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Central Serous Retinopathy in a 7-Year-Old Girl
VOL. 90, NO. 6
NOTES, CASES, INSTRUMENTS
Most conjunctival adrenochrome deposits are encapsulated by squamous epithelium. 21 The offending adrenochrome deposit in this case was not completely covered, allowing the initial nidus of adrenochrome to increase in size with continuing direct exposure to epinephrine. The upper tarsus is the second most common site of adrenochrome deposits. 10 In this case, its juxtaposition to the superotemporal corneal erosion and the erosion's rapid resolution after removal of the adrenochrome strongly suggests a causal relationship. Ophthalmologists should consider the possibility of an exposed adrenochrome deposit in patients taking glaucoma medications who have a corneal foreign-body sensation or corneal erosion. SUMMARY
A 64-year-old man with open-angle glaucoma had used topically applied epinephrine for 13 years. He developed a foreign-body sensation and persistent superotemporal corneal erosion as a result of an adrenochrome deposit on the upper tarsus. Removal of the deposit ended the corneal erosion and returned visual acuity to normal.
871
tation deposits from topically administered epinephrine. Arch. Ophthalmol. 82:836, 1969. 9. Green, W. R, Kaufer, G. J., and Dubroff, S.: Black cornea. A complication of topical use of epinephrine. Ophthalmologica 154:88, 1967. 10. Mooney, D.: Pigmentation after long term topical use ofadrenaline compounds. Br. J. Ophthalmol. 54:823, 1970. 11. Lowenstein, H.: Kiinstliche Hervorrufung melanotischer Geschwiilstchen in der Bindehaut. Ber. Zusammenkunft Dtsch. Ophthalmol. Ges. 46:439, 1927. 12. Giles, C. L.: Glaucoma and conjunctival foreign bodies. Mich. Med. 65:183, 1966. 13. Schmitt, H., and Remler, 0.: Adrenochrome Bindehauteinschliisse als Folge einer ortlichen Adrenalintherapie. Klin. Monatsbl. Augenheilkd. 165:332, 1974. 14. Sugar, J.: Adrenochrome pigmentation of hydrophilic lenses. Arch. Ophthalmol. 91:11, 1974. 15. Miller, D., Brooks, S. M., and Mobilia, E.: Adrenochrome staining of soft contact lenses. Ann. Ophthalmol, 8:65, 1976. 16. Ferry, J. F.: Black prosthesis. A complication of the topical use of epinephrine. Am. J. Ophthalmol. 64:162, 1967. 17. Romano, A., Barishak, R, and Stein, R: Obstruction of lacrimal puncta caused by topical epinephrine. Ophthalmologica 166:301, 1973. 18. Spaeth, G. L.: Nasolacrimal duct obstruction caused by topical epinephrine. Arch. Ophthalmol. 77:355, 1967. 19. Nicolaus, R A.: Melanins. Paris, Hermann Press, 1968, p. 206. 20. Heacock, R A., and Powell, W. S.: Adrenochrome and related compounds. Prog. Med. Chern. 9:275, 1972. 21. Corwin, M. E., and Spencer, W. H.: Conjunctival melanin deposits. A side effect of topical epinephrine therapy. Arch. Ophthalmol. 69:317, 1963.
REFERENCES 1. Drance, S. M., and Ross, R A.: The ocular effects of epinephrine. Surv. Ophthalmol. 14:330, 1970. 2. Spiers, F., and Eldrup-jorgensen, P.: External side effects of Eppy. Trans. Ophthalmol. Soc. U.K. 86:255, 1966. 3. Davidson, S. I.: Systemic effects of eye drops. Trans. Ophthalmol. Soc. U.K. 94:487, 1974. 4. Calmettes, L., Deodati, F., and Bechac, G.: Pigmentation corneennee par Ie bitartrate d'epinephrine. Arch. Ophtalmol. 28:303, 1968. 5. McCarthy, R W., and Leblanc, R: A "black cornea" secondary to topical epinephrine. Can. J. Ophthalmol. 11:336, 1976. 6. Reinecke, R D., and Kuwabara, T.: Corneal deposits secondary to topical epinephrine. Arch. Ophthalmol. 70:170, 1963. 7. Donaldson, D. D.: Epinephrine pigmentation of the cornea. Arch. Ophthalmol. 78:74, 1967. 8. Krejci, L., and Harrison, R: Corneal pigmen-
CENTRAL SEROUS RETINOPATHY IN A 7-YEAR-OLD GIRL STUART L. FINE, M.D" AND SARAH L. OWENS, B.S,
Baltimore, Maryland
Central serous retinopathy typically begins with the sudden onset of mild From the Retinal Vascular Center, Wilmer Ophthalmological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland. Reprint requests to Stuart L. Fine, M. D., Retinal Vascular Center, Wilmer Ophthalmological Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21205.
872
AMERICAN JOURNAL OF OPHTHALMOLOGY
DECEMBER, 1980
Resolution of the serous retinal detachment generally occurs in one to several months. Applying argon laser photocoagulation to the focal area or areas of leakage demonstrated on the angiogram may hasten resolution.P" Whereas most patients with central serous retinopathy are 20 to 45 years old, we recently studied a 7-year-old girl with this condition. CASE REPORT
Fig. 1 (Fine and Owens). Right eye. Serous detachment of sensory retina at initial examination. Visual acuity was 3/60 (10/200).
visual loss and metamorphopsia. 1,2 Visual acuity in the affected eye may be reduced 1 or more lines on the Snellen chart, and the patient almost always sees distortion of the parallel lines of the Amsler grid. The diagnosis is based on a serous detachment of the sensory retina and confirmed with fluorescein angiography, which shows early-phase focal dye leakage and late-phase dye pooling under the sensory retina.
A 7-year old girl had been treated for intermittent extropia since January 1978. Visual acuity had been recorded at 6n.5 (20/25) in each eye. On Sept. 7, 1979, she complained of reduced visual acuity in the right eye. An ophthalmologist in the local emergency room found that visual acuity was R. E.: 6/60 (20/200) and L. E.: 6/6 (20/20). He also noted a macular lesion in the right eye. She was referred here. On Sept. 11, 1979, visual acuity was R.E.: 3/60 (10/200), and L. E.: 6/6 (20/20). Neither pinhole nor refraction techniques could improve the visual acuity. The only ocular abnormality found was a serous detachment of the sensory retina, 3 disk diameters in size, in the right eye (Fig. 1). Fluorescein angiography showed many areas of early-phase focal leakage through the retinal pigment epithelium and late-phase pooling of dye under the sensory retina (Fig. 2). There was no suggestion of a choroidal neovascular membrane. The angiogram of the left macula was normal. No specific treatment was recommended. Two weeks later, visual acuity had improved to 6/12 (20/40), and there was significant reabsorption of
Fig. 2 (Fine and Owens). Right macula. Left, Early phase shows many areas of foca1 dye leakage through retinal pigment epithelium. Right, Late phase shows pooling of dye under sensory retina.
VOL. 90, NO. 6
NOTES, CASES, INSTRUMENTS
873
afebrile. Additionally, there were no other findings in either eye suggesting intraocular or extraocular inflammation. Because of the unusual features in this patient, she was examined at two-week intervals until the sensory retinal detachment completely resolved. Although these features were unusual for a 7-year-old patient, the typical ophthalmoscopic appearance and the prompt resolution of the sensory retinal detachment led us to conclude that this was central serous retinopathy. Fig. 3 (Fine and Owens). Right eye, one month after initial examination, has subtle retinal pigment epithelial transmission defects in area of previous sensory retinal detachment. the subrefinal fluid. Two weeks later (one month after the initial examination) visual acuity remained 6/12 (20/40) and no subretinal fluid was visible on biomicroscopic examination of the macula. The pigment epithelium in the macula appeared mottled, however, in the area corresponding to the previous serous detachment. Fluorescein angiography at this time showed only subtle retinal pigment epithelial transmission defects through the area of the previous sensory retinal detachment (Fig. 3). Two months after the initial examination, visual acuity had returned to 617.5 (20/25) and the sensory retina was flat. DISCUSSION
There were two unusual features to this case. The first was the patient's age. The second was the angiographic finding of many areas of focal dye leakage through the retinal pigment epithelium. Because of these unusual features, we considered the possibility of a focal choroiditis, possibly related to a pre-existing or coexisting viral infection. There was no history of a preceding upper respiratory infection or other systemic disease, and the patient was otherwise well and
SUMMARY
A 7-year-old girl experienced sudden loss of central visual acuity in one eye. Ophthalmoscopy disclosed a serous detachment of the sensory retina, and fluorescein angiography showed many areas of focal dye leakage through the pigment epithelium. Visual acuity returned to 617.5 (20/25), and the subretinal fluid was reabsorbed completely over the next two months. To our knowledge, this is the youngest patient with central serous retinopathy ever described. REFERENCES 1. Gass, J.: Stereoscopic Atlas of the Macula, 2nd ed. 51. Louis, C. V. Mosby Co., 1976. 2. Lewis, M.: Idiopathic serous detachment of the retinal pigment epithelium. Arch. Ophthalmol. 96:620, 1978. 3. Klein, M., Van Buskirk, M., Friedman, E., Gragoudas, E., and Chandra, 5.: Experience with non-treatment of central serous retinopathy. Arch. Ophthalmol. 91:247, 1974. 4. Watzke, R.: Ruby laser photocoagulation therapy of central serous retinopathy. Trans. Am. Acad. Ophthalmol. Otolaryngol. 78:205, 1974. 5. Leaver, P., and Williams, C.: Argon laser photocoagulation in the treatment of central serous retinopathy. Br. J. Ophthalmol. 63:674, 1979.
NOTES, CASES, INSTRUMENTS
Most conjunctival adrenochrome deposits are encapsulated by squamous epithelium. 21 The offending adrenochrome deposit in this case was not completely covered, allowing the initial nidus of adrenochrome to increase in size with continuing direct exposure to epinephrine. The upper tarsus is the second most common site of adrenochrome deposits. 10 In this case, its juxtaposition to the superotemporal corneal erosion and the erosion's rapid resolution after removal of the adrenochrome strongly suggests a causal relationship. Ophthalmologists should consider the possibility of an exposed adrenochrome deposit in patients taking glaucoma medications who have a corneal foreign-body sensation or corneal erosion. SUMMARY
A 64-year-old man with open-angle glaucoma had used topically applied epinephrine for 13 years. He developed a foreign-body sensation and persistent superotemporal corneal erosion as a result of an adrenochrome deposit on the upper tarsus. Removal of the deposit ended the corneal erosion and returned visual acuity to normal.
871
tation deposits from topically administered epinephrine. Arch. Ophthalmol. 82:836, 1969. 9. Green, W. R, Kaufer, G. J., and Dubroff, S.: Black cornea. A complication of topical use of epinephrine. Ophthalmologica 154:88, 1967. 10. Mooney, D.: Pigmentation after long term topical use ofadrenaline compounds. Br. J. Ophthalmol. 54:823, 1970. 11. Lowenstein, H.: Kiinstliche Hervorrufung melanotischer Geschwiilstchen in der Bindehaut. Ber. Zusammenkunft Dtsch. Ophthalmol. Ges. 46:439, 1927. 12. Giles, C. L.: Glaucoma and conjunctival foreign bodies. Mich. Med. 65:183, 1966. 13. Schmitt, H., and Remler, 0.: Adrenochrome Bindehauteinschliisse als Folge einer ortlichen Adrenalintherapie. Klin. Monatsbl. Augenheilkd. 165:332, 1974. 14. Sugar, J.: Adrenochrome pigmentation of hydrophilic lenses. Arch. Ophthalmol. 91:11, 1974. 15. Miller, D., Brooks, S. M., and Mobilia, E.: Adrenochrome staining of soft contact lenses. Ann. Ophthalmol, 8:65, 1976. 16. Ferry, J. F.: Black prosthesis. A complication of the topical use of epinephrine. Am. J. Ophthalmol. 64:162, 1967. 17. Romano, A., Barishak, R, and Stein, R: Obstruction of lacrimal puncta caused by topical epinephrine. Ophthalmologica 166:301, 1973. 18. Spaeth, G. L.: Nasolacrimal duct obstruction caused by topical epinephrine. Arch. Ophthalmol. 77:355, 1967. 19. Nicolaus, R A.: Melanins. Paris, Hermann Press, 1968, p. 206. 20. Heacock, R A., and Powell, W. S.: Adrenochrome and related compounds. Prog. Med. Chern. 9:275, 1972. 21. Corwin, M. E., and Spencer, W. H.: Conjunctival melanin deposits. A side effect of topical epinephrine therapy. Arch. Ophthalmol. 69:317, 1963.
REFERENCES 1. Drance, S. M., and Ross, R A.: The ocular effects of epinephrine. Surv. Ophthalmol. 14:330, 1970. 2. Spiers, F., and Eldrup-jorgensen, P.: External side effects of Eppy. Trans. Ophthalmol. Soc. U.K. 86:255, 1966. 3. Davidson, S. I.: Systemic effects of eye drops. Trans. Ophthalmol. Soc. U.K. 94:487, 1974. 4. Calmettes, L., Deodati, F., and Bechac, G.: Pigmentation corneennee par Ie bitartrate d'epinephrine. Arch. Ophtalmol. 28:303, 1968. 5. McCarthy, R W., and Leblanc, R: A "black cornea" secondary to topical epinephrine. Can. J. Ophthalmol. 11:336, 1976. 6. Reinecke, R D., and Kuwabara, T.: Corneal deposits secondary to topical epinephrine. Arch. Ophthalmol. 70:170, 1963. 7. Donaldson, D. D.: Epinephrine pigmentation of the cornea. Arch. Ophthalmol. 78:74, 1967. 8. Krejci, L., and Harrison, R: Corneal pigmen-
CENTRAL SEROUS RETINOPATHY IN A 7-YEAR-OLD GIRL STUART L. FINE, M.D" AND SARAH L. OWENS, B.S,
Baltimore, Maryland
Central serous retinopathy typically begins with the sudden onset of mild From the Retinal Vascular Center, Wilmer Ophthalmological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland. Reprint requests to Stuart L. Fine, M. D., Retinal Vascular Center, Wilmer Ophthalmological Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe St., Baltimore, MD 21205.
872
AMERICAN JOURNAL OF OPHTHALMOLOGY
DECEMBER, 1980
Resolution of the serous retinal detachment generally occurs in one to several months. Applying argon laser photocoagulation to the focal area or areas of leakage demonstrated on the angiogram may hasten resolution.P" Whereas most patients with central serous retinopathy are 20 to 45 years old, we recently studied a 7-year-old girl with this condition. CASE REPORT
Fig. 1 (Fine and Owens). Right eye. Serous detachment of sensory retina at initial examination. Visual acuity was 3/60 (10/200).
visual loss and metamorphopsia. 1,2 Visual acuity in the affected eye may be reduced 1 or more lines on the Snellen chart, and the patient almost always sees distortion of the parallel lines of the Amsler grid. The diagnosis is based on a serous detachment of the sensory retina and confirmed with fluorescein angiography, which shows early-phase focal dye leakage and late-phase dye pooling under the sensory retina.
A 7-year old girl had been treated for intermittent extropia since January 1978. Visual acuity had been recorded at 6n.5 (20/25) in each eye. On Sept. 7, 1979, she complained of reduced visual acuity in the right eye. An ophthalmologist in the local emergency room found that visual acuity was R. E.: 6/60 (20/200) and L. E.: 6/6 (20/20). He also noted a macular lesion in the right eye. She was referred here. On Sept. 11, 1979, visual acuity was R.E.: 3/60 (10/200), and L. E.: 6/6 (20/20). Neither pinhole nor refraction techniques could improve the visual acuity. The only ocular abnormality found was a serous detachment of the sensory retina, 3 disk diameters in size, in the right eye (Fig. 1). Fluorescein angiography showed many areas of early-phase focal leakage through the retinal pigment epithelium and late-phase pooling of dye under the sensory retina (Fig. 2). There was no suggestion of a choroidal neovascular membrane. The angiogram of the left macula was normal. No specific treatment was recommended. Two weeks later, visual acuity had improved to 6/12 (20/40), and there was significant reabsorption of
Fig. 2 (Fine and Owens). Right macula. Left, Early phase shows many areas of foca1 dye leakage through retinal pigment epithelium. Right, Late phase shows pooling of dye under sensory retina.
VOL. 90, NO. 6
NOTES, CASES, INSTRUMENTS
873
afebrile. Additionally, there were no other findings in either eye suggesting intraocular or extraocular inflammation. Because of the unusual features in this patient, she was examined at two-week intervals until the sensory retinal detachment completely resolved. Although these features were unusual for a 7-year-old patient, the typical ophthalmoscopic appearance and the prompt resolution of the sensory retinal detachment led us to conclude that this was central serous retinopathy. Fig. 3 (Fine and Owens). Right eye, one month after initial examination, has subtle retinal pigment epithelial transmission defects in area of previous sensory retinal detachment. the subrefinal fluid. Two weeks later (one month after the initial examination) visual acuity remained 6/12 (20/40) and no subretinal fluid was visible on biomicroscopic examination of the macula. The pigment epithelium in the macula appeared mottled, however, in the area corresponding to the previous serous detachment. Fluorescein angiography at this time showed only subtle retinal pigment epithelial transmission defects through the area of the previous sensory retinal detachment (Fig. 3). Two months after the initial examination, visual acuity had returned to 617.5 (20/25) and the sensory retina was flat. DISCUSSION
There were two unusual features to this case. The first was the patient's age. The second was the angiographic finding of many areas of focal dye leakage through the retinal pigment epithelium. Because of these unusual features, we considered the possibility of a focal choroiditis, possibly related to a pre-existing or coexisting viral infection. There was no history of a preceding upper respiratory infection or other systemic disease, and the patient was otherwise well and
SUMMARY
A 7-year-old girl experienced sudden loss of central visual acuity in one eye. Ophthalmoscopy disclosed a serous detachment of the sensory retina, and fluorescein angiography showed many areas of focal dye leakage through the pigment epithelium. Visual acuity returned to 617.5 (20/25), and the subretinal fluid was reabsorbed completely over the next two months. To our knowledge, this is the youngest patient with central serous retinopathy ever described. REFERENCES 1. Gass, J.: Stereoscopic Atlas of the Macula, 2nd ed. 51. Louis, C. V. Mosby Co., 1976. 2. Lewis, M.: Idiopathic serous detachment of the retinal pigment epithelium. Arch. Ophthalmol. 96:620, 1978. 3. Klein, M., Van Buskirk, M., Friedman, E., Gragoudas, E., and Chandra, 5.: Experience with non-treatment of central serous retinopathy. Arch. Ophthalmol. 91:247, 1974. 4. Watzke, R.: Ruby laser photocoagulation therapy of central serous retinopathy. Trans. Am. Acad. Ophthalmol. Otolaryngol. 78:205, 1974. 5. Leaver, P., and Williams, C.: Argon laser photocoagulation in the treatment of central serous retinopathy. Br. J. Ophthalmol. 63:674, 1979.