Glaucomatous Peripapillary Retinoschisis

This 70YO male was referred for possible macular edema in his left eye. He underwent a successful vitrectomy for a retinal detachment in his right eye 8 months earlier. He had no visual complaints, and vision was 20/20 OD and 20/25 OS. Intraocular pressure was 14 mmHg OD and 22 mmHg OS.

Optos color RG imaging shows increased optic nerve cupping with a blister of retinal fluid extending temporally. Triton swept-source OCT shows both outer retinal elevation and schisis, and a small area of more temporal subretinal fluid. The outer retinal schisis directly communicates with the nerve.

At least 0.8 optic nerve cupping was noted OU, along with dense superior arcuate scotoma on 30-2 visual field testing (not shown).

Generic Cosopt OU BID was prescribed. Six weeks later, vision was 20/30 OD and 20/25 OS. IOP was 9 mmHg OD and 11 mmHg OS. The outer retinal schisis and fluid were decreasing.

Learning Points:
While peripapillary retinoschisis (PPRS) secondary to congenital optic disc cavitary abnormalities is well known, similar findings in patients with glaucomatous cupping but without nerve head cavitation are a more recently described and less common finding (Fujimoto et al., Ophthalmology Retina 2023;7:811-818).

The retinal nerve fiber layer is most commonly involved in glaucoma, whereas in optic pit maculopathy, outer and inner nuclear layer schisis, foveal involvement, and subretinal fluid are more frequently noted.

Most cases of glaucoma-related PPRS are asymptomatic and spontaneously resolve. However, in fovea-involving or symptomatic cases, surgical intervention may improve vision and decrease time to resolution.

There is no consensus on the optimal treatment approach, including pars plana vitrectomy alone or with juxtapapillary laser treatment, ILM peeling, inner retinal fenestration, and/or autologous platelet concentrate.