First Author: K.Ornek TURKEY
Co Author(s): K. Örnek Z. Onaran R. Oğurel 0 0 0 0 0 0 0 0 0
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Tilted disc syndrome (TDS) is a congenital anomaly where the disc appears rotated and tilted around its axis. Herein we report a case of tilted disc syndrome with inferior staphyloma associated with inferior retinoschisis and multifocal retinal detachment.
A 53-year-old man visited for routine glaucoma examinations. He has been treated with travoprost/timolol fixed combination for a year. He did not have any ocular complaints. His medical history did not reveal any pathologies.
Best corrected visual acuity, intraocular pressure with Goldmann applanation tonometry, ultrasound pachymeter, gonioscopy, biomicroscopic and dilated fundus examination were performed. OCT and visual field tests also done for glaucoma evaluation.
Best corrected visual acuities were 20/30 in the right eye (OD) and 20/40 in the left eye (OS). Intraocular pressures (IOP) were 17 mmHg OD and 18 mmHg OS. Average corneal thickness measurements were 556µm OD and 565 µm OS. Tilted disc with an inferior staphyloma and no pathologic cupping was demonstrated in both eyes (OU). Gonioscopy revealed open angles in OU. Ganglion cell complex (GCC) in the inferior half of the macula and retina nerve fiber layer (RNFL) in the inferior part of TSNIT thickness graph was significantly thinner in OU. Thinner part of RNFL was situated on the inferior staphyloma. OCT also demonstrated inferior retinoschisis associated with inferior staphyloma and inferior multifocal retinal detachment was detected in the retinoschisis area. Vitreus traction was also shown in the inferior retina on the retinoschisis area with OCT. There was a generalized reduction in retinal sensitivity and scotomas were present in the upper hemifield on both sides. These structural and functional changes seem to be related to inferior staphyloma. We stopped travoprost/timolol fixed combination and after 4 weeks, IOP was 18mmHg in OD and 20mmHg in OS. Intraocular pressure measurements and visual field findings did not change during the follow up.
Coexistence of structural defects like retinoschisis and multifocal retinal detachment in TDS may interfere with the reliability of retinal nerve fiber layer and ganglion cell complex analysis and may change the treatment plan before the diagnosis of glaucoma or these structural changes may cause visual field detoriations and may mimic glaucoma as in this case. Therefore,structural defects detected with OCT and functional defects detected with visual field testing have not been related to glaucoma in TDS. Very often in clinical practice, various optic disc anomalies may also be over diagnosed and labeled as glaucoma. Until normative data are validated for tilted discs, the role of new imaging technologies for the optic nerve head is limited. Also OCT overestimates the optic disc and neuroretinal rim area because of the algorithm that automatically locates the deep margin of the disc area without operator input. Familiarity with the spectrum of ophthalmoscopic appearance and the clinical manifestations of tilted discs may be the most critical factors in avoiding misdiagnosis. To conclude, we recommend OCT examinations in myopic eyes and in TDS patients to define structural defects like retinoschisis and multifocal retinal detachments before the diagnosis of glaucoma.