Choroidal folds

Increased choroidal thickness in a patient with acquired hyperopia and choroidal folds syndrome

Purpose

syndrome of acquired hyperopia with choroidal folds is a rare syndrome characterized by flattening of the posterior pole with subsequent hyperopization of the eye and a creation of a space between the optic nerve and its sheath. Though uncommon and more often benign, it represents a diagnostic and therapeutic challenge. Correct diagnosis is helpful to exclude other possible causes of choroidal folds.

Observations

here we report a case of a 39-year-old woman who presented with sudden monolateral hyperopia and choroidal folds in the affected eye.

Conclusions and Importance

we performed a specific assessment of the thickness of choroid with the purpose to give further information for the understanding of the underlying condition. To date, the aspect and the thickness of the choroid in this condition, has not been evaluated yet.

Retinal and Optic Nerve Deformations Due to Orbital Versus Intracranial Venous Hypertension

INTRODUCTION

Abnormal forces around the optic nerve head (ONH) due to orbital diseases, intracranial hypertension (IH), glaucoma, and space travel, are associated with alterations of the ONH shape. Elevated cerebral and ophthalmic venous pressure can contribute to stress and strain on the ONH and peripapillary retina. We hypothesize that IH and elevated ophthalmic venous pressure without IH cause different ONH and retinal changes.

METHODS

We compared MRI and spectral domain optical coherence tomography (SDOCT) findings in patients with cavernous sinus arteriovenous shunts (CSAVSs), where orbital venous pressure is known to be elevated, with patients with intracranial dural venous sinus thrombosis and secondary IH. We also compared the results to those obtained in the Idiopathic IH (IIH) Treatment Trial.

RESULTS

Among 18 patients with dural venous sinus thrombosis, the MRI/magnetic resonance venography displayed partial empty sella (61%) and optic nerve sheath distension (67%). None exhibited ophthalmic vein dilation or signs of orbital congestion. SDOCT of these eyes and IIH eyes showed a similar frequency of abnormal thickening of the mean retinal nerve fiber layer, anterior displacement of the basement membrane opening, peripapillary wrinkles, retinal folds (RF), and choroidal folds (CF). Among 21 patients with CSAVSs, MRI showed ipsilateral dilated superior ophthalmic vein (76%) and orbital congestion (52%) without distension of the optic nerve sheath or globe distortion. SDOCT showed CF (19%), one with overlying RF, and no ONH deformations.

CONCLUSIONS

SDOCT findings for dural venous sinus thrombosis are similar to those seen with IIH but distinct from changes due to local ophthalmic venous hypertension. These data support the concept that IH even if due to a vascular cause and local orbital venous hypertension cause different stresses and strains on the ONH.

Retinal Fundus Multi-Disease Image Dataset (RFMiD): A Dataset for Multi-Disease Detection Research

The world faces difficulties in terms of eye care, including treatment, quality of prevention, vision rehabilitation services, and scarcity of trained eye care experts. Early detection and diagnosis of ocular pathologies would enable forestall of visual impairment. One challenge that limits the adoption of computer-aided diagnosis tool by ophthalmologists is the number of sight-threatening rare pathologies, such as central retinal artery occlusion or anterior ischemic optic neuropathy, and others are usually ignored. In the past two decades, many publicly available datasets of color fundus images have been collected with a primary focus on diabetic retinopathy, glaucoma, age-related macular degeneration and few other frequent pathologies. To enable development of methods for automatic ocular disease classification of frequent diseases along with the rare pathologies, we have created a new Retinal Fundus Multi-disease Image Dataset (RFMiD). It consists of 3200 fundus images captured using three different fundus cameras with 46 conditions annotated through adjudicated consensus of two senior retinal experts. To the best of our knowledge, our dataset, RFMiD, is the only publicly available dataset that constitutes such a wide variety of diseases that appear in routine clinical settings. This dataset will enable the development of generalizable models for retinal screening.

Recognition, Diagnosis and Treatment of Chorioretinal Folds: Current Perspectives

Chorioretinal folds (CRFs) are undulations of the choroid and overlying Bruch’s membrane, retinal pigment epithelium and neurosensory retina. CRFs represent a clinical sign that is mandatory to investigate assuming their association with several ocular and extra-ocular disorders. Recent advances in retinal imaging have improved the characterization of CRFs. More importantly, retinal imaging may be useful to detect ocular complications secondary to chronic CRFs, including the development of choroidal neovascularization.

Multimodal imaging of chorioretinal folds induced by orbital vascular malformation in two cases

PURPOSE

To investigate the alterations in the retinal pigment epithelium (RPE) in the crest and trough portions of chorioretinal folds (CRFs) induced by an orbital vascular tumor.

METHODS

Review of multimodal imaging in two eyes of two patients with globe compression and CRFs from an orbital vascular tumor.

RESULTS

Fundus photography demonstrated obliquely extending CRFs with alternating hyperpigmented and hypopigmented linear alterations in both eyes. Fundus autofluorescence (AF) imaging showed obliquely oriented hypoAF lines, incompletely alternating with hyperAF lines. In Case 1, the hyperAF lines had interspersed hypoAF segments and Case 2 had peripapillary mottling of AF. Fluorescein angiography (FA) showed alternating hyper and hypofluorescent lines in the late phase in Case 1. Optical coherence tomography (OCT) documented relative thinning of RPE at the folded crests in Case 1 and preservation of RPE in Case 2. Swept-source OCT angiography (SS-OCTA) demonstrated oblique hyporeflective lines in the outer retina and choriocapillaris layers in Case 2. These findings suggest that the crest of a CRF represents thinned or rarified RPE with hypoAF, transmission hyperfluorescence (FA), partially attenuated RPE layer (OCT), and isoreflectivity (SS-OCTA) while the trough represents compressed RPE with irregular hyperAF, transmission hypofluorescence (FA), thickened RPE layer (OCT), and hyporeflectivity (SS-OCTA).

CONCLUSION

The anatomic and functional status of the RPE in CRFs based on multimodal imaging reveals normal to attenuated RPE with hypofunctionality at the fold crest and compacted, thickened RPE at the trough with segmental functional impairment on AF imaging. Anatomic information regarding CRFs is evident on OCT, FA, and SS-OCTA while the functional status is depicted on AF.

Immunoglobulin G4-related dacyroadenitis presenting as bilateral chorioretinal folds from severely enlarged lacrimal glands

Purpose

To describe a case of immunoglobulin G4 (IgG4)-related dacyroadenitis presenting as bilateral chorioretinal folds from eyeball compression by massively enlarged lacrimal glands.

Observations

A 51-year-old woman with severely enlarged bilateral lacrimal glands was diagnosed as having IgG4-related dacryoadenitis. The glands strongly compressed the globes, forming chorioretinal folds resembling those found in orbital malignancy. Eventual treatment with oral prednisolone dramatically reduced the volume of the lacrimal glands and released globe compression on magnetic resonance imaging. However, the chorioretinal folds remained in the right fundus and symptoms of blurred vision improved but persisted.

Conclusions and importance

This is the first account of chorioretinal fold formation by severely enlarged lacrimal glands appearing in IgG4-related dacryoadenitis. Chorioretinal fold formation by an enlarged lacrimal gland occurring bilaterally may represent a basis for suspecting IgG4-related dacryoadenitis. Prompt treatment is recommended for patients presenting with very large lacrimal glands to avoid visual impairment.

Optical Coherence Tomography Angiography Features of Chorioretinal Folds: A Case Series

Purpose

To report 3 cases of ocular chorioretinal folds from different etiologies and their aspect with the new imaging technology of optical coherence tomography (OCT) angiography (OCT-A).

Methods

Baseline data, investigational process on etiology, and follow-up data of patients referred for chorioretinal folds to the Medical Retina & Imaging Unit of San Raffaele Hospital in the period January-March 2016 were collected. Multimodal imaging evaluation, comprehensive of infrared, fundus autofluorescence, multicolor, spectral-domain OCT, and OCT-A, was performed on all patients.

Results

Four eyes of 3 men, 65, 46, and 50 years of age, showed chorioretinal folds secondary to central serous chorioretinopathy, postoperative hypotony (after deep sclerectomy), and anisometropia with unilateral hyperopia, respectively. In all cases, OCT-A imaging showed a signal reduction in the choriocapillaris layer in correspondence of the folds. Due to this signal reduction, the en face reconstruction of choriocapillaris layer showed, in all cases, a peculiar tigroid aspect. The aspect of the folds at OCT-A remained unchanged during the 3-month follow-up in all patients.

Conclusions

Optical coherence tomography angiography shows a typical linear signal reduction in the choriocapillaris layer in correspondence of the fold with a tigroid pattern. We hypothesize this aspect could be explained by blood flow alteration at the choriocapillaris level in correspondence of the fold.

Chorioretinal folds: associated disorders and a related maculopathy

PURPOSE

To describe a series of chorioretinal folds (CRFs) representing a clinical sign that may be associated with multiple systemic, orbital, and ophthalmologic disorders. We report the associations with systemic disease and describe 3 stages of a CRF-related maculopathy.

DESIGN

Observational, retrospective case series.

METHODS

We reviewed 57 affected eyes from 40 patients with the clinical sign of CRF from 1 of 2 academic institutions. A careful review of the medical histories and systemic diagnostic evaluations were conducted. Imaging studies were conducted.

RESULTS

The mean age at diagnosis was 64 ± 17 years. Most eyes (n = 18) were hyperopic (+2.60 ± +2.90 diopters). There were 20 patients (50%) with some form of autoimmune disorder. Overall, the mean presenting visual acuity was 20/50, declining slightly to 20/60 over 19 ± 30 months. Ten eyes had stage 3 CRF-related maculopathy, more common in older individuals with more chronic CRFs. Four stage 3 eyes had associated choroidal neovascularization, and these eyes had 20/60 presenting visual acuity that decreased to 20/100 over approximately 1.5 years. Stage 3 eyes without choroidal neovascularization had a mean presenting visual acuity of 20/40 that decreased to 20/65 over 2.1 years.

CONCLUSIONS

CRFs are associated with numerous ophthalmic and systemic disorders. A careful medical history and evaluation are essential. We describe 3 stages of a unique CRF-related maculopathy. Stage 3 resembles occult choroidal neovascularization, occurs primarily in older individuals with chronic CRFs, and is accompanied by a slow deterioration in central acuity.

Shape analysis of the peripapillary RPE layer in papilledema and ischemic optic neuropathy

PURPOSE

Geometric morphometrics (GM) was used to analyze the shape of the peripapillary retinal pigment epithelium-Bruch's membrane (RPE/BM) layer imaged on the SD-OCT 5-line raster in normal subjects and in patients with papilledema and ischemic optic neuropathy.

METHODS

Three groups of subjects were compared: 30 normals, 20 with anterior ischemic optic neuropathy (AION), and 25 with papilledema and intracranial hypertension. Twenty equidistant semilandmarks were digitized on OCT images of the RPE/BM layer spanning 2500 μm on each side of the neural canal opening (NCO). The data were analyzed using standard GM techniques, including a generalized least-squares Procrustes superimposition, principal component analysis, thin-plate spline (to visualize deformations), and permutation statistical analysis to evaluate differences in shape variables.

RESULTS

The RPE/BM layer in normals and AION have a characteristic V shape pointing away from the vitreous; the RPE/BM layer in papilledema has an inverted U shape, skewed nasally inward toward the vitreous. The differences were statistically significant. There was no significant difference in shapes between normals and AION. Pre- and posttreatment OCTs, in select cases of papilledema, showed that the inverted U-shaped RPE/BM moved posteriorly into a normal V shape as the papilledema resolved with weight loss or shunting.

CONCLUSIONS

The shape difference in papilledema, absent in AION, cannot be explained by disc edema alone. The difference is a consequence of both the translaminar pressure gradient and the material properties of the peripapillary sclera. GM offers a novel way of statistically assessing shape differences of the peripapillary optic nerve head.

Hypotony maculopathy

Hypotony maculopathy, first described in 1954 by Dellaporta, usually occurs after antiglaucomatous surgery or after perforating eye injuries; it is characterized by hypotony associated with fundus abnormalities, including papilloedema, vascular tortuosity and chorioretinal folds. In hypotony maculopathy, the scleral wall collapses inward, resulting in redundancy of the choroid and retina, leading to chorioretinal wrinkling. As the antero-posterior diameter of the vitreous cavity decreases, the very thick perivofeal retina surrounding the very thin foveal retina is thrown into radial folds around the fovea. It has been reported that hypotony maculopathy occurs in up to 20% of cases of glaucoma filtering surgery and has become more common after the introduction of antimetabolites. Young age, myopia, primary filtering surgery, systemic illnesses and elevated preoperative intraocular pressure (IOP) have been found to be associated with hypotony maculopathy. Hypotony maculopathy is treated with procedures designed to elevate IOP, which may reverse the inward scleral bowing and improve visual acuity. The successful treatment of hypotony maculopathy depends on the correct identification of its cause. Once the cause is detected, treatment should be employed as soon as possible because delayed normalization of the IOP may result in permanent macular chorioretinal changes and poor vision. This review will explore the definition, mechanisms, clinical findings and treatment of hypotony maculopathy.

Pervasive ocular anomalies in posterior microphthalmos

BACKGROUND

Posterior microphthalmos is a relatively rare condition that has been reported to coexist with several other ophthalmic conditions. However, to the best of the authors' knowledge, there are no previous reports that have found posterior microphthalmos and refractive, binocular, retinal, and neurologic considerations, along with a possible hereditary component. The following report documents the coexistence of posterior microphthalmos with severe hyperopia, esotropia, macular folds, and optic nerve hypoplasia in a pair of siblings.

CASE REPORT

A 9-year-old Hispanic girl presented for a comprehensive eye examination. Best-corrected visual acuity (VA) was reduced in both eyes with poorer VA in the right eye. Binocular testing found a small angle constant right esotropia (ET). On dilated fundus examination, a peculiar, elevated, dolphin-shaped folding of the macula was identified, the right eye greater than the left eye, that extended toward an anomalous optic nerve head in both eyes (OU), presumed to be a disc hypoplasia. The patient's brother, who also exhibited severe hyperopia and ET, presented with a similar acuity reduction, a nearly identical folded macular appearance, the right eye more so than the left eye, and a probable optic nerve hypoplasia. Pachymetry, ultrasonography, and ocular coherence tomography imaging of both siblings found thickened corneas in the presence of posterior microphthalmos OU and macular folds affecting only the retina, leaving the choroid and sclera unaffected.

CONCLUSIONS

Posterior microphthalmos may exist in the presence of ocular anomalies along with refractive, binocular, retinal, neurologic, and genetic considerations. In this case, optical coherence tomography provided information on the internal morphology of the macular folds, which helped direct the differential diagnosis. The similar presentation among siblings supports a hereditary component that warrants further investigation.

Optical coherence tomography of chorioretinal and choroidal folds

PURPOSE

To report the optical coherence tomography (OCT) findings in cases of chorioretinal and choroidal folds.

METHODS

Eight subjects with folds of the fundus of the eye were examined with fundus photography, fluorescein angiography, B-scan ultrasonography and Stratus OCT.

RESULTS

Two types patterns were found on OCT. Five cases showed undulating retinal as well as retinal pigment epithelial lines of normal thickness; these were defined as chorioretinal folds. The posterior vitreous surface often adhered to the crests of the folds only. Three cases exhibited a wavy appearance of the retinal pigment epithelium and a flat retinal surface; these were classified as choroidal folds.

CONCLUSIONS

Scanning by OCT can differentiate chorioretinal folds from choroidal folds and reveal the relationships between the folds and the posterior vitreous surface.

Prospective evaluation of fundus changes in patients with orbital mass lesions

PURPOSE

To study fundus changes associated with orbital mass lesions.

METHODS

In a prospective, interventional case series, 28 patients undergoing surgery for discrete orbital masses had detailed fundus examination under dilation using direct and indirect ophthalmoscopy. Preoperative visual acuity and the amount and duration of proptosis were noted. Fundus photographs were taken, and postoperative changes were documented. The main outcome measures were the frequency of various fundus changes and their correlation with other clinical features.

RESULTS

Nineteen (68%) of 28 patients had fundus changes; the commonest change was optic disk edema, seen in 14 patients (50%). The mean amount of proptosis +/- SD was 7.7 +/- 7.1 mm for patients with fundus changes and 4.22 +/- 2.1 mm for patients with normal fundus. Of 19 patients with fundus changes, 12 (63%) had an intraconal mass, and 11 (58%) had globe indentation. Twenty patients (71%) had diminished visual acuity preoperatively; of these patients, 8 (40%) had improvement in vision after surgery, 10 (50%) did not have any change in vision, and 2 (10%) had a postoperative decrease in visual acuity. Five (62%) of 8 patients with postoperative improvement in visual acuity had proptosis for < 2 years before surgery was undertaken, while only 1 (10%) of 10 patients retaining their preoperative vision had a duration of proptosis of < 2 years.

CONCLUSION

Fundus changes are frequently seen with orbital masses. An increased amount of proptosis, intraconal location, and globe indentation are associated with fundus changes. Postoperative improvement in visual acuity is less likely in patients with a longer duration of symptoms.

Bilateral choroidal folds and optic neuropathy: a variant of the crowded disk syndrome?

PURPOSE

To describe the clinical features of the syndrome that includes bilateral choroidal folds and optic neuropathy and to propose a novel etiology to explain this presentation.

DESIGN

Observational small case series.

PARTICIPANTS

Three patients.

METHODS

Three patients received an extensive clinical work-up including complete ocular examination, A and B scan ultrasonography, Humphrey visual field analysis, and imaging of the brain and orbit. Neurological consultation was obtained in each patient two of whom underwent lumbar puncture. The findings of this detailed investigation are reported.

RESULTS

Each patient demonstrated bilateral choroidal folds with optic disk congestion and leakage in one eye and optic atrophy in the fellow eye. Extensive ocular and extraocular investigation failed to uncover a specific etiology. Pseudotumor cerebri, a well-documented cause of papilledema and choroidal folds, was ruled out in each case. Each patient did demonstrate variable degrees of hyperopia and shortened axial lengths.

CONCLUSIONS

The syndrome of bilateral choroidal folds and optic neuropathy may have various etiologies. Pseudotumor cerebri needs to be definitively ruled out. Normal neuro-ophthalmological investigation including lumbar puncture may indicate an alternative cause. Idiopathic acquired hyperopia in middle-aged patients who are hyperopic with shortened axial lengths may be associated with choroidal folds and a constricted scleral canal causing optic disk congestion and complicated by nonarteritic anterior ischemic optic neuropathy due to a crowded disk.

Choroidal folds associated with increased intracranial pressure

PURPOSE

To determine whether a relationship exists between increased intracranial pressure and the presence of idiopathic choroidal folds.

METHODS

A prospective study in which 12 consecutive patients presenting with choroidal folds were evaluated by imaging studies (ultrasonography, magnetic resonance imaging, and/or computed tomography) to rule out known causes of choroidal folds, such as orbital disease, choroidal tumor, posterior scleritis, hypotony, and choroidal neovascular membrane. A lumbar puncture was performed on each of these patients, and measurement of opening pressure of cerebrospinal fluid was obtained.

RESULTS

Twelve patients with choroidal folds included nine men and three women. Six patients (50%) presented with papilledema in the eye with choroidal folds. The other six patients (50%) presented with only choroidal folds. In this study, 10 (83%) of 12 patients had an opening pressure greater than 230 mm H(2)O. In patients presenting with only choroidal folds, five (83%) of six patients had an opening pressure greater than 230 mm H(2)O, with an average opening pressure of 290 mm H(2)O.

CONCLUSION

Depending on the timing of the evaluation, papilledema may or may not be present, and only choroidal folds may be seen as a reflection of increased intracranial pressure. We believe that increased intracranial pressure from any source (that is, pseudotumor cerebri, sinus thrombosis, or intracranial mass) can present with only choroidal folds; therefore, these patients should have an appropriate work-up that should probably include a lumbar puncture before the title of "idiopathic" is given to their finding.

Choroidal folds and papilloedema

AIMS

To assess the clinical and fluorescein angiographic features of choroidal folds seen in association with papilloedema.

METHODS

In a retrospective study, the clinical data from a database on patients with choroidal folds (1963-97), including fundus photography and fluorescein angiography, from 32 patients (64 eyes) with choroidal folds in association with papilloedema were reviewed. The clinical and fluorescein angiographic features and the clinical course of choroidal folds in these patients are described.

RESULTS

32 patients had choroidal folds associated with papilloedema. Folds of two distinct categories were observed, either coarse folds or wrinkles. The folds persisted in all cases, even after resolution of papilloedema. Follow up ranged from 1 month to 20 years. Only one patient suffered permanent visual impairment as a result of a choroidal fold.

CONCLUSIONS

Choroidal folds exist in two forms, coarse folds and wrinkles. They persist even after papilloedema has resolved. Final visual acuity did not appear to be affected by the presence of choroidal folds in the majority of patients.

Aetiology and management of choroidal folds

Choroidal folds are known to be associated with a wide variety of pathological conditions, such as central serous retinopathy, choroidal naevi, tumours and papilloedema. They may also occur with surgical procedures, especially when hypotony of the globe occurs, such as following cataract surgery, laser therapy and from post-operative choroidal oedema or inflammation. However, choroidal folds are idiopathic in the majority of cases and can be associated with benign conditions, such as hypermetropia and optic disc drusen. Numerous patterns and orientations of choroidal folds are possible, with some authors suggesting that typical presentations are associated with particular pathological conditions. They may be seen as dark and light streaks on ophthalmoscopy (often more defined with red-free viewing) but are more apparent and differentiated from retinal folds by fluorescein angiography. The aetiology of choroidal folds appears to be linked to a combination of an anatomical attachment of Bruch's membrane to the underlying choriocapillaris and congestion of the choriocapillaris. This paper reviews aspects of the differential diagnosis of choroidal folds with guidelines for optometric management. Several case reports are presented to demonstrate some of the clinical features of choroidal folds.

Fundus manifestations of orbital disease and treatment of orbital disease

Disorders of the orbit can secondarily involve the eye. Although nonspecific, changes which can be noted on funduscopic examination including abnormalities of the retina, choroid, and optic nerve, can be secondary to an underlying orbital process. Awareness of these findings and their association with orbital disease is of great importance to the practicing ophthalmologist, since many orbital disorders are treatable and indeed, some are life-threatening. In addition, treatment of these disorders can potentially result in a variety of ocular complications. An understanding of the potential risks is of the utmost importance in planning treatment of an orbital disease.

Bilateral radial chorioretinal folds

Chorioretinal folds are most commonly idiopathic. Radial chorioretinal folds can be a sign of choroidal neovascularization. A case of bilateral radial chorioretinal folds as a presenting sign of age-related macular degeneration is reported. This patient has maintained good visual acuity in one eye in which the only sign of occult choroidal neovascularization is the presence of chorioretinal folds and minimal leakage on fluorescein angiography.

Retinal pigment epithelial folds associated with retinal pigment epithelial detachment in macular degeneration

The authors reviewed six eyes that had a shallow retinal pigment epithelial detachment with the retinal pigment epithelium (RPE) thrown into folds. A contraction of subpigment epithelial fibrovascular tissue causes a folding of the overlying, intimately adherent RPE. Retinal pigment epithelial folds are a sign of subretinal neovascularization and are another manifestation of age-related macular degeneration.

The etiology of choroidal folds. A biomechanical explanation

Folding of the choroid, Bruch's membrane, and the overlying retina occurs in a variety of ocular and orbital diseases and after certain surgical procedures. The etiology of the folding is explained, using the principles of deformation of materials and by considering the biomechanical properties of the choroid and sclera. Choroidal folds are likely to develop in association with any intra- or extraocular process that induces sufficient compressive stress within the choroid, Bruch's membrane, and retina to force these tissues to buckle. A detailed explanation of the pathogenesis of folding is presented in various clinical settings.

Abnormal scleral findings in uveal effusion syndrome

We successfully treated a patient with uveal effusion syndrome and abnormal sclera with a partial-thickness sclerectomy. Part of the sclera was immediately cultured, and the excised sclera and the cultured cells were examined by electron microscopy. The sclera demonstrated increased glycosaminoglycan-like deposits between the scleral fibers. The cultured scleral cells showed large intracellular glycogen-like deposits, which were not seen in cells cultured from two control scleras. These findings may be the result of a metabolic defect, which causes a thick, impermeable sclera in some cases of uveal effusion.

The natural history and CT appearance of acquired hyperopia with choroidal folds

Seven healthy adults with acquired hyperopic change in refractive error had choroidal folds in affected eyes. High resolution computerized tomographic scanning techniques used to obtain coronal, oblique coronal, and parasagittal reformations revealed flattening of the posterior globes and mild to moderate optic nerve enlargement. In 5 of 11 eyes, a space was noted between the optic nerve and its sheath, implying expansion of the sub-arachnoid perineural compartment. The clinical findings and natural history of this syndrome, based on an average follow-up of 4.5 years, are discussed.

Observations on long-term follow-up of posterior scleritis

Clinical features of posterior scleritis were noted in 12 eyes of nine patients followed up for one to seven years. The signs of this clinical entity varied from transitory choroidal folds in the fundus to extensive scleral and choroidal edema with associated edema of Tenon's space and of the optic nerve sheath. These were detected only by ultrasonography. Histopathologic examination of one eye disclosed granulomatous inflammatory reaction in the involved scleral and choroidal areas. Local and systemic treatment with corticosteroids seemed not to affect the clinical course or outcome.

The use of computed tomography and ultrasonography in the evaluation of orbital masses

The combined use of computed tomography scans with multiplanar reformation and ultrasonography makes it possible to locate orbital masses with a high degree of accuracy, and sometimes even to determine their histological nature without surgical biopsy. One of the unique features of computed tomography is its ability to distinguish both normal and abnormal structures of various tissue densities; this has contributed to very low false positive and false negative rates. Ultrasonography, while of limited use in the detection of posterior orbital lesions or lesions involving the orbital bones, provides an excellent cost-effective screening test for anterior and midorbit disease. It is also useful for the detection of extraocular muscle enlargement secondary to thyroid disease. In this article, a review of the characteristics and techniques of computed tomography and ultrasonography is followed by discussion of the advantages and limitations of each modality in the evaluation of six common types of orbital tumefaction.

Acquired hyperopia with choroidal folds

Six healthy adults suddenly developed a unilateral or bilateral hyperopic shift in refractive error of up to 6 diopters. Fundi of affected eyes showed typical choroidal folds. Visual acuity was improved to normal or near normal by plus lenses, and refraction and fundus appearance have remained stable for up to 23 years. The benign syndrome of acquired hyperopia with choroidal folds deserves emphasis in order to spare patients from unnecessary and potentially hazardous neurosurgical or orbital investigation.