Pathogenesis and treatment of maculopathy associated with cavitary optic disc anomalies.

PURPOSE To propose a unifying theory regarding the pathogenesis of maculopathy associated with cavitary optic disc anomalies and to describe a rational approach to achieving a permanent cure in affected eyes. DESIGN Interpretive essay. METHODS Review and synthesis of selected literature, with interpretation and perspective in relating pathoanatomic features to pathogenesis and treatment. RESULTS Congenital cavitary anomalies of the optic disc, including typical coloboma, optic pit (and other atypical colobomas), morning glory anomaly, and extrapapillary cavitation, are associated with an enigmatic maculopathy characterized by schisis-like thickening and serous detachment. The unifying anatomic theme of these anomalies is the presence of a scleral (or lamina cribrosa) defect permitting anomalous communications between intraocular and extraocular spaces. These communications enable the critical pathogenic mechanism responsible for the maculopathy, namely, dynamic fluctuations in the gradient between intraocular and intracranial pressures that direct the movement of fluid (vitreous humor or cerebrospinal fluid) into and under the retina. Vitreous traction does not seem to play a significant pathogenic role. Permanent cure of the maculopathy requires either elimination of the translaminar pressure gradient or closure of the pathway for fluid flow into the retina. We advocate carefully titrated juxtapapillary laser photocoagulation followed by vitrectomy with gas tamponade for creation of a permanent intraretinal and subretinal fluid barrier. CONCLUSIONS The peculiar features of cavitary optic disc maculopathy can be explained only by considering the pressure gradients that develop along anomalous communications between intraocular and extraocular spaces. A permanent cure for this condition can be achieved by closing the pathway for fluid migration from the cavitary lesion into and under the retina.