Intravitreal Gas Injection with Laser Photocoagulation for Highly Myopic Foveoschisis
Zhu X, Shen P, Li C, Li H, Huang H, Shi K, Wang L, Zhang X, Lu L. Retina. 2019 Jul;39(7):1305-1311
Myopic macular foveoschisis in patients is often a daunting clinical finding in many practices as progression and surgical outcomes are often variable. While present in 15-20% of myopic patients, progression to foveal detachment can occur in 35-72% of cases. Pars plana vitrectomy with or without ILM peeling and gas remains one of the mainstay treatments for progression, however, risk of inducing a macular hole (16-20% in some reports) or a retinal break with a detachment are common.
In the June issue of Retina, Zhu and colleagues describe a novel surgical approach that may be done in the office to treat progressive myopic foveoschisis (< -6.00 diopter spherical equivalent or axial length >= 26 mm). Twenty-three patients (30 eyes) underwent a combination of intravitreal C3F8 injection and temporal macular last photocoagulation with a mean follow up of 20.8 months. Sixteen eyes (69.5%) had a baseline foveal detachment.
In brief, an anterior chamber paracentesis is performed followed by an intravitreal injection of 0.5-0.7 mL of 66% C3F8 gas at either the 10 or 2 o’ clock positioning 3.5 mm posterior to the limbus. Patients are then instructed to be face down for 3 weeks. At 1 week post procedure, patients are brought back and 2-3 rows of light focal laser is performed in a “C” shaped fashion on the temporal side of the foveal avascular zone (“½ papillary diameter temporal to the fovea”) with the following parameters: 532 nm green laser, 100 mm spot size, laser power 100–150 mW, duration of exposure 100 ms. A repeat injection was performed if there was less than a 50% reduction in foveal thickness.
At final follow up, 76.7% had complete or partial attachment with a single or multiple injections. Seventeen eyes (56.7%) had complete attachment. Twelve eyes (40%) received a second injection 1 month after the initial treatment. While the authors report trends toward visual improvement, there was no statistically significant differences in mean and postoperative visual acuities. One eye developed a peripheral tear 5 months later and 1 eye developed a macular hole requiring a pars plana vitrectomy.
This paper illustrates a unique technique for a tough macular progressive macular disease. This technique may be a potential non-invasive option to offer patients who may not necessarily want incisional surgery or are not healthy enough for the operating room while achieving similar anatomic outcomes to vitrectomies.