Choroidal Folds Research Articles

The Cause of Retinal and Choroidal Folds in Optic Disc Drusen

The Cause of Retinal and Choroidal Folds in Optic Disc Drusen

Thyroid eye disease with choroidal folds

ABSTRACT Purpose: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED). Methods: A multi-center retrospective case series of patients with TED who developed CRF. Results: Ten patients (17 eyes) with CRF related to TED were identified. The mean age of presentation was 59.3 ± 8.3 years old. The majority of patients were male (70%), hyperthyroid (70%), hyperopic (53%), had a history of radioactive iodine (60%), and currently on methimazole treatment (30%). Three patients (3 eyes) had unilateral involvement of CRF with bilateral TED. The average clinical activity score was 3.6 ± 2.1 at the time of presentation. The most commonly enlarged extraocular muscles were medial (76%), inferior (64%), superior (64%) and lateral rectus (35%). Compressive optic neuropathy was seen in 47% of eyes. Treatment included oral prednisone (70%), orbital decompression (59%), thyroidectomy (20%) and tocilizumab (10%). The CRF did not resolve over a follow up period of 24.7 ± 23.7 months in 70% of eyes. There was no significant difference in average axial length (25.7 ± 4.9 mm) and optic nerve to optic strut distance (37.8 ± 3.9 mm) between patients with CRF and the eight age-and sex-matched TED control patients without CRF (p = 0.81 and 0.65 respectively). A univariable and multivariable analysis found an enlarged inferior rectus as a factor in TED patients with persistent CRF. Conclusions: CRF are often an indicator of visually threatening situations and often do not resolve despite treatment of TED.

Optic Nerve Tortuosity on Earth and in Space.

INTRODUCTION: Spaceflight Associated Neuro-ocular Syndrome (SANS) results from long-duration spaceflight and presents with a constellation of signs (e.g., optic disc edema, choroidal folds, globe flattening, refractive error shifts, etc.). Optic nerve tortuosity (ONT) has been detected in approximately 47% of astronauts after long-duration spaceflight but has not yet been fully analyzed. This review examines terrestrial ONT in order to better understand how the condition is caused and measured.METHODS: References were identified by PubMed and ScienceDirect searches covering 1955 to October 2018 using the terms "optic nerve tortuosity," "optic nerve kinking," "optic disc torsion," "optic kinking," and "ocular torsion." Additional references were identified by searching relevant articles.RESULTS: ONT measurements have evolved and become more objective. One measure consists of meeting two criteria: 1) lack of optic nerve congruity in >1 coronal section; and 2) subarachnoid space dilation. This "criteria measure" is objective, sensitive, and specific for determining the presence of tortuosity. Another measure is the tortuosity index, which offers additional benefits by measuring the degree of ONT, including the potential to track changes over time. There are numerous terrestrial ONT causes, including intracranial hypertension, hydrocephalus, Chiari malformation, neurofibromatosis, glaucoma, and progeria, among others.DISCUSSION: To accurately measure ONT, it is crucial to adhere to objective, standardized techniques. The tortuosity index offers the potential to measure intraindividual change in ONT. Among the varied conditions associated with ONT, one commonality is pressure change. The impact of intracranial pressure on the vascular system and vice versa may offer insight into what is occurring in space.Scott RA, Tarver WJ, Brunstetter TJ, Urquieta E. Optic nerve tortuosity on Earth and in space. Aerosp Med Hum Perform. 2020; 91(2):91-97.

Idiopathic choroidal folds

Idiopathic choroidal folds

Использование термографии при заднем склерите

Aim: to evaluate the utility of thermography in posterior scleritis (PS).Patients and Methods: this prospective observational case-control study included 6 patients with monolateral PS (study group) and 10 healthy volunteers (control group). Ocular surface temperature (OST) was measured in all participants using a non-contact thermal camera (FLIRTM) integrated onto a smartphone (CAT S 60). The difference in OST between the affected eye and the healthy (fellow) eye on thermograms (Δt) was measured at each visit in both groups. Maximum (ΔtMax) and minimum (ΔtMin) Δt for each eye as well as the amplitude of fluctuations (ampΔt) referred to as the difference between ΔtMax and ΔtMin were calculated for each eye. AmpΔt was compared between the groups.Results: in a total of 6 PS patients, B-scan ultrasonography revealed the thickening of the posterior sclera. Choroidal folds (n=4), internal limiting membrane fold (n=2), subretinal fluid (n=3), and optic disc edema (n=2) were identified by eye fundus exam. At presentation, Δt was maximum in all PS patients and reduced unequally after starting treatment. Mean ampΔt was 1.21 °C (1.47–1.04 °C) in PS group and 0.44 °C (0.13–0.63 °C) in the control group. 3 out 6 PS patients were diagnosed with recurrences as demonstrated by OST spikes compared to previous measurements.Conclusion: this article describes a novel technique of the measurement and monitoring of OST. It was demonstrated that PS is associated with the increase in OST measured by thermography. Further large-scale studies are needed to evaluate the potentialities of thermography for detecting occult or subclinical intraocular inflammation.Keywords: ocular thermography, posterior scleritis, ocular surface temperature, eye temperature, occult inflammation.For citation: Kawali A., Sanjay S., Mahendradas P., Shetty R. Thermography in posterior scleritis. Russian Journal of Clinical Ophthalmology. 2020;20(4):204–208. DOI: 10.32364/2311-7729-2020-20-4-204-208.

Posterior scleritis: Cause of diagnostic confusion

Posterior scleritis can occur in isolation or concomitantly with anterior scleritis. Some investigators include posterior scleritis as an anterior variant of inflammatory pseudotumor. The main clinical manifestations are pain, exophthalmia, decreased visual acuity, and occasionally, restricted ocular motility. Choroidal folds, exudative retinal detachment, papillary edema, and angle-closure glaucoma secondary to choroidal thickening may be observed. The diagnosis can be missed in the absence of associated anterior scleritis. Demonstration of thickened posterior sclera by echography, computed tomographic scan, or magnetic resonance imaging may be helpful in establishing the diagnosis. Often, no related systemic disease can be found in patients with posterior scleritis.

Choroidal Structural Changes in Sympathetic Ophthalmia on Swept-Source Optical Coherence Tomography

ABSTRACT Purpose: To analyze choroidal angioarchitecture in sympathetic ophthalmia (SO) using swept-source optical coherence tomography (SS-OCT) images. Methods: Case–control study of six patients with SO. Qualitative changes and quantitative parameters, including choroidal thickness (CT) and choroidal vascularity index (CVI), were analyzed. Results: Qualitative findings in the acute phase of SO on SS-OCT included retinal serous detachment with hyperreflective septa, choroidal folds, alterations in angioarchitecture with loss of vascular lacunae, and Dalen-Fuchs nodules. There was significantly higher CT in SO (284.05 ± 24.12 µm) compared to healthy controls (229.57 ± 46.67 µm, p = 0.04) and also increased CVI in SO (62.06 ± 2.07% vs 56.79 ± 3.15%, p = 0.006). Conclusions: CVI was significantly increased in SO, representing a novel noninvasive biomarker of disease activity. SS-OCT provides a useful qualitative and quantitative parameter, which can be potentially explored in the diagnosis and monitoring of patients with SO.

From international ophthalmology to space ophthalmology: the threats to vision on the way to Moon and Mars colonization.

To report the ophthalmological risks of space travel. The literature about the effect of microgravity and cosmic radiation on the human eye has been reviewed, focusing on the so-called "spaceflight related neuro-ocular syndrome (SANS)", and possible remedies. The eye is the major candidate to suffer from the adverse space conditions, so much so that SANS is the main concern of the National Aeronautics and Space Administration (NASA). SANS, that affects astronauts engaged in long-duration spaceflights, is characterized by optic nerve head swelling, flattening of the posterior region of the scleral shell, choroidal folds, retinal cotton wool spots, and hyperopic shift. Even if it seems related to an increased volume of the cerebrospinal fluid in the brain and the optic nerve sheaths, its pathogenesis is still unclear. In addition, cataract is related to the effect of galactic cosmic rays on the lens. Centrifuges, pressurizing chambers, and mechanical counter-pressure suits have been advanced to counteract the upward fluid shift responsible for the SANS syndrome. Shields with a high content of hydrogen, magnetic shielding systems, and wearable radiation shielding devices are under study to mitigate the exposure to galactic cosmic rays. Since 1961, the year of the first manned mission outside the Earth, history has shown that the human being may venture in space. Yet, visual impairment is the top health risk for long-duration spaceflight. Effective remediation is mandatory in anticipation of long space missions and Moon and Mars colonization.

Brain Physiological Response and Adaptation During Spaceflight.

More than half of astronauts returning from long-duration missions on the International Space Station present with neuro-ocular structural and/or functional changes, including optic disc edema, optic nerve sheath distension, globe flattening, choroidal folds, or hyperopic shifts. This spaceflight-associated neuro-ocular syndrome (SANS) represents a major risk to future exploration class human spaceflight missions, including Mars missions. Although the exact pathophysiology of SANS is unknown, evidence thus far suggests that an increase in intracranial pressure (ICP) relative to the upright position on Earth, which is due to the loss of hydrostatic pressure gradients in space, may play a leading role. This review focuses on brain physiology in the spaceflight environment, specifically on how spaceflight may affect ICP and related indicators of cranial compliance, potential factors related to the development of SANS, and findings from spaceflight as well as ground-based spaceflight analog research studies.

The escape of retrobulbar cerebrospinal fluid in the astronaut's eye: mission impossible?

Ophthalmic abnormalities including unilateral and bilateral optic disc edema, optic nerve sheath distention, globe flattening, choroidal folds, and hyperopic shifts have been observed in astronauts during and after long-duration spaceflight. An increased understanding of factors contributing to this syndrome, termed spaceflight-associated neuro-ocular syndrome, is currently a top priority for the ESA and NASA, especially since this medical obstacle could impact the visual health of astronauts as well as the success of future missions, including continued trips to the International Space Station, a return to the moon, or a future human mission to Mars. Currently, the exact mechanisms causing this neuro-ocular syndrome are not fully understood. In the present paper, we propose a hypothetical framework by which optic disc edema in astronauts may result, at least partly, from the forcing of perioptic cerebrospinal fluid into the optic nerve and optic disc along perivascular spaces surrounding the central retinal vessels, related to long-standing microgravity fluid shifts and variations in optic nerve sheath anatomy and compliance. Although this hypothesis remains speculative at the present time, future research in this area of investigation could not only provide exciting new insights into the mechanisms underlying microgravity-induced optic disc swelling but also offer opportunities to develop countermeasure strategies.

Optic Nerve Sheath Meningocele With Optic Disc Pit: A Rare Finding

A 13-year-old girl presented with complaints of painless, progressive protrusion of her left eye for last 2 years with mild visual blurring. She had 4 mm proptosis in her left eye with relative afferent pupillary defect. Visual acuity in the right eye was 20/20 and in the left eye was 20/25 on Snellens acuity testing. MRI revealed a well-circumscribed, cerebrospinal fluid signal intensity cystic lesion medial to the optic nerve (Figs. 1 and 2). Optic nerve sheath meningocele is a primary enlargement of the optic nerve sheath. Optic nerve sheath meningocele can present with progressive hyperopia and choroidal folds in middle-aged males. Proposed theories of pathophysiology of optic nerve sheath meningocele are either congenital narrowing of the optic/cranio-orbital junction causing cerebrospinal fluid accumulation in the perioptic subarachnoid space or a difference in osmotic gradient between the cerebral and perioptic subarachnoid space. The radiologic examination of choice is MRI with fat suppression which shows enlargement of the optic nerve sheath isointense with cerebrospinal fluid. There has been no consensus about management for these patients. Patients with progressive visual loss have been treated by optic nerve sheath fenestration leading to halting of the progression. Supplementary management with acetazolamide, especially in patients with associated increased intracranial pressure, is advisable. Our patient has no such complaints and is under periodic review.FIG. 1.: Clinical and investigational pictures of patient of optic nerve sheath meningocele with optic disc pit. Upper right Fundus photograph of left eye showing the posterior pole with a nasal optic disc pit with RNFL edema and radiating choroidal folds. Left Humphrey Visual Field of the left eye. Lower right Worm’s view external photograph of the patient.FIG. 2.: Clinical and investigational pictures of patient of optic nerve sheath meningocele with optic disc pit. A, T1-weighted image of axial MRI. B: T2-weighted fat-suppressed image showing intraconal cystic lesion medial to the optic nerve with similar signal intensity as cerebrospinal fluid. C, T2-weighted sagittal MRI.

Chorioretinal folds: a proposed diagnostic algorithm.

To create a diagnostic algorithm for the management of chorioretinal folds. We reviewed the existing literature about chorioretinal folds focusing our attention on three specific conditions and created a diagnostic algorithm in order to otpimize the choice and the number of investigations. Chorioretinal folds are visible striations of the fundus usually arranged in parallel lines and disposed horizontally. They may be either unilateral or bilateral, symptomatic or asymptomatic and are often associated with different possible ocular and extra ocular pathologies, including systemic diseases like autoimmune disorders and intracranial hypertension. They are named idiopathic when no apparent cause for their development is detectable. However, with improved diagnostic testing, the patients with idiopathic choroidal folds are likely to represent only a smaller portion of the total. Since choroidal folds be the sole sign of an underlying disease possibly requiring a multidisciplinary approach, an appropriate work-up varying according to the specific clinical features of each case is needed to define the etiology and the treatment. A diagnosting algorithm may be useful in order to optimize the diagnostic approach and management.

Optic Nerve Sheath Meningocele With Optic Disc Pit

A 13-year-old girl presented with complaints of painless, progressive protrusion of her left eye for last 2 years with mild visual blurring. She had 4 mm proptosis in her left eye with relative afferent pupillary defect. Visual acuity in the right eye was 20/20 and in the left eye was 20/25 on Snellens acuity testing. MRI revealed a well-circumscribed, cerebrospinal fluid signal intensity cystic lesion medial to the optic nerve (Figs. 1 and 2). Optic nerve sheath meningocele is a primary enlargement of the optic nerve sheath. Optic nerve sheath meningocele can present with progressive hyperopia and choroidal folds in middle-aged males. Proposed theories of pathophysiology of optic nerve sheath meningocele are either congenital narrowing of the optic/cranio-orbital junction causing cerebrospinal fluid accumulation in the perioptic subarachnoid space or a difference in osmotic gradient between the cerebral and perioptic subarachnoid space. The radiologic examination of choice is MRI with fat suppression which shows enlargement of the optic nerve sheath isointense with cerebrospinal fluid. There has been no consensus about management for these patients. Patients with progressive visual loss have been treated by optic nerve sheath fenestration leading to halting of the progression. Supplementary management with acetazolamide, especially in patients with associated increased intracranial pressure, is advisable. Our patient has no such complaints and is under periodic review.FIG. 1.: Clinical and investigational pictures of patient of optic nerve sheath meningocele with optic disc pit. Upper right Fundus photograph of left eye showing the posterior pole with a nasal optic disc pit with RNFL edema and radiating choroidal folds. Left Humphrey Visual Field of the left eye. Lower right Worm’s view external photograph of the patient.FIG. 2.: Clinical and investigational pictures of patient of optic nerve sheath meningocele with optic disc pit. A, T1-weighted image of axial MRI. B: T2-weighted fat-suppressed image showing intraconal cystic lesion medial to the optic nerve with similar signal intensity as cerebrospinal fluid. C, T2-weighted sagittal MRI.

An overview of spaceflight-associated neuro-ocular syndrome (SANS)

Over the last decade, the National Aeronautics and Space Administration's (NASA) Space Medicine Division has documented a variety of unusual physiological and pathological neuro-ophthalmic findings in astronauts during and following long duration space flight. These ndings include optic disc swelling, globe flattening, choroidal folds, and hyperopic shifts in refraction. Cephalad fluid shift has been proposed as a possible unifying etiology, but the specific mechanism responsible for these changes remains obscure. This manuscript reviews the history, clinical findings, and potential neurophysiological etiologies for spaceflight-associated neuro-ocular syndrome.

Spaceflight-related ocular changes: the potential role of genetics, and the potential of B vitamins as a countermeasure.

Within the last decade, it was realized that during and after long-duration spaceflight, some astronauts experience ophthalmic abnormalities including refractive changes, optic disc edema, globe flattening, choroidal folds, and cotton wool spots. Much research has been initiated and conducted, but little evidence is available to differentiate affected crewmembers. The first published data to distinguish between affected and nonaffected crewmembers identified biochemical differences in affected astronauts: one-carbon pathway metabolite concentrations were higher in these individuals than in nonaffected astronauts, even before flight. These data led to findings that genetics and B-vitamin status were predictors of the incidence of the ophthalmic abnormalities. A multihit hypothesis was developed, with genetics and B-vitamin status as two of several important elements that all contribute to endothelial dysfunction and ultimately to ophthalmic changes after flight. One of these contributing factors - response to carbon dioxide exposure - was recently documented to be affected by the same one-carbon pathway genetics. This line of research may help identify which astronauts are at risk of these ophthalmic changes, and allow targeted treatment. This research may have implications for clinical populations, including patients with polycystic ovary syndrome, that have similar biochemical, endocrine, and genetic characteristics, and it may shed light on why links between cardiovascular disease and the metabolites homocysteine and folate have been elusive and confounded.

PERIPAPILLARY PACHYCHOROID SYNDROME.

To describe the features of peripapillary pachychoroid syndrome (PPS), a novel pachychoroid disease spectrum (PDS) entity. Medical records of 31 eyes (16 patients) with choroidal thickening associated with intraretinal and/or subretinal fluid in the nasal macula extending from the disk were reviewed (patients with PPS). Choroidal thickness was compared with 2 age-matched cohorts: typical PDS (17 eyes with central serous chorioretinopathy or pachychoroid neovasculopathy) and 19 normal eyes. The patients with PPS were 81% men aged 71 ± 7 years. Peripapillary pachychoroid syndrome eyes displayed thicker nasal versus temporal macular choroids, unlike PDS eyes with thicker temporal macular choroids (P < 0.0001). Peripapillary intraretinal and/or subretinal fluid was often overlying dilated Haller layer vessels (pachyvessels). Fundus autofluorescence and fluorescein angiography illustrated peripapillary pigmentary mottling without focal leakage. Most PPS eyes (70%) exhibited other PDS findings including serous pigment epithelial detachment or gravitational tracks. Indocyanine green angiography illustrated dilated peripapillary pachyvessels and choroidal hyperpermeability. The disk was usually crowded, with edema noted in 4/31 (13%) eyes and mild late fluorescein disk leakage identified in half of the cases. Choroidal folds (77%), short axial lengths (39% less than 23 mm), and hyperopia (86%) were common. Peripapillary pachychoroid syndrome is a distinct PDS variant, in which peripapillary choroidal thickening is associated with nasal macular intraretinal and/or subretinal fluid and occasional disk edema. Recognition of PPS is important to distinguish it from disorders with overlapping features such as posterior uveitis and neuro-ophthalmologic conditions.

Microgravity-induced ocular changes are related to body weight.

On Earth, tissue weight generates compressive forces that press on body structures and act on the walls of vessels throughout the body. In microgravity, tissues no longer have weight, and tissue compressive forces are lost, suggesting that individuals who weigh more may show greater effects from microgravity exposure. One unique effect of long-duration microgravity exposure is spaceflight-associated neuroocular syndrome (SANS), which can present with globe flattening, choroidal folds, optic disk edema, and a hyperopic visual shift. To determine whether weight or other anthropometric measures are related to ocular changes in space, we analyzed data from 45 individual long-duration astronauts (mean age 47, 36 male, 9 female, mean mission duration 165 days) who had pre- and postflight measures of disk edema, choroidal folds, and manifest ocular refraction. The mean preflight weights of astronauts who developed new choroidal folds [78.6 kg with no new folds vs. 88.6 kg with new folds ( F = 6.2, P = 0.02)] and disk edema [79.1 kg with no edema vs. 95 kg with edema ( F = 9.6, P = 0.003)] were significantly greater than those who did not. Chest and waist circumferences were also significantly greater in those who developed folds or edema. The odds of developing disk edema or new choroidal folds were 55% in the highest- and 9% in the lowest-weight quartile. In this cohort, no women developed disk edema or choroidal folds, although women also weighed significantly less than men [62.9 vs. 85.2 kg ( F = 53.2, P < 0.0001)]. Preflight body weight and anthropometric factors may predict microgravity-induced ocular changes.

Space flight-associated neuro-ocular syndrome (SANS)

Interesting novel and somewhat perplexing physiologic and pathologic neuro-ocular findings have been documented in astronauts during and after long duration space flight (LDSF). These findings collectively have been termed the "space flight-associated neuro-ocular syndrome" (SANS). The National Aeronautics and Space Administration (NASA) in the United States has meticulously and prospectively documented the clinical, ultrasound, optical coherence tomography imaging, and radiographic findings of SANS including unilateral and bilateral optic disc edema, globe flattening, choroidal and retinal folds, hyperopic refractive error shifts, and nerve fiber layer infarcts (i.e., cotton wool spots). NASA and collaborating researchers continue to study SANS in preparation for future manned missions to space, including continued trips to the ISS, a return to the moon, or perhaps new voyages to the asteroid belt, or the planet, Mars.

Clinical profile of patients with posterior scleritis: A report from Eastern India.

Purpose:This study aimed to report the clinical profile of patients with posterior scleritis at a tertiary eye center in Eastern India.Methods:This was a single-center retrospective case series of patients who were diagnosed as posterior scleritis between January 2010 and December 2014, with a follow-up period of at least 6 months.Results:The study included 18 patients of posterior scleritis with a mean age of 41.2 ± 10.6 years (range: 26–63 years). With female preponderance (55.6%), majority of the posterior scleritis cases were unilateral (88.9%). Sixteen patients reported with diminution of vision, eleven patients (61.1%) had ocular pain on presentation, and five patients complained of headache. Concurrent anterior scleritis was found in three eyes (15%) with posterior scleritis. Choroidal folds and subretinal fluid at the posterior pole were the most common fundus findings and were seen in seven eyes (35%) each. No systemic association was detected in any patient even after extensive laboratory workup and multidisciplinary consultation. All patients received oral steroid, and 11 (61.1%) of them required intravenous pulse steroid therapy. Immunosuppressive was used in 6 (33.3%) patients, and oral azathioprine was the most common immunosuppressive used in the study. Recurrence was noted in eight eyes (40%). The mean best-corrected visual acuity improved to logarithm of the minimal angle of resolution (logMAR) 0.06 ± 0.051 at the final follow-up from 0.47 ± 0.45 logMAR at presentation (P = 0.00608).Conclusion:Posterior scleritis is relatively rare but can occur without systemic involvement. Aggressive immunomodulatory therapy is required to treat vision-threatening condition.

Simultaneous bilateral and unilateral recurrent posterior scleritis

Posterior scleritis is an ocular inflammatory disease that affects the sclera e whose diagnosis is difficult. The main clinical manifestations are worsening of visual quality, ocular pain and finding in the posterior segment, such as serous retinal detachment, choroidal folds, optic disc edema and sclera thickening. We should award for systemic findings, because it is often accompanied by rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease and infections, such as syphilis and tuberculosis.This paper aims to describe two cases: one [...]