Diagnosis of Serous Neuroretinal Detachments of the Macula in Severe Preeclamptic Patients with Optical Coherence Tomography

Objective: Visual symptoms are common in patients with preeclampsia, and are caused by various underlying pathological changes in the retina. Blurred vision may be one of these symptoms. We describe three cases in which the underlying retinal pathology of blurred vision was clarified using optical coherence tomography (OCT), a novel, non-invasive ophthalmic imaging technique that provides micrometer-scale resolution images of the human retina. Methods: Three patients with preeclampsia complained of blurred vision postpartum. In all cases, ophthalmoscopy was performed at the bedside, followed by the assessment of best corrected visual acuity, slit-lamp biomicroscopy, fluorescein angiography (FLA), and OCT. In all cases, the presence of central visual defects was examined by an Amsler-grid. Results: In one case, the symptoms were bilateral. In all affected eyes, the patients complained of a relative central scotoma. Ophthalmoscopy showed edema in the affected maculae, while OCT examination clarified a serous neurosensory detachment of the macula. In one case, a neurosensory detachment was also detected in the papillomacular region of a fellow eye with no symptoms. In two cases, FLA was performed, but only in one case could we detect late leakage and subretinal exudates. The serous detachments observed showed total resolution in all cases within 5 to 10 weeks, with restoration of visual acuity. Conclusion: In patients with preeclampsia, OCT may provide a useful method for the precise assessment of retinal changes, distinguishing retinal edema from serous neurosensory detachments. This finding may help to clarify the pathophysiological circulatory changes seen in preeclampsia.     

Third nerve palsy and serous retinal detachment with preeclampsia.

Visual disturbances occur more frequently during preeclampsia than during pregnancy in general, but visual disturbances due to cranial nerve palsy are rare. We present the case of a 35-year-old preeclamptic woman with left third nerve palsy and left serous retinal detachment. The patient complained of visual disturbance and double vision soon after cesarean section. Left third nerve palsy and left serous retinal detachment were diagnosed by urgent ophthalmologic evaluation. Aneurysm and organic brain lesion were ruled out by diagnostic imaging. By 2 months postpartum, the visual disturbance had improved spontaneously.     

Plenary Sessions

Visual disturbances occur more frequently during preeclampsia than during pregnancy in general, but visual disturbances due to cranial nerve palsy are rare. We present the case of a 35-year-old preeclamptic woman with left third nerve palsy and left serous retinal detachment. The patient complained of visual disturbance and double vision soon after cesarean section. Left third nerve palsy and left serous retinal detachment were diagnosed by urgent ophthalmologic evaluation. Aneurysm and organic brain lesion were ruled out by diagnostic imaging. By 2 months postpartum, the visual disturbance had improved spontaneously.     

Visual disturbances in (pre)eclampsia

This review aims to summarize existing information concerning visual disturbances in (pre) eclampsia that have been described in the literature. Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality worldwide. Visual disturbances in (pre)eclampsia seem to be frequent phenomena. Therefore, the obstetrician/gynecologist may encounter women with serious, and sometimes debilitating, pathology of the visual pathways. Established ophthalmic entities associated with (pre)eclampsia are cortical blindness, serous retinal detachment, Purtscher-like retinopathy, central retinal vein occlusions, and retinal or vitreous hemorrhages. Ensuing visual symptoms include blurry vision, diplopia, amaurosis fugax, photopsia, and scotomata, including homonymous hemianopsia. In general, aside from lowering the blood pressure and preventing (further) seizures with magnesium sulfate, no specific therapy seems indicated for (pre)eclamptic women who experience visual changes. Although in most cases visual acuity returns to normal within weeks to months after the onset of symptoms, rarely permanent visual impairment can occur. Health care providers such as emergency room physicians, obstetricians, family physicians, neurologists, and ophthalmologists should be aware that acute onset of visual symptoms in pregnant women can be the first sign of (pre)eclampsia. Given that visual changes are a diagnostic criterion for severe preeclampsia, obstetricians should appreciate the significance of these changes and discuss appropriate diagnostic options with the ophthalmologist. Affected women can be reassured that most cases are transient. TARGET AUDIENCE: Obstetricians and gynecologists, ophthalmologists, neurologists, family physicians, emergency room physicians LEARNING OBJECTIVES: After completing this CME activity, obstetricians and gynecologists should be better able to classify visual disturbances at an early stage during pregnancy, interpret acute onset of visual disturbances as the first sign of preeclampsia, and evaluate possible residual visual symptoms during follow-up.     

Bilateral serous retinal detachment as a complication of acquired peripartum thrombotic thrombocytopenic purpura bout

We report a case of a 26-year-old primigravid woman, believed to have HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome, which turned out to be a thrombotic thrombocytopenic purpura (TTP) bout. At the 40th gestational week, based on the clinical picture of HELLP syndrome, a cesarean section was performed and a dysmature male newborn was delivered. Afterwards, clinical symptoms and laboratory abnormalities persisted. Severe ADAMTS13 deficiency with the presence of inhibitory anti-ADAMTS13 antibodies revealed acquired thrombotic thrombocytopenic purpura bout, which was complicated with bilateral vision decrease due to bilateral retinal detachment. At the first ophthalmological examination, ultrasonography and binocular indirect ophthalmoscopy confirmed the diagnosis of the serous retinal detachment. After the diagnosis of acquired TTP bout, the patient was treated with multiple plasmapheresis and intravenous immunoglobulin with rapid improvement of the clinical and laboratory parameters. The ophthalmologic complications disappeared later without sequelae. At the 18-month examination, substantial visual acuity improvement without serous retinal detachment and full best corrected visual acuity were observed.     

Headache in late pregnancy: a symptom for Vogt–Koyanagi–Harada disease

Headache in late pregnancy is warning of the presence of severe and/or lethal disorders. Here, we present a case of Vogt–Koyanagi–Harada disease (VKH), in which headache was the preceding and predominant symptom. At 37 weeks of pregnancy, a Japanese 1-para woman with an uneventful pregnancy complained of severe headache and then blurred vision. Although we initially diagnosed this condition as pregnancy-associated retinal detachment, headache and blurred vision persisted after delivery. Eye anterior segment lesions appeared and VKH disease was diagnosed, with systemic steroid administration completely ameliorating both the headache and visual disturbance. Obstetricians must be aware that headache may be the first sign of VKH disease.     

Bilateral exudative retinal detachment in a patient with early onset severe preeclampsia

This article describes a rare case of early onset severe preeclampsia presenting with loss of vision in both eyes due to retinal detachment. Retinal detachment has been mainly reported in late onset preeclampsia unlike in this case. Though, some authors believe that occurrence of maternal retinal detachment in cases of preeclampsia has no prognostic implication to the fetus, in this case, presence of retinal detachment was associated with foetal demise.     

Progressive outer retinal necrosis syndrome as an early manifestation of human immunodeficiency virus infection.

Progressive outer retinal necrosis syndrome is a recently recognized variant of necrotizing herpetic retinopathy, developing in patients with acquired immune deficiency syndrome (AIDS) or other conditions causing immune compromise. We report a case in which the diagnosis of retinal necrosis syndrome was made before the diagnosis of AIDS was confirmed. A 41-year-old man presented with a 1-month history of blurred vision in his left eye. Ophthalmologic examination revealed extensive retinal necrosis with total retinal detachment in his left eye and multifocal deep retinal lesions scattered in the posterior fundus as well as in the peripheral retina in his right eye. The serologic test for human immunodeficiency virus (HIV) was positive. Despite intravenous acyclovir treatment for 1 week, the lesions in the right eye showed rapid progression. High doses of intravitreal ganciclovir were then given in addition to intravenous acyclovir. After combined treatment for 1 month, the lesions became quiescent and the visual acuity improved to 20/30. Although the patient soon developed full-blown AIDS, the vision in his right eye remained undisturbed. Physicians should suspect progressive outer retinal necrosis syndrome in any patient with rapidly progressive necrotizing retinopathy and test the patient for HIV infection. Aggressive combined antiviral agent therapy should be considered to save vision.     

Postpartum retinal detachment. A case report

A postpartum progression of preeclampsia ultimately resulted in bilateral serous retinal detachment.     

Retinal detachment in a patient with microphthalmos and choroidal coloboma.

We report a rare case of retinal detachment with microphthalmos and choroidal coloboma. A 28-year-old man who had suffered from poor vision since early childhood was examined because of progressive deterioration of vision in his right eye. Examination of the anterior segment showed microphthalmos with microcornea and coloboma of the iris. Fundus examination revealed an inferior choroidal coloboma extending to the optic disc. The patient also had total bullous retinal detachment. Pars plana vitrectomy with silicone oil tamponade was performed, and the retina was reattached. Although rare, retinal detachment may develop in patients with microphthalmos and choroidal coloboma. Pars plana vitrectomy with additional scleral encircling buckle may be performed to treat this condition.     

妊娠期视网膜脱离临床发病特点及与围产结局的关系

目的:探讨妊娠期视网膜脱离患者临床发病特点及与围产结局的关系,以提高临床医师对视网膜脱离的认识和处理。方法:回顾性分析天津医科大学总医院2002年3月至2012年3月收治的22例视网膜脱离患者的临床资料。将22例患者按照重度子痫前期临床发病类型分为:突发型组(7例)和渐进型组(15例);按临床发病时间分为:早发型组(11例)和晚发型组(11例)。比较各组并发症及妊娠结局。结果:22例视网膜脱离的患者均为重度子痫前期患者,其中5例合并HELLP综合征,2例合并产前子痫;18例(81.82%)为双眼视网膜脱离,4例(18.18%)单眼视网膜脱离;产前诊断17例(77.27%),产后发生5例(22.73%);剖宫产终止妊娠者21例(95.45%);22例患者入院时均为低蛋白血症患者。早发型组与晚发型组的并发症发生率无显著差异(P>0.05)。22例胎(婴)儿中,6例轻度窒息,2例胎死宫内,3例重度窒息(1例放弃治疗后死亡),死亡率为13.64%(3/22)。突发型组与渐进型组新生儿Apgar评分无统计学差异(P=0.099);早发型组与晚发型组新生儿Apgar评分差异显著(P=0.000),早发型胎(婴)儿结局较晚发型组差。结论:(1)小动脉痉挛、低蛋白血症、溶血可能为重度子痫前期视网膜脱离危险因素;(2)早发型重度子痫前期合并视网膜脱离患者胎(婴)儿结局较差。(3)视网膜脱离作为重度子痫前期严重并发症,是全身各系统脏器灌注减少,发生器质性改变甚至功能衰竭的危险信号。     

Visual outcome in primary macula-off rhegmatogenous retinal detachment treated with scleral buckling.

BACKGROUND AND PURPOSE: To evaluate the visual outcome of primary macula-off rhegmatogenous retinal detachment after successful scleral buckling. METHODS: A retrospective, non-controlled case series study was conducted in 93 patients (93 eyes) who underwent primary successful scleral buckling procedure for retinal detachment. Factors including duration of macular detachment, patient age, preoperative best-corrected visual acuity (VA), surgical management of subretinal fluid, and refractive error were analyzed statistically to determine their association with final visual outcome. RESULTS: Postoperative VA of 20/50 or better was found in 53.6% of eyes with duration of macular detachment within 7 days, and 29.7% of eyes with macular detachment for more than 7 days (Fisher's exact test, p = 0.019). VA better than 20/50 was found in 61% of eyes with preoperative VA better than 20/400 and in 33.9% with preoperative VA worse than 20/400 (Fisher's exact test, p = 0.008). Patients aged 30 years or less achieved better mean postoperative VA than those aged 31 to 50 and those aged 50 years and older (ANOVA, p = 0.003). Patients with low-grade myopia (< -6D) regained significantly better mean postoperative VA as compared with high myopia (> -6D) and emmetropic eyes (0 to +3D) (ANOVA, p < 0.001). Subretinal fluid drainage procedure did not affect postoperative visual result. Multivariate logistic regression analysis revealed that the duration of macular detachment was the only variable affecting the visual result. CONCLUSION: Scleral buckle surgery performed within the first week, preoperative vision more than 20/400, age younger than 30 years old, and low-grade myopia were associated with significantly better visual recovery from macular-off rhegmatogenous retinal detachment.     

Syphilitic uveitis as the initial manifestation of HIV infection.

Syphilis is an uncommon cause of uveitis in HIV-infected patients. We report a case of bilateral panuveitis and describe its characteristics as the initial manifestation of HIV infection. A 74-year-old heterosexual male complained of blurred vision and floaters in both eyes for 40 days. Slit lamp examination showed diffuse keratic precipitates and cells in the anterior chamber of both eyes. Fundus examination revealed multiple small white dots and scattered retinal hemorrhage over the mid-equatorial retina with marked vitritis. Physical examination disclosed multiple erythematous papules over bilateral palms compatible with secondary syphilis. Serologic tests--the venereal disease research laboratory (VDRL) test, fluorescent treponemal antibody absorption (FTA-ABS) test, and Treponema pallidum hemagglutination (TPHA) test--were all positive. Aqueous fluid also showed positive FTA-ABS reaction. Under the impression of acquired secondary syphilis, enzyme-linked immunosorbent assay and Western blot test were performed and revealed concurrent HIV infection. After intravenous administration of penicillin-G, 18 million units daily for 2 weeks, the vitritis and retinochoroiditis improved. All patients with panuveitis of unknown cause should undergo VDRL and FTA-ABS screening. Subsequent testing for HIV antibody in leutic uveitis is also mandatory.     

Bilateral total loss of vision following eclampsia--a case report

Visual loss following eclampsia is usually reported to be a result of retinopathy, exudative retinal detachment or cortical blindness. This paper reports the case of a 31-year-old para 5 + 0 housewife who developed bilateral visual loss following eclampsia and presented to the ophthalmologist four weeks later with a vision of light perception in both eyes. Examination showed evidence of hypertensive retinopathy. Convinced that the ocular findings were not responsible for such marked visual loss, she was commenced on systemic, topical and sub-conjunctival injection of steroids, acetazolamide and multivitamins. Her vision improved progressively to 6/6 right eye and 6/9 left eye after three weeks. Obstetricians are advised to refer cases of visual loss following eclampsia promptly to the ophthalmologist who should in turn manage aggressively with systemic, topical and sub-conjunctival steroids.     

Reversible hypertensive retinopathy in a child with bilateral pheochromocytoma after tumor resection.

Pheochromocytoma is very rare in children. We report a case of bilateral pheochromocytoma in a 12-year-old boy who had blurred vision due to hypertensive retinopathy. Abdominal ultrasound and computed tomography revealed bilateral suprarenal tumors. Resection of the bilateral tumors along with right total and left subtotal adrenalectomy were performed. Blood pressure and visual acuity returned to normal after surgery.     

Serious Visual (Ocular) Complications in Pre-eclampsia and Eclampsia

Introduction

Complete loss of vision is an uncommon ocular complication of pre-eclampsia/eclampsia. The conditions which lead to visual loss in pre-eclampsia include cortical blindness, retinal detachment, retinal vascular thrombosis and optic nerve atrophy.

Objectives

The objective was to describe the cause, clinical course and prognosis in blindness complicating pre-eclampsia.

Methodology

This is a prospective observational study conducted at the Govt. Hospital for Women and Children, Chennai, from January 2006 to December 2010. Sixteen women who were diagnosed with blindness complicating pre-eclampsia were analysed for the cause of blindness, clinical details and prognosis.

Results

The incidence of blindness among women with pre-eclampsia and eclampsia was 0.17%. The cause of visual loss was cortical blindness in 14 patients and retinal detachment in two patients. Blindness manifested predominantly in the intrapartum and postpartum period in 13/16 cases (81.25%). Seven patients (43.75%) suffered from severe pre-eclampsia, and nine patients (56.25%) suffered from eclampsia. HELLP syndrome, gestational diabetes mellitus (GDM) and anaemia were seen in two patients each. Seven patients also presented with motor deficits. CT scan imaging showed cortical vein thrombosis in five cases, arterial infarcts in two cases, widespread hypodense areas in the occipito-parietal region in six cases. In patients with cortical blindness, recovery of vision occurred within 10 days.

Conclusion

Cortical blindness and retinal detachment are rare complications of pre-eclampsia and eclampsia. The prognosis is usually good especially with cortical blindness where the loss of vision is transient. The mainstay of management is effective treatment of pre-eclampsia/eclampsia along with termination of pregnancy.

     

Retinal detachment in association with pre-eclampsia, eclampsia, and HELLP syndrome

Objective

To review case reports of retinal detachment in women with pre-eclampsia/eclampsia.

Methods

Medline was searched for case reports of retinal detachment associated with pre-eclampsia/eclampsia. Articles written in English, Spanish, or Portuguese and published between 1990 and 2010 were reviewed.

Results

A total of 28 cases of retinal detachment were identified; 15 were associated with severe pre-eclampsia (3 of these probably had hemolysis, elevated liver enzymes, and low platelets [HELLP] syndrome), 9 with HELLP syndrome, 2 with eclampsia, and 2 with both HELLP syndrome and eclampsia. The majority (60%) of women were nulliparous, 4 had abruptio placentae, and cesarean delivery was performed in 76%. Retinal detachment was bilateral in 89% and associated with delivery of the fetus in 96%; 69% were diagnosed postpartum. Within 2-12 weeks postpartum, all patients had complete recovery of vision with clinical management.

Conclusion

Retinal detachment in pre-eclampsia/eclampsia might be associated with HELLP syndrome, indicating that microangiophatic hemolysis might have a role in the pathophysiology of retinal detachment. Its occurrence might not be correlated with the severity of pre-eclampsia because pre-eclampsia is a constellation of signs and symptoms (persistent vasospasms with hemolysis and hypoalbuminemia) rather than simply being hypertension.     

Ocular safety in patients using sildenafil citrate therapy for erectile dysfunction

Sildenafil citrate improves erectile function in men with erectile dysfunction (ED) by selectively inhibiting cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5), which is present in all vascular tissue. Sildenafil also has a weaker inhibitory action on PDE6, located in the rod and cone photoreceptors. Modest, transient visual symptoms, typically blue tinge to vision, increased brightness of lights, and blurry vision, have been reported with sildenafil use and occur more frequently at higher doses. Visual function studies in healthy subjects and in patients with eye disease suggest that sildenafil does not affect visual acuity, visual fields, and contrast sensitivity. Transient, mild impairment of color discrimination can occur around the time of peak plasma levels. Spontaneous postmarketing reports of visual adverse events, including nonarteritic anterior ischemic optic neuropathy (NAION), have been reported during the 7 years that sildenafil has been prescribed to more than 27 million men worldwide. However, because men with ED frequently have vascular risk factors that may also put them at increased risk for NAION, a causal relationship is difficult to establish. No consistent pattern has emerged to suggest any long-term effect of sildenafil on the retina or other structures of the eye or on the ocular circulation.     

Early visual development: implications for the neonatal intensive care unit and care

Much of the early development of the human visual system occurs while the preterm infant is in the neonatal intensive care unit (NICU). Critical events and processes happen between 20 and 40 weeks' gestational age, before the onset of vision at term birth. Knowledge of the development of the visual system and the timing of the processes involved is essential to adapting NICU care to support all neurosensory development including visual development.     

Rare Case of Small-Cell Carcinoma Arising from the Endometrium with Paraneoplastic Retinopathy

We present the fourth known case of endometrial carcinoma, and the second case of endometrial small-cell carcinoma, to be associated with paraneoplastic retinopathy. Initial symptoms were decreased visual acuity and a narrowing of the visual field. Endometrial carcinoma was diagnosed several months later. An antibody to 34-kDa bovine retinal antigen was detected in the patient's serum. Thus, autoimmunity was suspected as the cause of the retinopathy. In patients with endometrial carcinoma with visual disturbance of unknown cause, paraneoplastic retinopathy should be suspected.