Traumatic Macular Retinoschisis

Sir,

Recently Bonyadi[1] described the case of a 30-year-old man who lost vision in the left eye following trauma due to an explosion of a vehicle tire tube. Optical coherence tomography (OCT) showed subfoveal fluid and intraretinal vertical schisis cavities involving the outer retina at presentation. At 2 weeks after the trauma, the eye showed foveal atrophy.[1] I wish to discuss a few facts regarding this case.

Figure 1[1] is a multicolor image from the Spectralis machine and not an infrared reflectance image, as has been described in the manuscript.[1] Such images are in pseudocolor as specific wavelengths are used in the confocal scanning laser ophthalmoscope and an image is reconstructed. A true color image uses white light with a continuous spectrum of wavelengths. It would be interesting to analyze the color fundus photograph and fundus fluorescein angiogram in the acute phase if these were obtained.

OCT [Figure 2][1] also shows some reflectivity just superficial to the retinal pigment epithelium beneath and nasal to the fovea in the acute phase. It would be interesting to know if the author noted any subretinal bleeding in this patient. Some images (upper left and lower left, Figure 2)[1] also show mild inner retinal hyperreflectivity. The author also noted a “thickening and yellow discoloration of the macula and a mild vitreous hemorrhage.” An unusual feature of the presented case is the rapid evolution of foveal atrophy over 2 weeks. Was a traumatic central retinal arterial occlusion/macular ischemia and/or central retinal venous occlusion excluded in the patient? Did the author also note any pigmentary changes involving the macula on follow-up?

Though temporal relation with trauma and other findings suggest a traumatic origin of the features, retinoschisis at multiple levels may need exclusion of other diseases including optic disc pit maculopathy and juvenile retinoschisis. The other eye's fundus and OCT findings should be provided.

The author[1] mentions that OCT findings in the present case are very similar to the pathologic findings of whiplash maculopathy.[2] However, the cited article[2] evaluated the postmortem histological features and showed “retinoschisis (retinal splitting) between the photoreceptor nuclei and the intact, but folded, photoreceptor inner and outer segments.”[2] Retinal pigment epithelial detachment was also noted. This report[2] does not exactly match the findings of the current case.[1] The available literature on OCT[3] in retinoschisis in shaken baby syndrome revealed focal posterior vitreous detachment (PVD), sub-internal limiting membrane (ILM) cavity,[4] multilayered retinoschisis with prominent inner retinal cavities at the location of attachment of focal PVD/ILM, preretinal hemorrhage, and foveolar detachment. The statement that “OCT findings in our case may indicate that vitreous traction is one of the main pathogenic mechanisms for development of retinal splitting in the current case”[1] is not substantiated by the provided OCT image, which does not show any evidence of vitreous traction. The changes predominantly affect the outer retina.[1]

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