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Recently, Lam et al.  concluded that patients with macular pucker and foveoschisis had a higher risk of postoperative macular oedema. Since only 5/17 cases had baseline fluorescein angiography it is unclear how they distinguished foveoschisis due to tangential traction, versus cystoid macular edema (CME). Is it possible that postoperative CME was recurrent and not new? In our experience, resolution of foveoschisis takes much longer than the relatively swift resolution in 25% and partial resolution in 68.8% of cases at 1 month, so perhaps CME was a confounding factor. Indeed, Figure 3 appears more like exudative cyst than ‘foveoschisis’.
Previous studies  found that nearly half of patients with macular pucker had multiple centers of retinal contraction which were associated with a higher prevalence of intraretinal cysts and greater macular thickening. Was en face OCT performed to determine the number of contraction centers and its relationship to foveoschisis as well as outcomes of surgery? Additionally, anomalous PVD with vitreoschisis  and vitreo-papillary adhesion  may be important in the pathogenesis of macular pucker. Did the authors correlate these with foveoschisis and postoperative outcomes?
There was no significant difference in postoperative visual acuity (VA) between the foveoschisis and control groups, but this may not be the best outcome measure in macular pucker surgery. Studies  have shown that quantifying contrast sensitivity fu...
There was no significant difference in postoperative visual acuity (VA) between the foveoschisis and control groups, but this may not be the best outcome measure in macular pucker surgery. Studies  have shown that quantifying contrast sensitivity function (CSF), distortions (3-D Threshold Amsler Grid), and 3-D macular volume (as opposed to 2-D central thickness) more completely characterizes the benefits of surgery. Specifically, VA, CSF, and macular thickness all improved (34%, 35%, 33%, respectively; P<0.001 for each) postoperatively, but did not normalize relative to control (fellow) eyes.  In fact, only the Distortions Index (92% improved, P<0.01) and macular volume normalized, demonstrating the discriminating power and sensitivity of these outcome measures of surgical success. What is not known, however, is the relationship to ‘foveoschisis’.
1. Lam M, Philippakis E, Gaudric A, Tadayoni R, Couturier A. Postoperative outcomes of idiopathic epiretinal membrane associated with foveoschisis. Br J Ophthalmol. 2021 Feb 17:bjophthalmol-2020-317982. doi: 10.1136/bjophthalmol-2020-317982. Epub ahead of print. PMID: 33597194.
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