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Idiopathic Choriovitreal Membrane a Case Report Br J Ophthalmol: First Published As 10.1136/Bjo.76.9.567 on 1 September 1992

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Idiopathic Choriovitreal Membrane a Case Report Br J Ophthalmol: First Published As 10.1136/Bjo.76.9.567 on 1 September 1992 British3'ournal ofOphthalmology 1992; 76: 567-568 567 Idiopathic choriovitreal membrane a case report Br J Ophthalmol: first published as 10.1136/bjo.76.9.567 on 1 September 1992. Downloaded from Stephen H Sinclair, Brian D Salmenson Abstract eye and was documented by fluorescein angio- A case of a macular idiopathic choriovitreal graphy (Fig IA and B). No drusen, retinal membrane is described which developed in a pigment epithelial changes, or macular retinal diabetic man. Oninitial examination the patient exudates were observed in either fundus. was found to have a pigment epithelial Proliferative diabetic retinopathy was present in detachment with a choroidal neovascular both eyes with disc and peripheral retinal neo- membrane (CNVM) in the right eye. Two vascularisation as well as vitreous haemorrhage months after the first visit the CNVM was seen noted in the right eye (Fig 1A). Panretinal to have penetrated the retina and presented as photocoagulation (PRP) was begun in both eyes a choriovitreal membrane. Panretinal photo- because of the high risk characteristics of pro- coagulation was applied after which the liferative diabetic retinopathy. During the choriovitreal membrane demonstrated fibrotic course ofthe laser the CNVM in the right eye was involution. This case is unusual in that the observed by stereoscopic biomicroscopy to have choriovitreal membrane developed in the broken through the surface of the retina within absence of a choroidal or retinal pigment the fovea and to grow as an epiretinal, fibro- epithelial disease process that may be vascular membrane internal to the surface of the associated with a CNVM as weli as in the retina. The posterior hyaloid had not separated absence ofprevious macular laser treatment. from the surface ofthe macula (Fig 2). The visual (Br_r Ophthalmol 1992; 76: 567-568) acuity in the right eye had decreased to hand movements at 1 metre. On follow-up examination a few weeks after completion of panretinal Choroidal neovascular membranes (CNVMs) are photocoagulation to the right eye, the macular usually confined to the subpigment epithelial or epiretinal fibrovascular membrane demonstrated subretinal space unless the retina has been progressive fibrosis with adherence to the traumatised (for example, by laser photo- posterior hyaloid and elevation from the surface coagulation), in which case they have been of the retina producing a tractional retinal reported to produce chorioretinal or choriovitreal detachment (Fig 3). Vitreous surgery was neovascularisation. We report a case of an idio- attempted to reduce the progressing retinal pathic CNVM which penetrated an intact retina detachment. At the time of delamination of the to produce a choriovitreal fibrovascular epiretinal membrane, a fibrous stalk was noted membrane. to extend from the subretinal space through the http://bjo.bmj.com/ foveal region to the epiretinal component Department of attached to the posterior hyaloid. Ophthalmology, Hahnemann University Case report Medical School, A 69-year-old insulin-dependent diabetic man Philadelphia, PA, USA presented with decreased vision in both eyes due Discussion S H Sinclair B D Salmenson to vitreous haemorrhage from disc and peripheral Numerous causes of CNVMs are recognised, all to occur with a on September 27, 2021 by guest. Protected copyright. Correspondence to: retinal neovascularisation. The visual acuity in of which are known or thought Stephen H Sinclair, MD, the right eye was counting fingers at 2 metres and defect in Bruch's membrane. When no cause can Department of Ophthalmology, Hahnemann in the left eye 6/12. The anterior segments were be determined clinically they may be labelled as University Medical School, normal except for nuclear sclerosis of both idiopathic. In the case described here a subretinal Broad and Vine Streets, man Philadelphia, PA 19102, USA. lenses. On biomicroscopy of the posterior seg- CNVM developed in an elderly diabetic Accepted for publication ments, a pigment epithelial detachment with a without drusen, without previous laser therapy 28 February 1992 CNVM was noted beneath the fovea of the right or evidence of optic disc drusen, or a retinal Figure I (A) A red-free photograph ofthe right fundus atfirstpresentation demonstrating a subfoveal choroidal neovascular membrane and diabetic retinopathy with epipapillary neovascularisation (arrow) and vitreous haemorrhage. (B) Fluorescein angiogram ofthe rightfundus atfirst presentation demonstrating thefoveal choroidal neovascular membrane and leakagefrom the epipapillary neovascularisation. hIg''hFittA1A I1? 568 Sinclair, Salmenson Br J Ophthalmol: first published as 10.1136/bjo.76.9.567 on 1 September 1992. Downloaded from Figure 2 Red-freefundus photograph ofthe right eye Figure 3 Fundus photograph demonstrating thefibrotic demonstrating afibrovascular membrane on the inner surface lesion in the right maculafollowing panretinal ofthe retina overlying the macular retinal vessels. photocoagulation. pigment epithelial disease process that has been contributed to the formation of the CNVM and associated with CNVM. The early appearance of promoted its penetration of the thin retina at the the CNVM confined to the subretinal space foveola where it arose. appeared similar to those described by Yeo et al,' Choriovitreal neovascularisation has in general where subretinal fibrosis developed in diabetic been thought not to respond to panretinal photo- macular oedema associated with large lipid coagulation. Augsburger et all however observed deposits. In only one of their cases was the regression of such neovascularisation in two subretinal fibrosis secondary to a CNVM and in patients following scatter photocoagulation of all of their cases the nodular subretinal fibrosis areas of retinal ischaemia peripheral to an area of followed extensive macular exudate, which was choriovitreal neovascularisation after treatment not observed here. Within 2 months the CNVM for malignant melanoma. Although the CVNM observed in our patient had grown through the in our case did demonstrate some fibrosis prior to retina and appeared as an epiretinal fibrovascular photocoagulation for the proliferative diabetic membrane with adherence to the posterior retinopathy, the involution of the membrane vitreous hyaloid and on surgery was noted to appeared to have been accelerated by the photo- extend from the subretinal space as choriovitreal coagulation. Choriovitreal neovascularisation neovascularisation. was successfully treated with direct argon and/or Subretinal neovascular membranes of xenon photocoagulation in two of four eyes choroidal vascular origin have been reported treated by Dizon-Moore.2 Direct treatment was following heavy photocoagulation for diabetic not considered in our case owning to the location http://bjo.bmj.com/ macular oedema, proliferative diabetic of the membrane. Because of the progressive retinopathy, proliferative sickle retinopathy, tractional retinal detachment, vitrectomy with central serous chorioretinopathy, presumed en bloc membrane delamination was attempted ocular histoplasmosis syndrome, choroidal and was successful at releasing the detachment haemangiomas, and choroidal melanomas. and improving the central scotoma and vision, Extension of the CNVM to form choriovitreal though the macula remained puckered due to the neovascular membranes has been described subretinal fibrosis. on September 27, 2021 by guest. Protected copyright. following intense photocoagulation for pro- liferative sickle cell reinopathy,2 proliferative 1 Yeo JH, Murphy RP, Lewis H. Subretinal fibrosis developing diabetic retinopathy,3 sarcoidosis,4 and malig- after macular lipid in diabetic macular edema. Invest Ophthal Vis Science 1988; 29 (suppl): 69. nant melanoma.5 To our knowledge, however, 2 Dizon-Moore RV, Jampol LM, Goldberg MF. Chorioretinal this is the first report of a CNVM spontaneously and choriovitreal neovascularization; their presence after photocoagulation ofproliferative sickle cell retinopathy. Arch growing through an intact retina to produce Ophthalmol 1981; 99: 842-9. choriovitreal neovascularisation. 3 Wallow I, Johns K, Barry P, Chandras S, Bindley C. Chorioretinal and choriovitreal neovascularization after CNVMs following intense photocoagulation photocoagulation for proliferative diabetic retinopathy. A are thought to develop through a disruption in clinicopathologic correlation. Ophthalmology 1985; 92: 523- 32. Bruch's membrane and have been reproduced in 4 Galinos SO, Asdourian GK, Woolf MB, Goldberg MF, Busse rhesus monkeys. In the animal model infiltration BJ. Choroidovitreal neovascularization after argon laser photocoagulation. Arch Ophthalmol 1975; 93: 524-30. of the retina occurred if there was coexistent 5 Augsburger JJ, Piro PA, Shields JA, Magargal LE, Donoso inner retinal ischaemia which was the case in our LA. Scatter photocoagulation for choroidovitreal neo- vascularization. Retina 1984; 4: 171-6. patient's eye. Inner retinal ischaemia may also be 6 Archer DB, Gardiner TA. Experimental inner retinal ischemia associated with changes at the level of the retinal and blood-retinal barriers. In: Cunha-Vaz, JG, ed. The blood- retinal barriers. New York: Plenum, 1980; 279-99. pigment epithelium (RPE).6 The diabetic eye 7 Yanoff M, Fine BS. Ocular pathology. Philadelphia: Lippincott may demonstrate thickening of the RPE base- 1989; 567. 8 Tso MOM, Cunha-Vaz JG, Shih C, Jones CW. Clinicopatho- ment membrane and narrowing of the chorio- logic study of blood-retinal barrier in experimental diabetes capillaris lumen,78 all of which may have mellitus. Arch Ophthalmol 1980; 98: 2032-40..
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