- Email: [email protected]
Ultrasonographic documentation of a spontaneously resolved peripheral senescent retinoschisis
Correspondence This unique case demonstrated stable visual acuity 2 years after both standard and modified treatments of a juxtapapillary RCH. We shortened the interval between infusion and laser, and increased the laser exposure time. As well, we treated the lesion directly because its location did not allow for treatment of the feeder vessels. We altered the protocol, hypothesizing less collateral retinal and optic nerve damage. Few cases of PDT management of VHL juxtapapillary lesions have been documented. Treatment success using PDT for VHL may depend on the PDT protocol and the location of the RCH.
verteporfin and photodynamic therapy. Arch Ophthalmol 2005;123:328–32. 3. Singh AD, Nouri M, Shields CL, Shields JA, Perez N. Treatment of retinal capillary hemangioma. Ophthalmology 2002;109:1799–806. 4. Schmidt-Erfurth UM, Kusserow C, Barbazetto IA, Laqua H. Benefits and complications of photodynamic therapy of papillary capillary hemangiomas. Ophthalmology 2002;109:1256–66. 5. Atebara NH. Retinal capillary hemangioma treated with verteporfin photodynamic therapy. Am J Ophthalmol 2002;134:788–90.
Leah Wittenberg, Patrick Ma REFERENCES
University of British Columbia, Vancouver, B.C.
1. Gauthier D, D’Amico DJ, Mukai S. von Hippel-Lindau Disease. Int Ophthalmol Clin 2001;41:173–87. 2. Aaberg TM Jr, Aaberg TM Sr, Martin DF, Gilman JP, Myles R. Three cases of large retinal capillary hemangiomas treated with
Correspondence to Leah Wittenberg, MD: [email protected]
Ultrasonographic documentation of a spontaneously resolved peripheral senescent retinoschisis
The patient was re-evaluated twice over the next 14 months. Seven months after the initial evaluation, the schisis was noted to have reduced to approximately 8 mm in diameter and 2 mm in height (Fig. 2), and subjective peripheral visual complaints had resolved. Fourteen months after the initial evaluation, the schisis cavity was noted to have completely collapsed (Fig. 3), and the patient remained asymptomatic. Additionally, no posterior vitreous detachment was clinically apparent at that visit. Ultrasonographic documentation of the resolution of a senescent retinoschisis has not previously been reported in the literature. Spontaneous resolution of senescent (senile) retinoschisis has been documented since 19721 and has been reported to occur in up to 9% of cases.2 Resolution has been reported in both asymptomatic1 and symptomatic 3 patients, even in the presence of schisis detachments. Observation continues to be the clinical standard regarding follow-up of these patients, surgical intervention being used only for rare cases when the development of schisis detachment involves the macula.
A
73-year-old white man with type 2 diabetes, hypertension, and hyperlipidemia presented with a complaint of mild peripheral visual distortions in the right eye with no acute changes for approximately 1 month. Bestcorrected visual acuity remained 6/6 in both eyes with mild hypermetropic corrections. Entrance testing and anterior segment examination were remarkable only for longstanding heterochromia of the right iris. Fundus examination revealed a 10 mm diameter, 5 mm high, bullous elevation superotemporally in the right eye. The result of transverse B-scan ultrasonography at initial presentation is shown in Fig. 1. There were no inner or outer layer breaks noted at that time, and the eye was without posterior vitreous detachment or visible traction along the edge of the schisis cavity. Fundus examination of the left eye was unremarkable, and no diabetic retinopathy was present in either eye. The diagnosis of senescent retinoschisis without breaks or detachment was made at that time.
Fig. 1—Initial B-scan of senescent retinoschisis in patient’s right eye.
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CAN J OPHTHALMOL—VOL. 43, NO. 5, 2008
Can J Ophthalmol 2008;43:605–6 doi:10.3129/i08-105
Fig. 2—Intermediate B-scan of same retinoschisis 7 months later.
Correspondence reoretinal mechanical traction may provide the most complete explanation of spontaneous schisis resolution. The natural course for senescent retinoschisis appears to be benign—with or without spontaneous resolution—and, interestingly enough, will more often spontaneously resolve than advance to symptomatic schisis detachments.2 When spontaneous resolution does occur, it would appear that the time course for resolution of even large senescent retinoschises is approximately 1 year. REFERENCES
Fig. 3—Final B-scan of resolved retinoschisis after 14 months.
The etiology of this acquired form of retinoschisis is generally felt to be idiopathic. Histopathologically, the splitting of the sensory retina between the outer plexiform and inner nuclear layers appears to be the result of the formation of cystic cavities of hyaluronic acid.4 Coupled with vitreoretinal traction, the inertia from the movement of the intraretinal fluid can greatly enlarge the schisis cavity. The presence of inner or outer layer breaks may facilitate the initial introduction of fluid into the intraretinal spaces. The basis for spontaneous resolution of retinoschisis also remains obscure but has been posited to be related to a fluid-pumping mechanism of the retinal pigment epithelium to remove fluid from the intraretinal space.5 The combination of this biochemical mechanism with reduced vit-
A case of permanent retinal disturbance postpartum following administration of ergometrine
A
31-year-old woman was seen a day after normal delivery. She complained of persistent blurring below central fixation in the left eye. Symptoms were not accompanied by headache or focal neurology and began 4 hours after delivery. The patient recalled 5 identical scotomatous episodes, which had started 18 months previously. However, these episodes had completely resolved within 30 minutes. The patient had no other relevant medical history. Two uncomplicated vaginal deliveries were noted over 10 years previously. Pregnancy was unremarkable. The patient took only 400 μg folate daily. Spontaneous vaginal delivery was in the 41st week following 5 hours of labour. Only 500 μg ergometrine and 5 IU of syntocin were injected intramuscularly into the shoulder during delivery. On examination, pin-hole acuity was 6/12 bilaterally because of significant astigmatism. Amsler grid illustrated a scotoma below central fixation in the left eye. Fundal examination revealed an area of pallor and swelling superior to the fovea in the left eye in the domain of the cilioretinal artery (Fig. 1).
1. Byer N. Spontaneous regression of senile retinoschisis. Arch Ophthalmol 1972;88:207–9. 2. Buch H, Vinding T, Neilsen NV. Prevalence and long-term natural course of retinoschisis among elderly individuals: the Copenhagen City Eye Study. Ophthalmology 2007;114:751–5. 3. Durnian J, Pollock W, McLeod D. Spontaneous stabilisation of symptomatic schisis detachments. Br J Ophthalmol 2004;88:722–3. 4. Jones WL. Atlas of the Peripheral Ocular Fundus. Boston, Mass.: Butterworth-Heinemann; 1998:74. 5. Clare G, Sullivan P, Gregor Z. Spontaneous regression of degenerative retinoschisis associated with outer leaf retinal breaks. Retina 2005;25:1116–7.
Paul Varner John J. Pershing Veterans Affairs Medical Center, Poplar Bluff, Mo. Correspondence to Paul Varner, OD: [email protected] Can J Ophthalmol 2008;43:606–7 doi:10.3129/i08-093
Fluorescein angiogram showed normal filling of the cilioretinal artery. Hematology, thrombophilia screen, and lipid profile were normal. Electrocardiogram, echocardiogram, and carotid ultrasound were also unremarkable. No
Fig. 1—(A) Fundal photograph taken 1 week after initial symptoms, revealing an area of edema superior to the fovea in the cilioretinal artery territory. (B) Red-free photograph, highlighting pallor in retina supplied by the cilioretinal artery. (C, D) Fundal fluorescein angiography 1 week after initial symptoms, illustrating early and complete cilioretinal artery filling. CAN J OPHTHALMOL—VOL. 43, NO. 5, 2008
607
verteporfin and photodynamic therapy. Arch Ophthalmol 2005;123:328–32. 3. Singh AD, Nouri M, Shields CL, Shields JA, Perez N. Treatment of retinal capillary hemangioma. Ophthalmology 2002;109:1799–806. 4. Schmidt-Erfurth UM, Kusserow C, Barbazetto IA, Laqua H. Benefits and complications of photodynamic therapy of papillary capillary hemangiomas. Ophthalmology 2002;109:1256–66. 5. Atebara NH. Retinal capillary hemangioma treated with verteporfin photodynamic therapy. Am J Ophthalmol 2002;134:788–90.
Leah Wittenberg, Patrick Ma REFERENCES
University of British Columbia, Vancouver, B.C.
1. Gauthier D, D’Amico DJ, Mukai S. von Hippel-Lindau Disease. Int Ophthalmol Clin 2001;41:173–87. 2. Aaberg TM Jr, Aaberg TM Sr, Martin DF, Gilman JP, Myles R. Three cases of large retinal capillary hemangiomas treated with
Correspondence to Leah Wittenberg, MD: [email protected]
Ultrasonographic documentation of a spontaneously resolved peripheral senescent retinoschisis
The patient was re-evaluated twice over the next 14 months. Seven months after the initial evaluation, the schisis was noted to have reduced to approximately 8 mm in diameter and 2 mm in height (Fig. 2), and subjective peripheral visual complaints had resolved. Fourteen months after the initial evaluation, the schisis cavity was noted to have completely collapsed (Fig. 3), and the patient remained asymptomatic. Additionally, no posterior vitreous detachment was clinically apparent at that visit. Ultrasonographic documentation of the resolution of a senescent retinoschisis has not previously been reported in the literature. Spontaneous resolution of senescent (senile) retinoschisis has been documented since 19721 and has been reported to occur in up to 9% of cases.2 Resolution has been reported in both asymptomatic1 and symptomatic 3 patients, even in the presence of schisis detachments. Observation continues to be the clinical standard regarding follow-up of these patients, surgical intervention being used only for rare cases when the development of schisis detachment involves the macula.
A
73-year-old white man with type 2 diabetes, hypertension, and hyperlipidemia presented with a complaint of mild peripheral visual distortions in the right eye with no acute changes for approximately 1 month. Bestcorrected visual acuity remained 6/6 in both eyes with mild hypermetropic corrections. Entrance testing and anterior segment examination were remarkable only for longstanding heterochromia of the right iris. Fundus examination revealed a 10 mm diameter, 5 mm high, bullous elevation superotemporally in the right eye. The result of transverse B-scan ultrasonography at initial presentation is shown in Fig. 1. There were no inner or outer layer breaks noted at that time, and the eye was without posterior vitreous detachment or visible traction along the edge of the schisis cavity. Fundus examination of the left eye was unremarkable, and no diabetic retinopathy was present in either eye. The diagnosis of senescent retinoschisis without breaks or detachment was made at that time.
Fig. 1—Initial B-scan of senescent retinoschisis in patient’s right eye.
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CAN J OPHTHALMOL—VOL. 43, NO. 5, 2008
Can J Ophthalmol 2008;43:605–6 doi:10.3129/i08-105
Fig. 2—Intermediate B-scan of same retinoschisis 7 months later.
Correspondence reoretinal mechanical traction may provide the most complete explanation of spontaneous schisis resolution. The natural course for senescent retinoschisis appears to be benign—with or without spontaneous resolution—and, interestingly enough, will more often spontaneously resolve than advance to symptomatic schisis detachments.2 When spontaneous resolution does occur, it would appear that the time course for resolution of even large senescent retinoschises is approximately 1 year. REFERENCES
Fig. 3—Final B-scan of resolved retinoschisis after 14 months.
The etiology of this acquired form of retinoschisis is generally felt to be idiopathic. Histopathologically, the splitting of the sensory retina between the outer plexiform and inner nuclear layers appears to be the result of the formation of cystic cavities of hyaluronic acid.4 Coupled with vitreoretinal traction, the inertia from the movement of the intraretinal fluid can greatly enlarge the schisis cavity. The presence of inner or outer layer breaks may facilitate the initial introduction of fluid into the intraretinal spaces. The basis for spontaneous resolution of retinoschisis also remains obscure but has been posited to be related to a fluid-pumping mechanism of the retinal pigment epithelium to remove fluid from the intraretinal space.5 The combination of this biochemical mechanism with reduced vit-
A case of permanent retinal disturbance postpartum following administration of ergometrine
A
31-year-old woman was seen a day after normal delivery. She complained of persistent blurring below central fixation in the left eye. Symptoms were not accompanied by headache or focal neurology and began 4 hours after delivery. The patient recalled 5 identical scotomatous episodes, which had started 18 months previously. However, these episodes had completely resolved within 30 minutes. The patient had no other relevant medical history. Two uncomplicated vaginal deliveries were noted over 10 years previously. Pregnancy was unremarkable. The patient took only 400 μg folate daily. Spontaneous vaginal delivery was in the 41st week following 5 hours of labour. Only 500 μg ergometrine and 5 IU of syntocin were injected intramuscularly into the shoulder during delivery. On examination, pin-hole acuity was 6/12 bilaterally because of significant astigmatism. Amsler grid illustrated a scotoma below central fixation in the left eye. Fundal examination revealed an area of pallor and swelling superior to the fovea in the left eye in the domain of the cilioretinal artery (Fig. 1).
1. Byer N. Spontaneous regression of senile retinoschisis. Arch Ophthalmol 1972;88:207–9. 2. Buch H, Vinding T, Neilsen NV. Prevalence and long-term natural course of retinoschisis among elderly individuals: the Copenhagen City Eye Study. Ophthalmology 2007;114:751–5. 3. Durnian J, Pollock W, McLeod D. Spontaneous stabilisation of symptomatic schisis detachments. Br J Ophthalmol 2004;88:722–3. 4. Jones WL. Atlas of the Peripheral Ocular Fundus. Boston, Mass.: Butterworth-Heinemann; 1998:74. 5. Clare G, Sullivan P, Gregor Z. Spontaneous regression of degenerative retinoschisis associated with outer leaf retinal breaks. Retina 2005;25:1116–7.
Paul Varner John J. Pershing Veterans Affairs Medical Center, Poplar Bluff, Mo. Correspondence to Paul Varner, OD: [email protected] Can J Ophthalmol 2008;43:606–7 doi:10.3129/i08-093
Fluorescein angiogram showed normal filling of the cilioretinal artery. Hematology, thrombophilia screen, and lipid profile were normal. Electrocardiogram, echocardiogram, and carotid ultrasound were also unremarkable. No
Fig. 1—(A) Fundal photograph taken 1 week after initial symptoms, revealing an area of edema superior to the fovea in the cilioretinal artery territory. (B) Red-free photograph, highlighting pallor in retina supplied by the cilioretinal artery. (C, D) Fundal fluorescein angiography 1 week after initial symptoms, illustrating early and complete cilioretinal artery filling. CAN J OPHTHALMOL—VOL. 43, NO. 5, 2008
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