Juxtapapillary choroidal neovascular membrane following optic neuritis

Retinal Manifestations of Idiopathic Intracranial Hypertension

TOPIC

This review presents a case series and systematic review to understand retinal changes in patients with idiopathic intracranial hypertension (IIH) using fundus photography and OCT.

CLINICAL RELEVANCE

IIH is a condition of raised intracranial pressure of unknown cause, usually observed in young, obese women. Ophthalmologic manifestations of IIH such as papilledema and abducens nerve palsy are well recognized, but less common retinal manifestations may occur.

METHODS

A retrospective institutional chart review (July 2018-March 2020) was performed on consecutive IIH patients. Fundus photographs were obtained followed by neuro-ophthalmology assessment to elicit clinical characteristics and for diagnosis. Patients who met the modified Dandy criteria were included. A systematic review of observational studies was conducted using Ovid MEDLINE and EMBASE to November 17, 2019, to supplement the case series data.

RESULTS

Of 144 consecutive IIH clinical patients reviewed, 10 (6.9%) and over 182 patients from the literature showed retinal findings (% in case series, % in literature, respectively): subretinal fluid (SRF; 30,9), chorioretinal folds (30,68), macular exudate (ME; 20,5), choroidal neovascular membrane (CNVM; 10,15), venous stasis retinopathy (VSR; 10,2), choroidal infarction (0,1), and branch retinal artery occlusion (BRAO; 0,1). Eight clinical patients were women (80%), average age was 32.00 ± 13.99 years, body mass index was 40.63 ± 7.43 kg/m², baseline visual acuity (VA) was 0.79 ± 0.30 in both eyes, and visual field (VF) results were -9.89 ± 11.52 dB in both eyes. Among clinical patients, 2 (1 with SRF, 1 with CNVM) had distinctive retina-related VF defects at presentation. Outer retinal abnormalities persisted on OCT in patients after resolution of SRF and papilledema. Surgical treatment (peritoneal shunt) was required for 2 patients (1 with VSR, 1 with SRF); others were treated with weight loss and acetazolamide alone. The patient with significant ME had hypertension that was treated.

DISCUSSION

Significant retinal manifestations associated with IIH include CNVM, ME, SRF, VSR, chorioretinal folds, choroidal infarction, and BRAO. These may reduce VA or cause VF defects unrelated to papilledema, emphasizing the importance of a detailed dilated fundus examination. Consultation with a retina specialist is advised in patients with peripapillary CNVM.

Juxtapapillary pigment epithelium detachment observed in asymptomatic participants using optical coherence tomography

PURPOSE

To use three-dimensional optical coherence tomography (3D-OCT) to assess the prevalence of juxtapapillary retinal pigment epithelial detachments (jPED) in an asymptomatic population.

METHODS

Asymptomatic participants (i.e., family members of patients) were prospectively recruited over a 6-month period. Each subject completed a questionnaire prior to the acquisition of two undilated 45° fundus images and two undilated raster 3D-OCT scans (512 × 128) covering the macula and optic nerve from each eye using 3D-OCT-1000. Fundus images were graded for the presence of peripapillary atrophy (PPA), peripapillary pigment (PPP), drusen in the macula, and drusen elsewhere, whereas 3D-OCT scans were assessed for the presence of jPED, drusen in the macula, and drusen elsewhere.

RESULTS

In all, 276 eyes from 138 participants were evaluated. Mean participant age was 37.6 years (range: 18-74 years; SD: 15.5 years). In all, 87 jPEDs were detected in 26.1% (36/138) of asymptomatic participants (25 bilateral and 11 unilateral) or 17.0% (47/276) of asymptomatic eyes (23 in the right eye and 24 in the left). The maximum height of jPED was 198.3 ± 53.8 (range: 101.8-376.0) μm. The minimum distance of jPED to the border of optic nerve head (OPN) was 2.6 ± 11.1 (range: 0-61.9) μm. The occurrence of jPEDs or drusen elsewhere by subjects increased statistically with increasing age (P < 0.001, respectively).

CONCLUSIONS

In this study, definite jPEDs were observed by OCT in asymptomatic participants, which were not seen with fundus photography. jPEDs were seen more commonly with increasing age, although it is not known whether these lesions represent deposition of drusen-like material or aborted choroidal neovascularization adjacent to the natural break in Bruch's membrane at the optic disc.