Visual loss from choroidal ischemia

Choriocapillaris: Fundamentals and advancements

The choriocapillaris is the innermost structure of the choroid that directly nourishes the retinal pigment epithelium and photoreceptors. This article provides an overview of its hemovasculogenesis development to achieve its final architecture as a lobular vasculature, and also summarizes the current histological and molecular knowledge about choriocapillaris and its dysfunction. After describing the existing state-of-the-art tools to image the choriocapillaris, we report the findings in the choriocapillaris encountered in the most frequent retinochoroidal diseases including vascular diseases, inflammatory diseases, myopia, pachychoroid disease spectrum disorders, and glaucoma. The final section focuses on the development of imaging technology to optimize visualization of the choriocapillaris as well as current treatments of retinochoroidal disorders that specifically target the choriocapillaris. We conclude the article with pertinent unanswered questions and future directions in research for the choriocapillaris.

The choroidal structure changes in a case with hypertensive choroidopathy

Purpose

The aim of this study is to report clinical course and provide novel ophthalmic findings by spectral-domain optical coherence tomography (SD-OCT) in a patient with hypertensive choroidopathy secondary to hypertensive disorders of pregnancy (HDP).

Observations

A 27-year-old woman, who was diagnosed HDP complicated with disseminated intravascular coagulation (DIC), noticed abnormality of color vision and metamorphopsia in her right eye, a half day after an emergency cesarean delivery. Fundus examinations showed developing serous retinal detachment (SRD) from superior hemisphere to the posterior pole in her right eye. Then, fluorescein angiography (FA) showed some granular leakages from the areas above the optic disc in her right eye and around the optic disc in her left eye. Indocyanine green angiography (IA) also showed choroidal hypoperfusion during the early-phase and choroidal hyperpermeability during the mid-phase in the same areas of leakages in FA. SD-OCT also showed posterior SRD in her right eye and peripapillary flat SRD in her left eye, and enhanced depth imaging OCT (EDI-OCT) revealed increased choroidal thickness. SRD gradually disappeared and her symptoms improved during observation with appropriate treatment for hypertension and resolution of DIC. Moreover, increased choroidal thickness in right eye improved in the only areas showing abnormal angiography findings, but subfoveal choroidal thickness in both eyes did not change over the clinical course.

Conclusions

Our case shows that hypertensive choroidopathy with developing SRD and visual disorder in the patient with HDP, can be improved by appropriate treatment for general state. Moreover, SD-OCT shows a new finding that increased choroidal thickness improved in the abnormal angiography areas earlier than SRD was completely disappeared. OCT may be a useful module to evaluate the changes in the choroidal structures for diagnosis and follow-up in a patient with hypertensive choroidopathy.

Pregnancy-induced hypertension-related chorioretinitis resembling uveal effusion syndrome: A case report

RATIONALE

Pregnancy-induced hypertension (PIH) is a major cause of maternal and fetal mortality. Hypertensive choroidopathy is a preliminary sign of vasogenic edema in the choroid, and is associated with PIH. Here, we report a post-natal case of PIH-related chorioretinitis with bilateral severe serous retinal detachment (SRD) resembling uveal effusion syndrome.

PATIENT CONCERNS

A 35-year-old woman was diagnosed with severe PIH at 37 weeks of pregnancy. She underwent an emergency cesarean delivery. Four days after delivery, she perceived a sudden decrease of vision. At presentation, fundus examination demonstrated bullous SRD and multiple white mottles in the posterior poles of both eyes. Optical coherence tomography (OCT) showed macula edema and retinal pigment epithelium (RPE) folds. Indocyanine green angiography (ICGA) demonstrated delayed filling of choroidal circulation in the early phase and multiple hyperfluorescent spots in the mid phase.

DIAGNOSES

PIH.

INTERVENTIONS

Antihypertension treatment alone resulted in gradual resolution of the SRD.

OUTCOMES

At 463 days after delivery, fundus photographs of both eyes showed leopard spots corresponding to hyperautofluorescent spots with dark rim observed on fundus autofluorescence images.

LESSONS

Ophthalmologists should be aware of PIH-related chorioretinitis with similar clinical manifestations as uveal effusion syndrome, and should treat with antihypertensive agents in cooperation with obstetricians.

Neuro-ophthalmologic manifestations in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect different ocular structures, such as cornea, conjunctiva, episclera, sclera, uveal tract, retina, optic nerve and vessels. Neuro-ophthalmologic manifestations in SLE include different degrees of involvement of retina, choroid and optic nerve. Retinal changes are one of the most common ocular involvements and are frequently used as clinical criteria for activity, even if isolated. Studies show that up to 29% of patients with active SLE manifest retinal disease. The exact prevalence of choroidal disease is unknown, but is thought to be less common than retinopathy, due to under-diagnosis. Optic nerve disease, represented by optic neuritis and anterior/posterior ischaemic optic neuropathy, affects approximately 1% of SLE patients. These ocular manifestations have been associated with neurologic flares, antiphospholipid antibodies, nephropathy, and increased mortality. The aim of this paper is to review the different aspects of neuro-ophthalmologic involvement in SLE. Since these manifestations are frequent and potentially severe, a multi-professional team approach is needed to investigate properly and provide early aggressive treatment in order to avoid visual sequelae.

Choroidal thickening and macular serous retinal detachment in pregnancy-induced hypertension

OBJECTIVE

The purpose of this study was to report optical coherence tomography (OCT) and angiographic findings in a patient with pregnancy-induced hypertension (PIH).

CASE REPORT

A 39-year-old woman, who was diagnosed with PIH, reported blurred and distorted vision at 5 days after an emergency cesarean delivery. OCT revealed a large serous retinal detachment (SRD) that included areas in the macula, along with an increased choroidal thickness noted in both eyes. Indocyanine green angiograms indicated delayed filling of the choroidal circulation in the early phase but choroidal hyperpermeability in the mid-phase. The SRD was gradually resolving without any treatment except for antihypertensive drugs. At 40 days after the initial examination, OCT revealed both the disappearance of the SRD and marked improvement of the choroidal thickening.

CONCLUSION

Ophthalmologists need to be aware that PIH can cause choroidal ischemia, a breakdown of the outer blood-retinal barrier, and lead to the development of SRD.

Retino-choroidal ischemia in central retinal vein occlusion

A 41-year-old gentleman with insulin dependent diabetes had decreased vision in the right eye due to non-ischemic central retinal vein occlusion with macular edema. One month following intravitreal ranibizumab, he developed retino-choroidal ischemia with further loss of vision. Authors show the fluorescein angiographic transition from non-ischemic central retinal vein occlusion to retino-choroidal ischemia.

Posterior segment ophthalmic complications of aplastic anemia

Three patients with aplastic anemia were evaluated by the ophthalmology service within 2 months of the aplastic anemia diagnosis for bilateral visual loss. The mean age of diagnosis of aplastic anemia was 14.3 years (range: 5 to 19 years) and the mean follow-up was 25 months (range: 15 to 44 months). All 6 eyes demonstrated choroidal ischemia and vitreous hemorrhage. Pars plana vitrectomy was performed in four eyes of two patients for non-clearing vitreous hemorrhage; one patient was observed. Successful anatomic outcomes were achieved in 3 of 4 eyes that underwent vitrectomy. Initial visual acuity ranged from 20/80 to bare light perception and final visual acuity ranged from 20/20 to no light perception. All patients received immunosuppressive therapy including cyclosporine and anti-thymocyte globulin, and two underwent hematopoietic stem cell transplantation. All patients received perioperative platelet and blood transfusions. Pars plana vitrectomy resulted in functional and anatomic success in the majority of eyes in this series. Coordination of medical and surgical care with the hematology service is advisable to stabilize hematologic parameters prior to undertaking a vitreoretinal procedure.

Ocular involvement in connective tissue disorders

Connective tissue disorders have well-known ocular associations that may be presenting features of the disease or occur as complications during the course of the disorder. Keratoconjunctivitis sicca, keratitis, scleritis, uveitis, retinal vasculitis, choroidopathy, and their associations with rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, psoriatic arthritis, juvenile idiopathic arthritis, and polymyositis are reviewed.

Functional evaluation of retina and optic nerve in the rat model of chronic ocular hypertension

PURPOSE

To functionally characterize the rat retina and optic nerve after chronic elevation of the intraocular pressure (IOP) using electroretinography (ERG) and computerized pupillometry.

METHODS

Chronic elevation of the IOP was induced in Brown Norway rats by combined injection of indocyanine green dye (ICG) into the anterior chamber and diode laser treatment, followed by ERG and pupil light reflex (PLR) monitoring.

RESULTS

Laser treatment induced significant elevation of the IOP in operated eyes for 6 weeks, with maximal values observed 14 days postoperatively (ctrl=18.4+/-2.4 and operated=35+/-8.4 mmHg; mean+/-sd). Preoperative values for the PLR(ratio) were 68.5+/-4% (mean+/-sem; %). Three days postoperatively the PLR(ratio) decreased to 60.3+/-10.3%, but was not significantly different compared to preoperative values (p > 0.05 Kruskal-Wallis non-parametric test with Dunn's post-test). However, 7, 14 and 21 days postoperatively the PLR function dramatically decreased to 14.6+8.6, 11.5+/-6.7 and 12.6+/-4%, respectively, and was significantly smaller compared to preoperative values (p < 0.01). At day 28 the PLR significantly recovered and was not significantly different compared to preoperative values (PLR(ratio)=38.5+/-8.6, p > 0.05). However, 35 days after surgery the PLR started to decrease once again in the operated eyes (PLR(ratio)=17.2+/-7.4%) and was significantly smaller again compared to preoperative values (p < 0.05) The PLR values continued to decrease until the end of experiment (60 days postoperatively). ERG analysis of operated eyes revealed significantly decreased amplitudes of a- and b-waves 10d postoperatively, while oscillatory potentials (OPs) and flicker ERG (flERG) amplitudes were not detectable. However, 28 days postoperatively OPs significantly, but temporarily recovered, while a-wave, b-wave and flERG amplitudes did not significantly change compared to values observed 10d postoperatively. The ERG analysis of the operated eyes revealed significantly reduced amplitudes 60 days postoperatively. Histological analysis revealed degeneration of all retina layers and optic nerve axons.

CONCLUSIONS

Chronic ocular hypertension in rats produces dramatic damage to all retinal layers and optic nerves observed by morphological and functional methods which significantly correlate with the IOP elevation. Outer retina of glaucomatous rats seems to be more susceptible to the damage due to chronic elevation of the IOP. Chronic hypertensive rat eyes have capacity to temporarily recover function of the inner retina and optic nerve.

LASER-INDUCED MACULAR HOLES DEMONSTRATE IMPAIRED CHOROIDAL PERFUSION

PURPOSE

To evaluate choroidal perfusion following creation of a laser-induced macular hole in a nonhuman primate model.

METHODS

Six rhesus monkeys underwent macular exposures delivered by a Q-switched Nd:YAG laser. The lesions were evaluated with fluorescein angiography and indocyanine green angiography using scanning laser ophthalmoscopy.

RESULTS

Each lesion produced vitreous hemorrhage and progressed to a full-thickness macular hole. Indocyanine green angiography revealed no perfusion of the choriocapillaris beneath the lesion centers. Fluorescein angiography demonstrated mild enlargement of the foveal avascular zone due to loss of perifoveal capillaries. Histopathologic evaluation showed replacement of the choriocapillaris with fibroblasts and connective tissue.

CONCLUSIONS

Nd:YAG laser-induced macular holes result in long-term impairment of choroidal perfusion at the base of the hole due to choroidal scarring and obliteration of the choriocapillaris. Evaluation of choroidal perfusion may be useful in assessment of laser-injured patients. Impairment in choroidal perfusion may have functional implications for surviving photoreceptors.

Complications of general anesthesia using nitrous oxide in eyes with preexisting gas bubbles

PURPOSE

To present the visual and anatomical outcomes for patients with intraocular gas placed during vitreoretinal surgery who subsequently underwent surgery wherein general anesthesia with nitrous oxide was used.

METHODS

The authors reviewed the charts of patients who had undergone vitreoretinal surgery where a long-acting gas tamponade had been used. These patients underwent additional surgery for a variety of reasons at five different institutions and had nitrous oxide used during general anesthesia. The authors reviewed the preoperative and postoperative findings for patients receiving nitrous oxide following vitreoretinal surgery with gas tamponade.

RESULTS

The authors reviewed findings for five eyes of five patients. All eyes that underwent general anesthesia using nitrous oxide had significant preexisting intraocular gas bubbles ranging from 40% to 90%, and the surgical procedures lasted from 1 to 4 hours. These eyes were followed from 2 months to 9 years (median follow-up, 4 years). Four of five eyes had a final vision of 20/200 or worse and significant optic atrophy at the time of the last follow-up examination. Three eyes had no light perception.

CONCLUSION

The use of nitrous oxide during general anesthesia in gas-filled eyes may have disastrous visual results caused by gas expansion and elevated intraocular pressure. Patients must be advised of the potentially catastrophic results of undergoing general anesthesia before their intraocular gas bubble has resorbed. The use of nitrous oxide for patients with intraocular gas should be avoided. It may be prudent for patients with intraocular gas to wear notification bracelets warning anesthesiologists about the presence of intraocular gas lest emergency surgery be needed by a patient unable to advise anesthesia personnel about the potential danger.

Central serous chorioretinopathy and glucocorticoids

Central serous chorioretinopathy is a relatively common retinal disease characterized by the accumulation of subretinal fluid at the posterior pole of the fundus, creating a circumscribed area of serous retinal detachment. It typically affects young and middle-aged men with no previous medical and family history, and no systemic symptoms or signs. However, it has been noted that central serous chorioretinopathy is associated with different conditions, characterized by exposure to increased levels of endogenous or exogenous glucocorticoids. In fact, central serous chorioretinopathy has been described in patients with endogenous Cushing's syndrome. It is also prevalent in patients with type-A behavior, and following stressful events, and pregnancy probably represents a risk factor for central serous chorioretinopathy; these conditions are characterized by endogenous hypercortisolism. In addition, many cases of central serous chorioretinopathy have been described during or following treatment with glucocorticoids, administrated by any route, for various systemic or ocular conditions. Central serous chorioretinopathy, when related to the exposure to exogenous glucocorticoids, has a less prominent male predilection, presents more often with a chronic or atypical form, and is frequently bilateral. Furthermore, treatment of central serous chorioretinopathy with glucocorticoids was found to exacerbate the clinical picture. Based on these observations it could be suggested that glucocorticoids may be involved in the development of central serous chorioretinopathy, even though the exact pathogenic mechanism remains unclear. Glucocorticoids should not be used in the treatment of central serous chorioretinopathy and central serous chorioretinopathy should be added to the list of ocular complications of glucocorticoids.

Choroidal vascular occlusion in a child with a connective tissue disease and complement C4 deficiency

OBJECTIVE

To report the histopathologic findings in the eyes of a patient with a connective tissue disease and complement deficiency.

DESIGN

Human postmortem ocular histopathologic study.

INTERVENTION

A 15-year-old female died from complications of a connective tissue disease of uncertain etiology, particularly acute respiratory distress syndrome. Abnormalities seen in the eyes at autopsy were consistent with complement activation, granulocyte aggregation, and leukocyte embolization.

MAIN OUTCOME MEASURES

Both eyes were examined by light microscopy.

RESULTS

Some choroidal vessels were occluded by platelet-fibrin thrombi and occasionally by aggregates of granulocytes and fibrin. Serous retinal detachment involving the macula and peripheral retina was present in both eyes.

CONCLUSIONS

This is a report of the ocular histopathologic findings in a patient with connective tissue disease and complement C4 deficiency. The light microscopy findings were consistent with complement activation with granulocyte aggregation and leukocyte embolization and may represent another mechanism to explain the clinical findings in patients with connective tissue disease, particularly systemic lupus erythematosus.

Choroidopathy of systemic lupus erythematosus

PURPOSE

To describe the ocular and systemic manifestations associated with systemic lupus erythematosus (SLE) choroidopathy.

METHODS

Three new cases of choroidopathy in patients with active SLE were described. Twenty-five published cases of lupus choroidopathy were summarized.

RESULTS

There have been 28 cases of lupus choroidopathy (47 involved eyes) that have been reported in the English literature since 1968, including the three current cases. Only two of the patients were male. The choroidopathy was bilateral in 19 patients (68%). All 28 patients (100%) had active systemic vascular disease at the onset of their choroidopathy; 18 (64%) had nephropathy and 10 (36%) had central nervous system (CNS) lupus vasculitis. All but one of the patients had a known diagnosis of SLE at the onset of choroidopathy. 30 of the 47 involved eyes had presenting visual acuity of 20/40 or better; 14 eyes showed improvement in visual acuity with therapy. 23 patients (82%) had resolution of their choroidopathy when their systemic disease was brought under control. Despite treatment, 4 of the 28 patients (14%) died from complications of SLE.

CONCLUSIONS

Although less known than retinopathy, lupus choroidopathy may be more common than generally appreciated. It usually serves as a sensitive indicator of lupus activity. The presence of SLE choroidopathy is generally indicative of coexistent (although sometimes occult) nephropathy, CNS vasculitis, and other SLE visceral lesions. Immunomodulation of the systemic disease can lead to improvement and resolution of the systemic vasculitis as well as the choroidopathy.

Central serous retinopathy complicating systemic lupus erythematosus: a case series

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with widespread manifestations including the eye. Central serous retinopathy (CSR) has been associated as a complicating event in SLE, although it is uncommon. We present a case series of four female Chinese SLE patients who developed CSR during the course of their systemic disease. All four presented clinically with typical CSR. Angiographic findings did not show evidence of choroidal ischaemia or delayed choroidal filling. Resolution of the serous retinal detachment occurred in all four patients. Recovery of vision was seen in three patients. The clinical outcome was similar to that occurring in the usual male population. Central serous retinopathy as a manifestation of SLE may be caused by various factors. These include SLE-associated choroidopathy, systemic hypertension, renal disease, retinal pigment epithelial dysfunction and glucocorticoid therapy.

Central serous chorioretinopathy in patients with systemic lupus erythematosus

PURPOSE

To describe three patients with systemic lupus erythematosus in whom ophthalmoscopic and fluorescein angiographic evidence of central serous chorioretinopathy developed.

METHODS

The authors retrospectively reviewed the clinical and photographic records of three patients with systemic lupus erythematous in whom central serous chorioretinopathy developed.

RESULTS

Ophthalmoscopic changes observed in these patients with systemic lupus erythematosus included discrete areas of clumping and mottling of the retinal pigment epithelium (RPE), focal RPE detachments, serous elevations of the neurosensory retina, and late subretinal fibrosis with scar formation. Fluorescein angiographic findings included transmission hypofluorescence and hyperfluorescence corresponding to focal RPE alterations, early punctate intense hyperfluorescence corresponding to RPE leaks with progressive filling of sub-RPE detachment spaces, and slow late filing of subretinal detachment spaces.

CONCLUSION

Patients with systemic lupus erythematosus are at increased risk to have central serous chorioretinopathy develop. The pathogenetic implications for an association between systemic lupus erythematosus and central serous chorioretinopathy as well as the similarity to the chorioretinopathy seen with accelerated hypertension, pregnancy, hemodialysis, organ transplantation, and exogenous and endogenous hypercortisolism are discussed. Focal choroidal vasculature compromise with secondary dysfunction of overlying RPE cells is the proposed common mechanism.

Choroidal infarction after optic nerve sheath fenestration

PURPOSE

To describe a visual complication of optic nerve sheath fenestration.

METHODS

Case review of two patients who underwent seemingly uncomplicated optic nerve sheath fenestration.

FINDINGS

Both patients had a surgical complication that resulted in significant depression of their temporal visual field and development of a wedge-shaped region of subretinal pigmentation in the nasal fundus.

CONCLUSIONS

Both patients had choroidal infarctions as a complication of optic nerve sheath fenestration. Choroidal infarction should be considered in cases of unexpected loss of visual field after this type of surgery, although the funduscopic signs that assist in making the diagnosis may not be evident for several weeks after surgery.

Visual loss from central serous retinopathy in systemic lupus erythematosus

Images

Bilateral serous retinal detachments in the H.E.L.L.P. syndrome

The first case of the H.E.L.L.P. syndrome with ophthalmic signs is described. This syndrome of pregnancy is characterized by Haemolysis, Elevated Liver enzymes and Low Platelets in association with upper abdominal pain. Diagnosis and treatment is often delayed, while a non-obstetric cause for these findings is sought. The present report adds serous retinal detachments in association with sub-retinal opacities to the signs which should raise suspicion of this syndrome.