Final Test for a Wrinkle in Time Test Review

A 55-yr one-time Hispanic male presented for an evaluation of blurred vision in his correct eye. He explained that approximately one yr agone, he noted baloney in the right eye and color vision changes. An ophthalmologist noted fluid leaking in the back of his eye. The distortion resolved and his vision improved in a few months.

Then, three months ago he reported another episode of blurred vision and distortion, mostly while driving. He felt the vision had improved, but it withal was not "right." He has never had any center bug and his medical history was unremarkable.

Upon examination, his entering visual vigil measured twenty/30 OD and 20/20 OS. With a manifest refraction of +2.50D he was 20/xx OU. The left eye had a minimal hyperopic correction. Confrontation fields were total to careful finger counting in both eyes. Extraocular motility testing was unremarkable. His pupils were equally round and reactive; in that location was no afferent pupillary defect.

Anterior segment examination was unremarkable. Dilated fundus examination showed small cups with good rim coloration and perfusion in both of his eyes.

The posterior pole of the right middle showed changes (Figure 1). Fundus images of the left eye are too available (Figure 2).

An SD-OCT is also bachelor for review (Figures 3a and 3b).

Accept the Quiz
1. What are the changes seen in the posterior pole of the right eye?
a. Subretinal fluid.
b. Choroidal folds.
c. Retinal stria.
d. SubRPE tracking from a parasite.

2. What is the etiology?
a. Inflammation.
b. Hypotony.
c. Orbital tumor.
d. Idiopathic.

3. What is the likely explanation for the fluid in the back of his eye?
a. Impossible to tell.
b. Cystoid macular edema.
c. Choroidal neovascular membrane.
d. Idiopathic primal serous chorioretinopathy (ICSC).

4. What additional test would be helpful to confirm the diagnosis?
a. Fluorescein angiography.
b. MRI.
c. Orbital ultrasound.
d. Visual field.

5. How should this patient be managed?
a. Ascertainment.
b. Intravitreal anti-VEGF medication.
c. Refer to neuro-ophthalmologist.
d. Start anti-helminthic medications.

For answers, see below.

Discussion
Our patient has choroidal folds in the right center. On clinical exam, we can see, throughout the entirety of the posterior pole, horizontal linear lines that alternating in color between light and dark. These are folds, or wrinkles, in the inner portion of the choroid, retinal pigment epithelium (RPE) and neurosensory retina. They develop as a outcome of shrinkage of the sclera or from scleral thickening. ^ane This may occur in a number of weather including orbital inflammatory disease (posterior scleritis or inflammatory pseudotumor), hypotony post-obit intraocular surgery, choroidal neovascularization and orbital tumors, among others. Whatever of these weather condition tin result in shrinkage of the sclera which, in turn, causes a reduction in the area of the inner surface of the sclera. ¹ When this occurs, the choroid and RPE become redundant relative to the area of the sclera and choroidal folds develop.

In the majority of cases, choroidal folds will issue from idiopathic causes. They are normally an incidental finding in patients during a routine center examination.¹ They may involve nearly of the posterior pole of the eye, or can be confined to an area either above or below the macula and optic disc. Their distribution in both eyes is normally symmetric. In most instances visual acuity is unaffected.¹

Choroidal folds tin likewise be seen in moderate or high hyperopia due to these patients' shorter axial length and thick scleras.^ane This can occur at any age, only is well-nigh commonly seen in heart-aged adults. They can be unilateral, just are more oftentimes bilateral.^ane

It has been ingrained in near clinicians that unilateral choroidal folds may exist the effect of an orbital tumor pressing on the back of the world. However, it is important to note that orbital tumors will non cause choroidal folds, unless scleral thickening or shrinkage occurs.¹

The diagnosis of choroidal folds is generally based on the clinical appearance; however, fluorescein angiography may highlight the folds improve than what is seen on clinical examination. In our patient, the folds were quite obvious, so we did non feel we needed a fluorescein angiography to confirm the diagnosis. If at that place was business of an orbital mass or inflammatory procedure, an orbital ultrasound would have been helpful. We did not experience at that place was whatever resistance to retropulsion so we did not perform an ultrasound. Nosotros did perform an OCT, as there was RPE modeling in the macula. The OCT show some irregularity at the level of the RPE but there was no CNV (Figures 3a and 3b).

So why does our patient have choroidal folds? Based on the history our patient provided, nosotros thought he might take had an episode of primal serous chorioretinopathy.

The previous dr. told the patient in that location was fluid in the dorsum of his middle. This may take been a neurosensory detachment. As nigh cases of ICSC will resolve on its own without handling, that may very well be what happened.¹ The RPE mottling in the macula is consistent with resolved ICSC, and one-time ICSC has been known to event in choroidal folds.¹

We discussed these findings with our patient and explained to him that, should he notice any other changes in his vision, he should return to the office immediately for further evaluation.

1. Gass JD. Choioretinal folds. In: Gass JD, editor. Stereoscopic atlas of macular disease: Diagnosis and handling. 4th ed. St. Louis: Mosby; 1997. pp. 288–301.

Retina Quiz Answers:
one) b; two) d; 3) d; 4) a; 5) a.

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