Commentary: Current Trends in the Management of Optic Disc Pit Maculopathy

Optic disc pit (ODP) is a rare developmental defect of the optic nerve head with a reported incidence of 1 in 11000.[1] It does not cause any symptoms until complicated by the development of maculopathy (ODP-M), which results from the accumulation of fluid in different retinal layers, associated with or without neurosensory detachment. ODP-M complicates about 25–75% of ODP cases. When left untreated for long,[2] ODP-M leads to cystic degeneration of retina with pigmentary changes and poor visual recovery. The pathophysiology of ODP-M is not completely understood and the source of fluid remains debatable, with theories supporting both a) migration of cerebrospinal fluid through the connection of ODP with subarachnoid space and b) migration of liquefied vitreous. The current management of ODP-M is centered upon the prevention of fluid migration into the macula and facilitation of fluid resorption. These include pars plana vitrectomy (PPV) with posterior vitreous detachment (PVD), gas tamponade, laser photocoagulation to the temporal margins of the optic disc, internal limiting membrane peel, inner retinal fenestrations, and mechanically plugging the ODP. Gass was the first to describe the use of laser photocoagulation to the temporal disc margin with the aim to create a barrier, thereby preventing the migration of fluid into the retina.[3] The retinal reattachment was, however, observed to be very slow with limited functional improvement. Lincoff, Akiyama, and Lei later used gas tamponade along with laser so as to hasten the resolution of maculopathy. This increased the success rate to around 50%.[4] The rationale of PPV with PVD induction was according to the assumption of vitreo papillary and vitreomacular traction to be responsible for ODP-M. This was supported by the observation of the spontaneous resolution of maculopathy with PVD. Studies evaluating the role of PPV with PVD induction have shown promising long-term results, with anatomical success rates ranging from 50 to 95% and functional success beyond 50%.[5] Successful resolution of maculopathy with PPV and gas alone has led to the contemplation of the role for additional laser in these cases. A recent study comparing PPV and gas tamponade with or without laser has shown no additional benefit of doing laser photocoagulation.[6] Internal limiting membrane (ILM) contributes to tangential traction at the margins of ODP. ILM peel not only helps in relieving this traction but also ensures complete removal of vitreous and is thought to be helpful in facilitating resolution. Several reports have shown favorable outcomes with addition of ILM peeling in both adults and pediatric age groups. However, ILM peel can cause iatrogenic macular holes especially in patients with the thinned out retina and hence caution should be exercised while doing it in these subset of cases. Its use in management of OPD-M thus remains controversial. Several authors have demonstrated the successful resolution of OPD-M using techniques designed to seal the ODP. These include inverted ILM flap, ILM free flap, autologous serum, fibrin glue, and autologous sclera. Travassos was the first to describe a technique to seal ODP with the autologous sclera.[7] They recommended this procedure in select unsuccessful cases. Similarly, P. Shah also reported successful resolution of maculopathy using the above technique of plugging the ODP with autologous scleral graft.[8] Similarly, in the recent case report,[9] the authors demonstrated successful management of double ODP using two scleral plugs. Although scleral plugging seems to be an efficient option with favorable outcomes, its superiority and safety over PPV and gas is not established as the literature lacks comparative studies. On the basis of the current evidence, it would be fair to say that the most commonly used procedure for the management of ODP-M is PPV with gas tamponade and should be done as the primary procedure in all cases of ODP-M. Additional procedures like ILM peel, inverted ILM flap, ILM free flap, fibrin glue, and autologous scleral plug all have shown to be effective. However, these can be reserved for cases that fail to resolve after PPV and gas tamponade.