Spontaneous outer retinal layer recovery in a case of hypertensive choroidopathy secondary to pre-eclampsia: a multimodal evaluation

A 26-year-old woman presented at 28 weeks gestation with hypertensive choroidopathy associated with pre-eclampsia. Fundus photography, fundus autofluorescence, spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography, and indocyanine green angiography were performed in both eyes in the immediate postoperative period. SD-OCT images were obtained before delivery and during a 3-month follow-up. Fundus autofluorescence exhibited patchy hyper- and hypoautofluorescent lesions; fluorescein and indocyanine green angiography revealed areas of choroidal ischemia; and SD-OCT showed disorganization of the outer retinal layers and disruption of the ellipsoid zone. After her blood pressure was stabilized, progressive recovery of the outer retinal layer was monitored on SD-OCT.

Keywords:
Choroid diseases; Pre-eclampsia; Optical imaging; Tomography, optical coherence; Fluorescein angiography; Retinal photoreceptor cell outer segment; Blood-retinal barrier; Pregnancy; Case report

Authorship

Bruno Fortaleza de Aquino Ferreira Corresponding author: Bruno Fortaleza de Aquino Ferreira.. Av. Dr. Enéas de Carvalho Aguiar, 255 - São Paulo - SP - 05403-000 - Brazil E-mail: bruno.fortaleza@fm.usp.br

Department of Ophthalmology, Universidade de São Paulo, São Paulo, SP, Brazil.Universidade de São PauloBrazilSão Paulo, SP, BrazilDepartment of Ophthalmology, Universidade de São Paulo, São Paulo, SP, Brazil.

http://orcid.org/0000-0003-3555-9122

André Carvalho Kreuz

Patricia Martini Diniz

João Vitor Santos Sampaio Rocha

Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.Universidade de São PauloBrazilSão Paulo, SP, BrazilFaculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

Sérgio Luis Gianotti Pimentel

Corresponding author: Bruno Fortaleza de Aquino Ferreira.. Av. Dr. Enéas de Carvalho Aguiar, 255 - São Paulo - SP - 05403-000 - Brazil E-mail: bruno.fortaleza@fm.usp.br

Disclosure of potential conflicts of interest: None of the authors have any potential conflicts of interest to disclose.

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Figures

Figures (4)

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Figure 1
Multimodal imaging of the right eye 72 hours after delivery. (A) Fundus photography (Visucam, Zeiss, Oberkochen, Germany) revealed cotton wool spots (white arrowhead). (B) Autofluorescence (Spectralis, Heidelberg Engineering, Heidelberg, Germany) presented patchy hyper- and hypoautofluorescent lesions corresponding to RPE/outer retinal layer damage. (C, D) Fluorescein angiography (Spectralis), during the early phase (C) and late phase (D), demonstrated areas of choroidal ischemia (C, green asterisk) with poor arteriolar filling during the early phase and leakage in areas with RPE damage during the late phases (D, green arrowhead). Mild leakage from the optic disc was also observed. (E, F) Indocyanine green angiography (Spectralis), early phase (E) and late phase (F), revealed delayed choroidal filling and areas of chronic choroidal ischemia (green asterisks), corresponding to those observed on FA. (G) Spectral-domain optical coherence tomography (Spectralis) showed disorganization of the outer retinal layers (blue asterisk) and disruption of the ellipsoid zone (red arrowhead), with no intraretinal cysts.

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Figure 2
Multimodal imaging of the left eye 72 hours after delivery. (A) Fundus photography (Visucam, Zeiss, Oberkochen, Germany) revealed cotton wool spots (black arrowhead) and Elschnig spots (black arrow). (B) Autofluorescence (Spectralis, Heidelberg Engineering, Heidelberg, Germany) presented patchy hyper- and hypoautofluorescent lesions corresponding to RPE/outer retinal layer damage. (C, D) Fluorescein angiography (Spectralis), early phase (C) and late phase (D), showed areas of choroidal ischemia (C, green asterisk) with poor arteriolar filling during the early phase and leakage in areas with RPE damage during the late phases (D, green arrowhead). (E, F) Indocyanine green angiography (Spectralis), early phase (E) and late phase (F), revealed delayed choroidal filling and areas of persistent choroidal ischemia (E and F, green asterisk) corresponding to those observed on FA. (G) Spectral-domain optical coherence tomography (Spectralis) showed disorganization of the outer retinal layers (blue asterisk) and disruption of the ellipsoid zone (red arrowhead), with no intraretinal cysts.

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Figure 3
Follow-up of fundus photography (Visucam, Zeiss, Oberkochen, Germany) and focus-tracking optical coherence tomography (SD-OCT) (Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the right eye. (A) At baseline, focal arteriolar narrowing (yellow arrowhead), Elschnig spots (yellow arrows), and cotton wool spots (black arrowhead) were observed, gradually disappearing during follow-up evaluation (C, E, and G). (B) On SD-OCT, intraretinal cysts (yellow asterisk) were associated with disorganization of outer retinal layer (blue asterisk) and subretinal fluid (white asterisk). (D, F, and H) During follow-up, progressive regeneration of the outer retinal layers occurred (D, blue asterisk) with partial recovery of the ellipsoid zone (D and F, red arrowhead). Areas of thickened retinal pigment epithelium on SD-OCT corresponded to Elschnig spots in the posterior fundus on AF images (F and H, green arrowhead).

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Figure 4
Follow-up of fundus photography (Visucam, Zeiss, Oberkochen, Germany) and focus-tracking optical coherence tomography (SD-OCT) (Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the left eye. (A) At baseline, focal arteriolar narrowing (yellow arrowhead) and Elschnig spots (yellow arrow) were observed, gradually disappearing during the follow-up evaluation (C, E, and G). (B) On SD-OCT, intraretinal cysts (yellow asterisk) were associated with disorganization of outer retinal layer (blue asterisk) and subretinal fluid (white asterisk). (D, F, and H) During follow-up, progressive regeneration of the outer retinal layers occurred (D, blue asterisk) with partial recovery of the ellipsoid zone (D, F, and H, red arrowhead). Areas of thickened retinal pigment epithelium on SD-OCT corresponding to Elschnig spots in the posterior fundus on AF images (F and H, green arrowhead).

Figure 1 Multimodal imaging of the right eye 72 hours after delivery. (A) Fundus photography (Visucam, Zeiss, Oberkochen, Germany) revealed cotton wool spots (white arrowhead). (B) Autofluorescence (Spectralis, Heidelberg Engineering, Heidelberg, Germany) presented patchy hyper- and hypoautofluorescent lesions corresponding to RPE/outer retinal layer damage. (C, D) Fluorescein angiography (Spectralis), during the early phase (C) and late phase (D), demonstrated areas of choroidal ischemia (C, green asterisk) with poor arteriolar filling during the early phase and leakage in areas with RPE damage during the late phases (D, green arrowhead). Mild leakage from the optic disc was also observed. (E, F) Indocyanine green angiography (Spectralis), early phase (E) and late phase (F), revealed delayed choroidal filling and areas of chronic choroidal ischemia (green asterisks), corresponding to those observed on FA. (G) Spectral-domain optical coherence tomography (Spectralis) showed disorganization of the outer retinal layers (blue asterisk) and disruption of the ellipsoid zone (red arrowhead), with no intraretinal cysts.

Figure 2 Multimodal imaging of the left eye 72 hours after delivery. (A) Fundus photography (Visucam, Zeiss, Oberkochen, Germany) revealed cotton wool spots (black arrowhead) and Elschnig spots (black arrow). (B) Autofluorescence (Spectralis, Heidelberg Engineering, Heidelberg, Germany) presented patchy hyper- and hypoautofluorescent lesions corresponding to RPE/outer retinal layer damage. (C, D) Fluorescein angiography (Spectralis), early phase (C) and late phase (D), showed areas of choroidal ischemia (C, green asterisk) with poor arteriolar filling during the early phase and leakage in areas with RPE damage during the late phases (D, green arrowhead). (E, F) Indocyanine green angiography (Spectralis), early phase (E) and late phase (F), revealed delayed choroidal filling and areas of persistent choroidal ischemia (E and F, green asterisk) corresponding to those observed on FA. (G) Spectral-domain optical coherence tomography (Spectralis) showed disorganization of the outer retinal layers (blue asterisk) and disruption of the ellipsoid zone (red arrowhead), with no intraretinal cysts.

Figure 3 Follow-up of fundus photography (Visucam, Zeiss, Oberkochen, Germany) and focus-tracking optical coherence tomography (SD-OCT) (Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the right eye. (A) At baseline, focal arteriolar narrowing (yellow arrowhead), Elschnig spots (yellow arrows), and cotton wool spots (black arrowhead) were observed, gradually disappearing during follow-up evaluation (C, E, and G). (B) On SD-OCT, intraretinal cysts (yellow asterisk) were associated with disorganization of outer retinal layer (blue asterisk) and subretinal fluid (white asterisk). (D, F, and H) During follow-up, progressive regeneration of the outer retinal layers occurred (D, blue asterisk) with partial recovery of the ellipsoid zone (D and F, red arrowhead). Areas of thickened retinal pigment epithelium on SD-OCT corresponded to Elschnig spots in the posterior fundus on AF images (F and H, green arrowhead).

Figure 4 Follow-up of fundus photography (Visucam, Zeiss, Oberkochen, Germany) and focus-tracking optical coherence tomography (SD-OCT) (Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the left eye. (A) At baseline, focal arteriolar narrowing (yellow arrowhead) and Elschnig spots (yellow arrow) were observed, gradually disappearing during the follow-up evaluation (C, E, and G). (B) On SD-OCT, intraretinal cysts (yellow asterisk) were associated with disorganization of outer retinal layer (blue asterisk) and subretinal fluid (white asterisk). (D, F, and H) During follow-up, progressive regeneration of the outer retinal layers occurred (D, blue asterisk) with partial recovery of the ellipsoid zone (D, F, and H, red arrowhead). Areas of thickened retinal pigment epithelium on SD-OCT corresponding to Elschnig spots in the posterior fundus on AF images (F and H, green arrowhead).

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Spontaneous outer retinal layer recovery in a case of hypertensive choroidopathy secondary to pre-eclampsia: a multimodal evaluation

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[1] Corresponding author: Bruno Fortaleza de Aquino Ferreira.. Av. Dr. Enéas de Carvalho Aguiar, 255 - São Paulo - SP - 05403-000 - Brazil E-mail: bruno.fortaleza@fm.usp.br