Extensive peripapillary and macular myopic choroidal cavitations in a young myope

Description

A young male in his early 20s with high myopia came for a retinal evaluation. He had a history of retinal detachment surgery in his left eye 10 years ago with subsequent silicone oil removal. On examination, his corrected distance visual acuity in the right eye was 6/9 with −14.5 dioptre sphere (DS) /−4 dioptre cylinder (DC), and in the left eye was 6/15 with −15 DS/−5.5 DC. The axial length of the right eye was 30.89 mm, and that of the left eye was 31.04 mm. The anterior segment examination of both eyes was unremarkable. Intraocular pressure was 10 mm Hg and 14 mm Hg in the right and left eye, respectively. The fundus of the right eye showed a tilted optic disc with temporal peripapillary atrophy and a generalised tessellated background. The left eye fundus showed a tilted optic disc and temporal peripapillary atrophy. Extensive retinochoroidal scarring and pigmentation were seen in the inferior and inferotemporal periphery. A circumferential encircling band indent was seen with a residual silicone oil bubble in the superior vitreous cavity (figure 1A,B). In addition, multiple well-circumscribed yellowish-orange lobular lesions were noted in the left eye’s peripapillary area extending into the macula’s superior half (figure 2).

Figure 1.

Optos image of the right eye (A) with tilted disc and temporal crescent. (B) The left eye image showing a temporal crescent, inferior and inferotemporal scaring and pigmentation. A large residual silicone oil bubble is seen above the disc.

Figure 2.

Multiple yellowish-orange lesions in the peripapillary and macular region (arrowheads).

A widefield spectral domain optical coherence tomography (SD-OCT) of the right eye passing through the disc and foveal centre showed a normal-appearing macula, a relatively thin choroid and posterior bowing of the sclera (figure 3). An SD-OCT scan through the left eye showed a normal-appearing macula, an intact underlying retinal pigment epithelium (RPE)-Bruch’s complex and posterior bowing of the sclera. The choroid at the posterior pole and peripapillary regions displayed hyporeflectivity without back shadowing, corresponding to the yellowish-orange lobular lesions noted on fundus examination (figure 4A,B). An indocyanine green angiogram (ICG) of the left eye revealed the areas of choroidal hypofluorescence due to non-vascularity, again corresponding to lesions at the posterior pole. No abnormalities were noted in the right eye (figure 5A–D). A diagnosis of the left eye combined peripapillary and macular choroidal cavitations was made. Since the patient had no visual complaints, he was advised observation and periodic follow-up.

Figure 3.

Widefield SD-OCT of the right eye passing through the disc and macula showing chorioretinal atrophy corresponding to the myopic crescent. SD-OCT, spectral domain optical coherence tomography.

Figure 4.

A widefield SD-OCT horizontal scan (A) and at the 11-5° direction (B) showing extensive choroidal cavitations. SD-OCT, spectral domain optical coherence tomography.

Figure 5.

Normal early and late phase ICG scans in the right eye (A and C). Lobular hypofluorescence is noted in all phases corresponding to the cavitations seen on the SD-OCT scans. (B and D). ICG, indocyanine green angiogram; SD-OCT, spectral domain optical coherence tomography.

Myopic choroidal cavitations (MCCs) are described in eyes with pathological myopia and are frequently located in the peripapillary areas and at the borders of staphylomas.^{1 2} On SD-OCT, they appear as hyporeflective spaces beneath the unaltered RPE layer. Spaide et al postulated that bowing over time occurs in thinned-out sclera in response to intraocular pressure, resulting in cavitations.³ They are commonly observed in the elderly and high myopes with excessive globe elongation and thinning of the sclera, choroid and RPE, leading to weakening of the peripapillary area. Ohno-Matsui et al described them near areas of patchy chorioretinal atrophy, and their SD-OCT appearance was similar to that observed in peripapillary MCCs.⁴ They also speculate that these chorioretinal atrophic patches remodel in response to intraocular pressure, resulting in the development of cavitations similar to staphylomas.

The present case shows choroidal cavitations over a large area involving the peripapillary area and half of the macula, which has not been reported in the literature so far. The entire macula-RPE-choroid complex appears elevated with a clear separation from the underlying sclera. As the macular neurosensory retina was intact with normal architecture, the vision was normal without any symptoms. A few cases of retinoschisis, macular detachment and prolapse of retinal tissue into the cavitations have been observed in eyes with RPE-Bruch’s damage, resulting in decreased vision.^{2 5 6} The placement of a 360° encircling band and laser-induced extensive peripheral scarring may be linked to structural weakening of the sclera and choroid with subsequent development of choroidal cavitations in the present case. Despite a similar axial length and refractive error of both eyes, the unilaterality of the present case points to the possible role of surgical intervention in the causation of extensive choroidal cavitation. Myopic eyes that undergo retinal surgery should be monitored for such abnormalities to better understand the development, progression and consequences of these acquired changes.

Learning points.

• Choroidal cavitations described in the peripapillary or macular area are usually focal.

• Extensive choroidal cavitations may be secondary to acquired structural weakening of the scleral wall due to excessive globe elongation in this patient with a history of vitrectomy and encircling band placement.

• Myopic eyes undergoing retinal procedures should be monitored for the development of these cavitations.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).