Clinical observations concerning choroidal folds

Martinique (West Indies) crinkled retinal pigment epitheliopathy: clinical description

PURPOSE

To report a previously undescribed pattern of crinkled retinal pigment epithelium (RPE), observed in a family of black patients originating from Martinique, an island in the French West Indies.

METHODS

Three generations were examined by visual acuity measurement and fundus photography. Autofluorescence photography, fluorescein and indocyanine green angiography, visual field testing, electrophysiology, and spectral domain optical coherence tomography were performed in certain patients.

RESULTS

One 86-year-old grandmother, her 7 children, her nephew, and 18 of her 22 grandchildren were examined. Nine patients were affected: five children, one nephew, and three grandchildren. An unrelated patient originating from the same area was also affected. In the third generation, fundus findings were whitish deep lines located in the posterior pole. Optical coherence tomography showed a crinkled pattern of a slightly elevated RPE. In the second generation, a scalloped crinkled RPE was observed in the posterior pole and midperiphery, giving an image of dry desert land in fluorescein and indocyanine green angiography. Optical coherence tomography showed that the RPE formed ripples, giving it a crinkled appearance. Complications were observed in six cases: they included RPE atrophy (one case), subretinal and sub-RPE hemorrhages because of polypoidal choroidal vasculopathy (four cases), and fibrovascular scarring (one case). The grandmother's fundi were characterized by peripheral pigmentary changes, with severe visual loss.

CONCLUSION

The observed pattern appeared different from previously described dystrophies and could be referred to as Martinique crinkled retinal pigment epitheliopathy.

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.

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.