry, Chung Hwa University of Medical Technology, Tainan, Taiwan

a r t i c l e i n f o

Article history:Received 16 September 2013Received in revised form8 December 2013Accepted 24 December 2013Available online xxx

Keywords:focal choroidal excavationfoveoschisisoptical coherence tomography

Conflicts of interest: The authors have no conflictarticle.* Corresponding author. Department of Ophthal

Hospital, National Defense Medical Center, 325 ChengDistrict, Taipei 114, Taiwan.

E-mail addresses: yunhsiangchang@yahoo.com.tw(Y.-H. Chang).

2211-5056/$ e see front matter Copyright � 2014, Thhttp://dx.doi.org/10.1016/j.tjo.2013.12.006

Please cite this article in press as: Hsu C-K, edx.doi.org/10.1016/j.tjo.2013.12.006

a b s t r a c t

We report a rare case with a focal choroidal excavation (FCE) associated with foveoschisis. We describethe patient’s medical records and review the pertinent literature. A 51-year-old man had an FCE, whichwas considered to be associated with foveoschisis. Although the patient was treated with repeatedintravitreal injection of perfluoropropane, foveoschisis persisted. FCE-linked foveoschisis may be notedin a low myopic patient. Gas tamponade failed to induce retinal reattachment, and aggressive surgicaltherapy may be needed in this condition.Copyright � 2014, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights

reserved.

1. Introduction

Focal choroidal excavation (FCE) is an area of macular choroidalexcavation without evidence of a posterior staphyloma or scleralectasia. FCE was first reported by Jampol et al in 2006. Previousreports hypothesized congenital malformation or acquired cho-roiditis as the mechanism of FCE formation, and retinochoroidaldisorders have never been demonstrated to be associated with FCE.

We present our findings in one case of focal macular choroidalexcavation, which is the first reported to involve foveoschisisdetected by optical coherence tomography (OCT).

2. Case report

A 51-year-old man complained of metamorphopsia and blurredvision in his right eye of 1-week duration. He denied a personalhistory or a family history of systemic disease. His best correctedvisual acuities were 6/10 in the right eye and 6/6 in the left eye. Therefractive errors (spherical equivalent) were e3.5 diopters (D) inthe right eye and e2.25 D in the left eye. Slit lamp examination

s of interest relevant to this

mology, Tri-Service General-Kung Road, Section 2, Neihu

, yunsiang@ndmctsgh.edu.tw

e Ophthalmologic Society of Taiw

t al., Foveoschisis with focal c

showed no abnormality in the anterior segment of either eye.Fundus examination showed pigment mottling in themacula of theright eye (Fig. 1A). OCT demonstrated an FCE with foveoschisis atthe macula of the right eye (Fig. 1B). The FCE was bowl-shaped andlocated just under the fovea. The excavations involved the outerretinal layers up to the external limiting membrane (ELM). Theretinal layers from the outer plexiform layer to the retinal nervefiber layer were almost undisturbed.

We treated the patient’s right eye with an intravitreal injectionof 0.4 mL perfluoropropane, and he maintained a face-down posi-tion for 3 weeks. However, foveoschisis was still noted 1 monthlater. A repeated gas injection was given 1 month after the firstinjection, but failed to induce retinal reattachment. After 6 monthsof intravitreal injection, his best corrected visual acuity was still 6/10 in the right eye. After extensive discussion, the patient refusedsurgical treatment.

3. Discussion

Increasing numbers of FCEs have been analyzed recentlybecause of the widespread use of spectral-domain OCT (SDOCT).Margolis et al1 classified FCE into two types: conforming FCE andnonconforming FCE. In conforming FCE, there is no separation be-tween the photoreceptor tips and the retinal pigment epithelium(RPE). Conforming FCE can, over time, progress to nonconformingFCE, as stress on the outer retina results in separation of thephotoreceptor tips from the underlying RPE, leading tovisual disturbance.1e3 Some patients with FCE present with

an. Published by Elsevier Taiwan LLC. All rights reserved.

horoidal excavation, Taiwan Journal of Ophthalmology (2014), http://

Fig. 1. Images of a nonconforming focal choroidal excavation with foveoschisis in the right eye of a 51-year-old man. (A) Fundus photograph showing pigment mottling in themacula. (B) SDOCT demonstrating a bowl-shaped (arrowhead) choroidal excavation located just under the fovea. The excavation involves the outer retinal layer up to the ELM. Theband of photoreceptor outer segment tips disappears at the excavation, while the bands of ELM and the inner segment/outer segment junction are fairly well preserved. The retinallayers from the outer plexiform layer to the retinal nerve fiber layer are almost undisturbed. The retina is split by schisis cavities at the outer nuclear layer. ELM ¼ external limitingmembrane; SDOCT ¼ Spectral-domain optical coherence tomography. NFL: nerve fiber layer, GCL: ganglion-cell layer, IPL: inner plexiform layer, INL: inner nuclear layer, OPL: outerplexiform layer, ONL: outer nuclear layer, ELM: external limiting membrane, IS-OS: inner segment-outer segment membrane, RPE: retinal pigment epithelium.

C.-K. Hsu et al. / Taiwan Journal of Ophthalmology xxx (2014) 1e22

recurrent central serous chorioretinopathy and choroidal neo-vascularization,3 but the simultaneous development of FCE andfoveoschisis has not been reported previously.

Foveoschisis refers to a splitting of the neurosensory retina, andis usually noted in highly myopic patients and those with X-linkedretinoschisis (XLRS). However, there has been no previous report offoveoschisis secondary to FCE. In this patient, examinationsrevealed no specific findings such as optic pits, myopic degenera-tion with staphyloma, or vitreoretinal traction, and we presumethat the foveoschisis might have been triggered by FCE.

The development of FCE-linked foveoschisis may be related tothe complex of the outward force of the FCE and vitreoretinaladhesion. Histological studies show that in XLRS, the splitting oc-curs in the nerve fiber layer, whereas in myopic traction macul-opathy (MTM), the level of splitting is usually deeper within theretina. Our patient showed splitting in the outer retinal layer up tothe ELM, which is more like MTM. We speculate that FCE andmyopic foveoschisis have similar mechanisms.

Previous studies4 suggest that a simple gas injection achievesretinal reattachment in more than 50% of cases of myopic foveo-schisis. In our patient, repeated gas injections failed to achievereattachment. Johnson5 argues that MTM is caused by failure of apre-retinal structure, such as the posterior vitreous detachment,

Please cite this article in press as: Hsu C-K, et al., Foveoschisis with focal cdx.doi.org/10.1016/j.tjo.2013.12.006

the epiretinal membrane, and the internal limiting membrane.Surgical repair can be tailored successfully only after identifying themajor traction mechanism. Gas tamponade is helpful only in eyeswith amacular hole-associatedmacular detachment. We presumedthat the injected gas would act more widely on the dome of thestaphyloma and facilitate reattachment of the retina, but this maynot be true in cases of focal excavation.

In summary, foveoschisis may be triggered by FCE. Careful ex-amination with OCT and prompt treatment is necessary.

References

1. Margolis R, Mukkamala SK, Jampol LM, Spaide RF, Ober MD, Sorenson JA, et al.The expanded spectrum of focal choroidal excavation. Arch Ophthalmol.2011;129:1320e1325.

2. Katome T, Mitamura Y, Hotta F, Niki M, Naito T. Two cases of focal choroidalexcavation detected by spectral-domain optical coherence tomography. CaseReport Ophthalmol. 2012;3:96e103.

3. Kumano Y, Nagai H, Enaida H, Ueno A, Matsui T. Symptomatic and morphologicaldifferences between choroidal excavations. Optom Vis Sci. 2013;90:e110ee118.

4. Wu TY, Yang CH, Yang CM. Gas tamponade for myopic foveoschisis with fovealdetachment. Graefes Arch Clin Exp Ophthalmol. 2013;251:1319e1324.

5. Johnson MW. Myopic traction maculopathy: pathogenic mechanisms and sur-gical treatment. Retina. 2012;32:S205eS210.

horoidal excavation, Taiwan Journal of Ophthalmology (2014), http://