Video of the month | Mar 2023 | Stellate Nonhereditary Idiopathic Foveomacular Retinoschisis (SNIFR)

Presented and operated by: Paris Tranos MD, PhD, FRCS, ICOphth

Edited by: Penelope Burle de Politis MD

A 17-year-old male presented with decreased vision (CDVA 5/10) in his left eye for a couple of weeks. Multimodal imaging showed a stellate appearance of the retina, presence of intraretinal fluid, and a split of the retinal middle layers extending from the optic disc to the macula, yet failed to reveal an optic disc pit or any tractional element. Axial length was 24.77 mm and ERG was normal. Family history was unremarkable and there were no other known risk factors. After the exclusion of all other possible underlying conditions, the diagnosis of SNIFR was made, initially managed conservatively, given the relatively good visual acuity and the natural course of the disease, which may improve spontaneously. Topical CAI were administered, with no response. A year later, as further decrease in vision was noted (CDVA 2/10) and imaging showed progression of the retinal schisis with vitreoretinal traction, surgical approach was indicated (PPV). Outcome was favorable, with CDVA steadily increasing postoperatively and remaining stable at 6/10 (9 months later).

Surgical treatment in this case was particularly challenging due to the characteristics of the vitreous in the young eye (firm and attached). The surgical steps and timing in the video are as follows: Triamcinolone is injected in the vitreous chamber to facilitate vitreous visualization (00:07). PVD is attempted through aspiration (00:11), followed by a mechanical attempt to detach the posterior hyaloid membrane (00:24). PVD is finally accomplished with the combination of both maneuvers (00:52). A broad ILM peel with foveal sparing is performed in order to relieve retinal traction at the macular area (01:05). An inverted ILM flap is fashioned in order to tamponade the optic disc (02:30). A laser barrier is created temporally to the optic disc for extra stabilization of the folded flap (02:45). Fluid-air exchange is carried out with caution not to displace the ILM flap from over the optic disc (03:00). The
procedure ends with the air-gas (SF6) exchange (03:05).

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Nelson Mandela