tilted disc syndrome ( tds ) is a congenital anomaly characterized by a nasal - to - temporal    tilting  of the optic disc associated with inferonasal crescent , myopia , myopic astigmatism , visual field defect , inferior staphyloma , and retinal pigment epithelium ( rpe ) atrophy [ 14 ] . the syndrome is associated with complications such as macular serous neuroretinal detachment [ 5 , 6 ] or choroidal neovascularization . this case report is about a 70-year - old woman who presented with loss of visual acuity ( va ) in the left eye , with metamorphopsia dating from a few days before . the patient 's eyes were carefully examined including best - corrected va ( bcva ) testing ( snellen equivalent ) , optical coherence tomography ( stratus oct , carl zeiss , dublin , ca , usa ) and fluorescein angiography ( topcon corp . , japan ) .   after obtaining informed consent , off - label bevacizumab ( avastin , 1.25  mg/0.05  ml ) was injected intravitreally twice at monthly interval , in the operating theatre through a 30 gauge needle at 3.5 to 4  mm of inferotemporal limbus . when referred to our attention patient 's best corrected va was 20/100 ( refraction error : + 0.503@180d ) . fundus examination showed tilted insertion of the optic disk with atrophic peripapillary changes associated with inferior staphyloma . fluorescein angiography ( fa ) disclosed a foveal diffuse rpe atrophy / distrophy and a small hyperfluorescent spot with little leakage in the middle - late phases of the examination ( yellow arrow , figure 1 , top stripe ) , corresponding to the focal rpe leaking point . oct evidenced a foveal serous neuroretinal detachment ( figure 2 , top stripe ) in both vertical and horizontal scansion . at scheduled visit , oct depicted persistence of neuroretinal detachment ( figure 2 , bottom stripe ) whilst fa ( figure 1 , bottom stripe ) showed disappearance of previous hyperfluorescent spot . entity , distribution , and dimension of rpe atrophy / dystrophy area unchanged and primitive leaking dot was completely angiographically silent . subretinal leakage in myopic eyes with tds remains a poorly recognized disease entity   and a relatively young disease , as first reports were published in 1998 . although oct technology is a useful aid in diagnosis and followup , the natural history and pathophysiology of serous macular detachment are not well understood . anti - vegf therapy with intravitreal injection of ranibizumab and pegaptanib has been approved for neovascular age - related macular degeneration . additionally , bevacizumab is utilized worldwide as an off - label therapeutic option in many other retinal disease such as pathologic myopia and central serous chorioretinopathy ( csc ) , due to the low cost of the drug , with encouraging results . csc is a well - characterized disease with typical findings including subretinal leakage similar to aspects of tds - associated serous macular detachment . retinal pigment epithelium dysfunction has been suggested as a possible primitive step in both pathological conditions . intravitreal bevacizumab has been reported in 5 patients as a new option in the treatment of central serous chorioretinopathy   and was associated with visual improvement and reduced neurosensory detachment without adverse events .   in our patient , laser photocoagulation of the leakage was not possible in our opinion because of its foveal position , so we decided to employ 1.25  mg intravitreal avastin as off - label treatment . following bevacizumab , repeated fa documented the disappearance of the early leaking point ( red arrow , figure 1 , bottom stripe ) , but the serous fluid did not reduce on oct ( figure 2 , bottom stripe ) . this is difficult to explain , but some discordance is known between fa and oct imaging   . in our patient , it is noteworthy that persistent neuroretinal detachment was more strongly tied to functional recovery than angiographic pinpoint activity . as the prognosis of untreated tds - related macular serous detachment is not well defined , we can postulate that it can wax and wane similarly to chronic csc or perhaps that intravitreal avastin may have some influence on closing the leaking dot . it may have been illustrative to investigate the effects of further intravitreal treatments , but the patient experienced no bcva improvement and declined additional therapy ; macular serous detachment persisted at 6-month followup . in conclusion , the ideal treatment for macular serous detachment in tds remains unknown . in this single case , more data about avastin and other vegf inhibiters in the treatment of serous macular detachment - complicated tds are required to further define prognosis and efficacy .
background . tilted disc syndrome ( tds ) is a congenital anomaly characterized by  tilting  of the optic disc tipycally associated with myopic astigmatism , visual field defect , inferior staphyloma , and retinal pigment epithelium atrophy . 
 associated complications such as macular serous neuroretinal detachment are well described ; however , ideal therapy for such complication is unknown . methods . one interventional case report is hereby described . 
 a patient affected by macular serous neuroretinal detachment - complicated tilted disk syndrome underwent a complete ophthalmic examination . optical coherence tomography and fluorescein angiography 
 were taken at baseline and at scheduled visits . 
 two intravitreal treatments of bevacizumab ( avastin , 1.25  mg/0.05  ml ) were performed at monthly interval . 
 results . at scheduled visit , one month after the second injection , oct depicted persistence of neuroretinal detachment . 
 best - corrected visual acuity remain stable as well as metamorphopsia and functional discomfort . conclusion . 
 clinical evidence of this brief interventional case report indicates that one patient affected by recent serous macular detachment - complicated tds did not benefit from 2 consecutive monthly intravitreal avastin treatments . 
 best - corrected visual acuity remained stable over a total observation period of 6 months .