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Sir,

Posterior retinal breaks are most commonly associated with trauma, macular holes, high myopia or proliferative retinopathies.1 We present a case of a peripapillary retinal tear in a highly myopic eye.

Case report

A 45-year-old man with high myopia (−16.0 dioptres spherical equivalent OD) presented with a 2-day history of right eye floaters, without photopsia. Corrected visual acuity was 6/9 OD. There was a posterior vitreous detachment (PVD) with a Weiss ring, but cells and pigment were absent from the anterior vitreous. Optic disc examination revealed a slit-like retinal break at the disc margin inferiorly overlying an area of peripapillary atrophy (Figure 1). No visible operculum was attached to the Weiss ring. Automated visual field assessment showed a superior arcuate defect consistent with the retinal break (Figure 2). The patient was managed conservatively, with regular observation. After 12 months follow-up, the patient is now asymptomatic of floaters, visual acuity and visual field defect are unchanged, and the retina remains attached.

Figure 1
figure 1

The posterior pole of the right eye. There is a retinal tear at the disc margin in the 6 o'clock position. Note the myopic appearance of the fundus with peripapillary atrophy and larger choroidal vessels easily visible.

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Figure 2
figure 2

The greyscale and pattern deviation plots from a Humphrey 24-2 Central Threshold Test using SITA-Standard software. Tests A and B were taken 12 months apart and the scotoma remains stable.

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Comment

Peripapillary retinal tears are rare, and sometimes only recognised after failure of initial retinal detachment surgery.2 Other unusual retinal break locations include the margin of staphylomas, colobomas, commotio retinae, retinal laser photocoagulation sites, and Morning Glory Syndrome.3, 4

The absence of RPE within the peripapillary atrophy underlying this break made localised retinopexy impossible. Without vitreoretinal traction forces, retinal breaks are unlikely to progress to retinal detachment. However, even with an apparently complete PVD, ophthalmic ultrasound and optical coherence tomography imaging can reveal persistent strands of vitreous adherent to the retina.5 This patient is currently asymptomatic with unchanged clinical features after 12 months follow-up.

Conservative management of asymptomatic retinal detachments, with patient instruction on self-testing their visual field, is well known.6 Surgically, for very posterior retinal breaks, pars plana vitrectomy with gas or silicone oil tamponade are most commonly used,2, 7, 8 but external buckling procedures have been described, with good success rates reported for all modalities.5, 6 In this case, a peripapillary retinal break has not produced a retinal detachment, due to the absence of vitreoretinal traction.