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Retinal detachment and optic disc edema

  • 1.  Retinal detachment and optic disc edema

    Posted 07-09-2025 19:11
    Dear all,
    I was just asked today by my retina colleague to see a patient with optic disc edema. She is a 40 year old high myope (-10 OU) who noted a blurred vision and floaters in the right eye 2 weeks ago. She was found to have an inferior retinal detachment and referred to retina, who saw her today and noted disc edema in the same eye. She felt that the RD looked older than 2 weeks as there is a prominent demarcation line. Vision is 20/70 in that eye (previously known to be 20/20), but the RD is only up to the inferior arcade, and the amount of vitreous debris does not seem like enough to cause that big of a reduction. OCT macula is normal with no subretinal fluid. I had a quick look today, but she was already dilated. She describes subjective decreased brightness in that eye, and Ishihara colour plates were full, but slower compared to the other eye. Disc edema is grade 2, more prominent inferior than superior, no hgb, and no ODD on EDI OCT or FAF. The plan is to do a scleral buckle on Monday without vitrectomy. I'm bringing her back tomorrow morning to do a visual field and check pupils, but I have 2 questions:
    1. Is there a way to connect the optic disc edema with the chronic appearing RD? Or is this most likely 2 separate processes?
    2. Is there any reason to avoid a buckle in this setting?
    Thanks for your wise words!
    Lulu

    Lulu Bursztyn

    Comprehensive and neuro-ophthalmology

    Western University, London, Ontario

    lulu.bursztyn@sjhc.london.on.ca

    519-646-6214

     


    The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any computer. www.sjhc.london.on.ca


  • 2.  RE: Retinal detachment and optic disc edema

    Posted 07-09-2025 19:26
    What was tension? Sometimes RDs can have hypotony which may lead to disc edema?






  • 3.  RE: Retinal detachment and optic disc edema

    Posted 07-09-2025 19:30
    Ocular hypotony, vitreo-papulary traction?

    Russ Edwards




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  • 4.  RE: Retinal detachment and optic disc edema

    Posted 07-09-2025 19:56
    Some myopes will have peripapillary schisis that looks like disc edema, you can tell the difference if you look closely at the cross sectional OCT over the optic disc. Myopes are also common to have pseudopapilledema from tilted discs.

    At Iowa, they found that for each quadrant involved by RD you get a 0.3 log unit RAPD. So, a mild RAPD may be retinal rather than indicating optic neuropathy in your case.

    Did the retina doctor identify a break that is causing the RD? Is the fluid gravity dependent/ shifting to suggest it is exudative rather than rhegmatogenous? There are conditions that can cause exudative RD and disc edema (VKH and posterior scleritis are the most common).

    Uveitis with retinitis (particularly infectious causes such as toxoplasmosis and viral etiologies) can cause papillitis as well as retinal breaks leading to RD.

    A wife field fluorescein angiogram might be helpful.

    Best, 

    Drew




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  • 5.  RE: Retinal detachment and optic disc edema

    Posted 07-09-2025 21:56
    IOP was 12 in the affected eye, 15 in the other. So a little low, but not that asymmetric. No uveitis, although the vitreous was a little turbid. It's a big RD (about 1/3 of the retina), so I agree, there could be an RAPD from the RD and not the nerve. No shifting fluid, and nothing that would make me think VKH. I'm hoping an HVF will help, but my plan is to treat it like 2 unrelated problems. 
    If it was something compressive, like an ONSM, does anyone think there's a risk putting on a buckle?

    Lulu Bursztyn

    Comprehensive and neuro-ophthalmology

    Western University, London, Ontario

    lulu.bursztyn@sjhc.london.on.ca

    519-646-6214

     


    The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any computer. www.sjhc.london.on.ca



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  • 6.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 06:48

    If there was an inflammatory or ital process such as posterior scleritis, uveitis, or optic perineuritis then you would want to wait to buckle even if it is a rhegmatogenous RD until inflammation is controlled. Any other cause for disc edema such as sheath meningioma I don't think would be an issue.

    Best, 

    Drew



    ------------------------------
    Andrew Carey
    Associate Professor
    Wilmer Eye Institute, Johns Hopkins Medicine
    Baltimore MD
    ------------------------------

    Original Message


  • 7.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 07:21
    Turbid vitreous? What is that?
    S Forman, MD



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  • 8.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 10:42
    Your "plan is to treat it like 2 unrelated problems."

    I would disagree, I'm going with Occam's razor on this one. Let the retina specialist fix the RD, and then monitor the disc edema, it should resolve.

     

     

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  • 9.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 11:14
    I think Occam's razor is an outdated concept developed before medicine got as complex as it is. Multiple problems (not necessarily totally unrelated) are common and yes they occur in the same body but many are handled by different approaches.
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












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  • 10.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 11:27
    Things are not so simple especially when it comes to neuro-ophthalmology or retinal problems , then combined proposed simplicity may be a walking door to problems 





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  • 11.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 13:41

    Thanks everyone for your input, and an interesting debate on Occam's razor...

    Some updates, now that I've had a better look at her, and hopefully the images come through. She describes new floaters starting one week ago followed by a superior curtain defect over the past few days. Prior to this vision was her normal. Visual acuity remains 20/80 R, 20/20 left, colour 16/16 OU. IOP was 15 OU this morning. I actually cannot detect an RAPD despite the complaint of subjective decreased brightness. Anterior chamber is quiet, no vitritis, just a lot of vitreous syneresis (this is what I mean by turbid – very thick strands of floaters). There is an inferior temporal hole in the RD. There is bilateral fairly symmetric inferior RNFL thinning that I suspect is related to her high myopia, but there is also superonasal edema of the right disc. The visual fields show a superior field defect in the right as well as a small inferior defect in both eyes. I have requested an MRI (this is Canada, it's not happening today...) and have sent her for some blood work (CBC, CRP, syphilis, ENA, mitochondrial panel...). I will also see her back after the RD is fixed.

    Lulu

     

     

    Hole visible inferotemporal

    FAF, no visible ODD, but the RD really stands out nicely

     

    Lulu Bursztyn

    Comprehensive and neuro-ophthalmology

    Western University, London, Ontario

    lulu.bursztyn@sjhc.london.on.ca

    519-646-6214

     


    The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any computer. www.sjhc.london.on.ca



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  • 12.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 15:12

    Thanks for sharing the images. I think there's some vitreous traction on the disc in one of the edi images OD.In fact PVD is setting in OS also .If disc oedema is a concern , I m not sure if buckle surgery will reduce it , vitrectomy might be a better option for the VPT.All depends on if the loss of brightness is due to the disc swelling or something else.



    ------------------------------
    Shikha
    ------------------------------

    Original Message


  • 13.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 16:20
    Colleagues:

    This patient's optic nerves have very small diameters (half of normal size); the elevation of the peripapillary retinal nerve fiber layers, and the appearance of the nerve heads on OCT are consistent with optic disc drusen, bilateral.

    The floaters and vitreous findings are secondary to the rhegmatogenous retinal detachment, which is quite large and accounts for the reduction in brightness sense in the eye with the detachment.

    If you desire, enhanced-depth imaging on OCT can be performed to further elucidate the nerve head drusen.

    David M. Bachman, M.D.


    Original Message


  • 14.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 17:22
    If these are the photos of the patient that was described as having optic nerve edema with a retinal detachment, these optic nerves do not appear to be swollen in the least.
    I would do absolutely nothing from a neuro-ophth perspective.

    Matt


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  • 15.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 18:38
    Hi!
    I bet a PVD caused both a tear & detachment and also caused some traction at the disc as the vit separated off the optic nerve head. Is these a Weiss ring? I’ve seen real time disc edema and hemorrhage occur during RD repair when the surgeon is inducing a PVD. It’s wild.

    Wouldn’t stop the surgeon from doing a buckle if that’s what’s indicated from a retinal perspective.

    Christine


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  • 16.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 19:16
    Where do we stand on PVD and NAION? Possible "mild" case. VEP?

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  • 17.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 21:15
    Yes, I agree that the discs don't look all that impressive in the optos photos, but there is a clear asymmetry clinically, with the right disc being more elevated and hyperemic compared to the left. I thought the 10um difference and superior thickening on OCT confirmed my clinical impression.
    As for EDI OCT, our Heidelberg is currently down, so I got the deepest images I could on the Cirrus, but I feel confident about the lack of ODD (our study with Steffen showed that FAF is still pretty darn good). I did try to capture the one slice that showed the little papillary tuft, although I'm not convinced that it's enough (or in the right location) to be the cause. 
    For the surgical approach, a buckle without vitrectomy is the plan, since she is so young and so myopic. If she gets a post-vitrectomy cataract in that eye, she will not be able to tolerate the anisometropia if we fix it, which opens up a whole new set of issues.
    I think/hope I've answered all the questions.. As always, I appreciate everyone's input!
    Lulu

    Lulu Bursztyn

    Comprehensive and neuro-ophthalmology

    Western University, London, Ontario

    lulu.bursztyn@sjhc.london.on.ca

    519-646-6214

     


    The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any computer. www.sjhc.london.on.ca



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  • 18.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 21:16
    Lulu, the OCT shows a pretty convincing vitreopapillary traction and given the RD that is also messing with the vitreous and likely causing a lot more traction than usual, my bet is that RD repair will help the disc edema (At least the Vitrectomy will). Good luck and interesting case!
    Kim


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  • 19.  RE: Retinal detachment and optic disc edema

    Posted 07-09-2025 23:40
    Even a "narrow" field fluorescein would be helpful To determine if the optic nerve is truly leaking should the visual field  not demonstrate a nerve fiber bundle defect ;)

    Matt

    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone




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  • 20.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 03:05

    Hi

    Since the RD is inferior, and the disc swelling is also more in the inferior half, one of the ways to connect both with high myopia is an incomplete PVD. An incomplete PVD with a remnant attachment at the disc could be causing vitreopapillary traction. The visual symptoms(blurred vision and floaters) experienced 2 weeks before could be due to the VPT. Are there any tiny peripapillary haemorrhages too?

    It will be a nice learning tool if we could all see the EDI OCT images of the eye.



    ------------------------------
    Shikha
    ------------------------------



  • 21.  RE: Retinal detachment and optic disc edema

    Posted 07-10-2025 04:44
    Noticiting the disc in chronic RD , it might not be normal from different reasons , but if the RD didn't prove to be rhegmatogenous , then we have to go for exudative RD with different causes that are linked to inflammatory causes , so full immunology panel will be required , I would assume that in a detached retina will have a slow axoplasmic flow with some disc swelling , as Dr Kay said , the question about is it leaking or not is important , but also for me I would investigate as if the disc swelling does not accompany RD , full labs and imaging 



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