Fovea Saving Internal Limiting Membrane Surgical Approach to Safely Treat Myopic Foveoretinal Detachment

This chapter describes the microstructural and functional results of three highly myopic eyes that underwent macular surgery for myopic foveoretinal detachment (FRD).

High myopia is a major cause of legal blindness in industrialized countries. In the United States, it affects nearly 2% of the general population aged 12 to 54 years. Up to 34% of patients with pathologic myopia (PM) have myopic foveoschisis (MF), the first stage of myopic traction maculopathy (MTM), which naturally progresses to form FRD or macular holes (MHs) with or without macular hole retinal detachment (MHRD) in highly myopic eyes.

Three highly myopic patients (age = 52.3 ± 11 years) with significant vision loss were evaluated by an ophthalmologist and underwent preoperative examinations. We retrospectively reviewed symptomatic eyes that underwent successful fovea-saving internal limiting membrane peeling (FSIP) macular surgery for chronic myopic FRD at the Retina Department of Oftalmologia Integral ABC, Mexico City, Mexico. We performed postoperative multimodal microstructural and functional evaluations including spectral domain (SD) and swept source (SS) optical coherence tomography (OCT), autofluorescence evaluation, and automated microperimetric macular examination.

In this report, despite surgical reattachment of the FRD within the first months, chronic separation of the photoreceptors and the presence of stagnant SRF in contact with the retinal pigment epithelium (RPE) were considered causes of photoreceptor damage. There was a substantial difference between the best-corrected visual acuity (BCVA) before and after surgery in all three cases. Surgery was associated with significant improvement in visual acuity, as confirmed using a paired-sample permutation test. The mean presurgical BCVA value (LogMAR; mean ± SE) was 0.83 ± 0.15, and the postsurgical value was 0.43 ± 0.52 (p = 0.00065). The MF/FRD evaluation was 7.3 ± 3.5 months, with a mean postoperative follow-up time of 14 ± 4.08 months. At postoperative follow-up, postoperative multimodal imaging revealed an abnormal microstructural foveal SS-OCT pattern without signs of MH development. Using a stable central foveal fixation site and an anomalous retinal sensitivity analysis map, macular microperimetry confirmed subclinical reduced macular threshold sensitivity. Suble atrophic changes in the retinal pigment epithelium (RPE) were detected using autofluorescence imaging. Despite the successful microstructural disappearance of the myopic macular detachment, the last multidisciplinary functional and structural assessment demonstrated different subclinical macular alterations.