Focal choroidal excavation with foveoschisis

Abstract

Focal choroidal excavation with foveoschisisFocal choroidal excavation (FCE), first described by Jampol et al. 1 and later by Margolis et al., 2 is a region of focal thinning and concavity of the macular choroid typically found under the fovea or parafovea. FCE is commonly benign, and given that the retina overlying the FCE is often of normal appearance, it may only be detected on optical coherence tomography (OCT). Foveoschisis, a splitting of the neurosensory retina at the fovea, is a rare feature associated with FCE, with only a single previous description in the literature. 3 Here we present a case of a focal outer retinal foveoschisis overlying choroidal excavation in a myopic female and discuss the potential mechanisms involved.A 67-year-old myopic woman was referred for management of bilateral epiretinal membrane (ERM) with edema without altered acuity or metamorphopsia. The patient was otherwise healthy, was taking no medications, had no prior ocular history, and had a family history of glaucoma. Her best-corrected visual acuity was 20/30 OU, with normal intraocular pressure. Anterior segment examination showed 2+ nuclear sclerotic cataract bilaterally. Fundus examination found a mild ERM OD and a moderate ERM OS with associated vitreomacular traction but no pigmentary changes. Spectral-domain OCT confirmed the presence of bilateral ERMs and also identified retinoschisis OD at the level of the outer nuclear layer that was overlying a conforming FCE (Fig. 1A) and inner retinal traction and pseudocystic change OS (Fig. 1B). The central field thickness measurements of the right and left maculas were 423 and 334 mm, respectively.Given that the findings were of minimal functional significance, the patient was observed. At 14 months, the patient noted decreased acuity in the right eye, 20/50 OD and 20/ 30 OS, attributed to her ERM and intraretinal fluid. She was trialed on topical prednisolone acetate 1% and nepafenac 0.1% with some subjective improvement in her vision. Clinical examinations and OCTs over 4.5 years showed stability in the extent of her outer retinal schisis and ERM (Fig. 2). At the most recent follow-up in 2021, the patient's best-corrected visual acuity was 20/50 OD and 20/60+1 OS with evolution of cataract in both eyes; the patient is considering cataract surgery.FCE has been appreciated only in recent years through the increased availability of OCT. In a retrospective study of 4436 spectral-domain OCT scans by Chung et al. 4 in 2017, only 16 patients were found to have FCE, a prevalence of 0.3%, which has been reflected in other studies such as that of Turgut et al. 5 that same year. Patients are often identified in their fourth to sixth decades of life with no strong gender predilection. They are typically asymptomatic with respect to their FCE, although some may experience changes in visual acuity or metamorphopsia.