optic disc pits ( odps ) are congenital anomalies of the optic nerve head , first described by wiethe1 in 1882 as black cavities on the optic nerve head observed in one eye of a 62-year - old woman .
the prevalence of odp is estimated to be one in every 11,000 patients.2,3 in about 70% of cases , the odps are located on the temporal side of the disc and 85%90% are unilateral.4,5 visual acuity is usually unaffected unless the odps are associated with macular pathology , such as macular detachment , retinoschisis - like separation , outer layer macular hole , and retinal pigment epithelial atrophy .
macular detachment develops in one - third to two - thirds of patients , which may occur in childhood or later , the mean being at 30 years of age.6,7 vascular abnormalities such as colobomas and epipapillary membranes may also be associated .
it is assumed that fluid passes through the odp and enters the sensory retina creating a schisis - like separation.810 however , the source of the fluid is controversial .
two major possible sources have been proposed : vitreous cavity or cerebrospinal fluid.1114 other possible sources are abnormal vessels or vasculature with increased vascular permability.15 some authors have suggested a rhegmatogenous etiology with a small hole or tear in the membrane overlying the pit , which supports the notion that fluid leaks from the vitreous cavity.16,17 based on this hypothesis , our therapeutic approach was to seal the theoretical communication between the vitreous cavity and the retina with autologous platelet concentrate ( apc ) , which has been shown to promote tissue healing and successful results in macular hole surgery,1822 in order to address the etiology of the maculopathy .
the purpose of the present study was to evaluate the anatomical and functional results obtained with pars plana vitrectomy ( ppv ) plus apc and gas tamponade as treatment of odp - related maculopathy .
we performed a prospective interventional study of 19 eyes of 19 consecutive patients with macular detachment associated with congenital odp , treated between january 2001 and january 2013 at centro de oftalmologa barraquer , barcelona , spain and vissum madrid , madrid , spain .
all patients had a preoperative visual acuity of 20/40 or worse and no concomitant macular disease .
preoperatively , we recorded the best corrected visual acuity ( bcva ) by logmar , and intraocular pressure .
all patients underwent anterior and posterior segment slit - lamp biomicroscopy , using a 90 diopter noncontact lens , and optical coherence tomography ( oct ) .
the ethical committee of clinical research of centro de oftalmologa barraquer approval was obtained and informed consent was obtained from all patients .
surgery was performed by two surgeons , one at each participating center , using three - port 20 or 23-gauge ppv .
the internal limiting membrane ( ilm ) was not removed in any case . before fluid  air exchange , careful peripheral fundus examination was performed . under air , approximately 0.05 ml of apc was injected over the odp , sufficient to cover the odp and the optic disc cup .
this was followed by air15% perfluoropropane ( c3f8 ) gas tamponade exchange , to expel subretinal and intraretinal fluid and promote reabsorption .
postoperative measures included face - up positioning for 2 hours , to keep the apc in contact with the odp , and avoidance of the face - up position for the ensuing 10 days , in order to isolate the macula from fluid with long - acting gas .
lens extraction surgery plus intraocular lens implantation was not performed in patients under 50 years of age ( number = 16 ; 84.2% ) .
apc was prepared as described by our group in a previous report.23 briefly , blood samples were transferred to a sterile tube containing ethylenediaminetetraacetic acid .
the lower one - third of plasma , which is rich in platelets , was aspirated and centrifuged again .
part of the plasma was removed , leaving the platelets adhered to the tube walls .
the platelets thus obtained were dissolved in saline solution to yield a concentration of ~1,000,000 platelets / mm .
postoperatively , bcva and intraocular pressure were recorded ; anterior and posterior segment slit - lamp biomicroscopy , using a 90 diopter noncontact lens , and oct were performed at 1 month , 3 months , 6 months , 9 months , and 12 months , and then annually ( spectral - domain cirrus or stratus ; carl zeiss meditec ag , jena , germany ) .
outcome measures were bcva , improvement in quality of vision , macular attachment , and resolution of schisis - like intraretinal separation assessed by oct .
results are expressed as the median and range for continuous variables and as the frequency ( percentage ) for categorical variables . the wilcoxon test for repeated measures , with 95% confidence intervals , was used to analyze pre- and postoperative bcva .
nineteen patients ( median age : 30 years ; range : 1362 years ; ten women [ 52.6% ] ) were included in the present study .
odp and macular detachment were present in nine right eyes ( 47.4% ) and ten left eyes ( 52.6% ) ( table 1 ) .
preoperatively , all patients had decreased bcva and 10/19 had associated metamorphopsia during a median of 3 months ( range : 0.2524 months ) .
three patients ( cases 12 , 13 , and 14 ) had previous ppv , laser at the temporal edge of the optic nerve head , and gas tamponade as a first treatment of the odp - related maculopathy without success . in the preoperative examination , all patients presented with macular detachment associated with odp .
one patient had complete posterior vitreous detachment ( pvd ) , eight patients had incomplete pvd , and the remaining ten patients did not have pvd .
the median bcva was 0.70 ( range : 0.301.70 ) . the median refractive error was 0 diopters ( range : 6.50 to + 3.00 ) .
oct showed macular detachment in all cases , with variable degrees of intraretinal schisis - like separation in 17/19 patients ( 89.5% ) .
outer layer macular hole was present in 4/19 cases ( 21.1% ) . in two cases ,
oct showed a communication between the vitreous cavity and the retina ( figure 1 ) .
interestingly , in two cases , while the residual vitreous cavity fluid was being removed from the optic disc , the submacular fluid was aspirated through the odp and the macula was reattached .
it was in these two cases where communication between the vitreous cavity and the retina was seen on oct .
the median bcva was 0.22 ( range : 0.070.52 ) at 12-month follow - up , the difference being statistically significant ( p<0.05 ) in comparison with preoperative values .
bcva remained stable in 7/19 cases ( 36.8% ) and increased in 12/19 cases ( 63.2% ) at our last follow - up .
oct showed complete resolution of intraretinal schisis - like separation and macular detachment in all patients ( figure 2 ) .
retinal fluid reabsorption time varied considerably , with a median of 3.5 months ( range : 28 months ) .
minute defects in the outer segment of photoreceptors and/or the inner segment / outer segment lines were observed with high - resolution oct in all cases .
one patient ( case 11 ) presented with inferior exudative vitreous infiltrate , which disappeared 48 hours after surgery without repercussions .
as reported by lincoff et al24 macular detachment is associated with a schisis - like separation of the internal retinal layers in almost 90% of cases . in our study ,
moreover , four of the 19 cases also presented with an outer layer lamellar macular hole .
although spontaneous retinal attachment has been described in 25% of cases , the treatment of nonresolved cases remains controversial and the results are not encouraging .
the following therapeutic approaches have been reported : laser therapy , to produce a chorioretinal adhesion barrier at the optic disc border;17,25,26 intravitreal gas injection;27 ppv with or without laser ; ilm peeling ; glial tissue removal ; and/or air / gas exchange18,20,2834 or macular scleral buckling.35 initially , our group treated odp - related macular detachment with ppv , a photocoagulation barrier at the temporal optic disc border , plus gas . however , in our revision of 43 eyes , macular detachment persisted in almost 30% of cases , requiring additional photocoagulation plus gas treatment .
after this second treatment , almost 80% of patients presented with macular attachment . as a result of our poor rates
, we developed a new technique based on our experience with apc in macular hole surgery . in this
regard , our group has reported successful treatment of recurrent macular detachment secondary to optic nerve coloboma with an overlying retinal hole treated with apc.23 this lends support to the hypothesis of a rhegmatogenous etiology to explain submacular fluid associated with both optic nerve head coloboma and odp.14,36 the use of apc was first described by rosenthal et al37 in a patient with persistent macular detachment due to odp , after vitrectomy , posterior hyaloid removal , and gas tamponade , with good anatomical and functional results at 3 months of follow - up . however , their technique involved flute needle extraction of the subretinal fluid through the odp , creating a communication between the vitreous and the subretinal space . based on the hypothetical rhegmatogenous etiology of odp - related macular detachment , our technique involves posterior hyaloid peeling to eliminate vitreous  macular traction , and apc injection over the odp to promote healing of the suspected communication between the odp and the sensory retina .
the possible existence of communication at the level of the odp is related to epipapillary fibrous tissue traction and incomplete pvd , allowing liquefied vitreous to pass through the odp and dissect the retina , causing macular detachment or squisis.5,16,17,38 as in some cases described by other authors,1417 two of our patients presented with a break in the tissue overlying the odp , and the vitreous remained attached in both cases , visualized before and during surgery .
we believe that the use of apc with its mitogenic and chemotactic properties,39 associated with posterior hyaloid peeling to eliminate vitreomacular traction , favors the proliferative cellular response and closure of the suspected communication between the vitreous and the retina and , secondarily , promotes reabsorption of intra- and subretinal fluid .
our technique resulted in improved visual acuity in all cases , with a median gain of four snellen lines .
it also produced stable anatomical and functional improvement during a follow - up period of more than 5 years , without reoperation being required .
such results were not previously obtained by our group with complete ppv , photocoagulation , and gas tamponade alone .
furthermore , reabsorption of intra- and subretinal fluid occurred progressively and was completed within a median time of 4.5 months , which is in contrast to reabsorption times of approximately 1 year reported for other techniques , albeit with good results , such as macular vitrectomy or scleral buckling.33,35 this supports the hypothesis of a rhegmatogenous etiology for odp - related macular detachment , and the use of apc together with the release of posterior pole traction allowed us to achieve excellent results .
in conclusion , our technique with apc to treat odp - related macular detachment proved highly successful in terms of progressive and stable anatomical and functional improvement . as a promising alternative approach to conventional surgery , it appears to address the etiology of the problem .
however , the limited sample size means that this technique requires prospective multicenter studies to confirm its effectiveness .
 purposeto evaluate the anatomical and functional results obtained with pars plana vitrectomy ( ppv ) plus autologous platelet concentrate ( apc ) as a treatment for macular detachment associated with optic disc pit ( odp).methodswe performed a prospective interventional study of 19 eyes of 19 consecutive patients with posterior macular detachment due to odp . 
 all patients underwent ppv , posterior hyaloid peeling , fluid  air exchange , injection of 0.05 ml of apc over the odp and 15% perfluoropropane ( c3f8 ) endotamponade . 
 postoperative measures included face - up positioning for 2 hours and then avoidance of the face - up position during the ensuing 10 days . 
 all patients underwent complete ophthalmologic examination and optical coherence tomography preoperatively at 1 month , 3 months , 6 months , 9 months , and 12 months postoperatively and then annually . 
 outcome measures were best corrected visual acuity ( bcva ) by logmar , improvement of quality of vision , macular attachment , and resolution of intraretinal schisis - like separation.resultspreoperatively , the median bcva was 0.70 ( range : 0.301.70 ) and all patients showed improved visual acuity after surgery ; bcva was 0.22 ( range : 0.070.52 ) at 12 months follow - up . 
 all patients showed complete reabsorption of intraretinal fluid ( median time : 3.5 months [ range : 28 months ] ) and macular attachment at the end of follow - up ( median : 60 months [ range : 12144 months ] ) , with stable or improved visual acuity . 
 no reoperations were needed and no major adverse events were recorded.conclusionfor macular detachment associated with odp , the combination of ppv , posterior hyaloid peeling , apc , and c3f8 tamponade is a highly effective alternative technique with stable anatomical and functional results . 
Introduction
Methods
Results
Discussion
Conclusion