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Clinicopathologic Correlation of Successfully Treated Choroidal Neovascularizationlying Within the Notch of a Large Serous Retin

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Clinicopathologic Correlation of Successfully Treated Choroidal Neovascularizationlying Within the Notch of a Large Serous Retin CLINICOPATHOLOGIC REPORTS, CASE REPORTS, AND SMALL CASE SERIES SECTION EDITOR: W. RICHARD GREEN, MD layer, which reapposed the Bruch fingers at 4 ft. Funduscopic exami- Clinicopathologic membrane, allowing retention of very nation results of the right eye dis- Correlation of Successfully good vision for 21 months. Addition- closed a sharply circumscribed, Treated Choroidal ally, in an area of drusen resorption, dome-shaped detachment of the macular RPE, with a shallow over- Neovascularization Lying only small calcific deposits re- mained and there was no remaining lying sensory retinal detachment. Within the Notch of a basal laminar deposit. Large drusen were seen through- Large Serous Retinal Only a limited number of pre- out the posterior pole, and there was Pigment Epithelial vious reports describe histopatho- a small patch of geographic atro- Detachment logic correlative studies with recent phy temporal to the fovea within the fluorescein and ICG angiography in area of detached RPE. Examination We report the histopathologic fea- eyes with CNV associated with results of the left eye revealed dis- tures of a successfully treated serous AMD.1,2 In this study, we report, to ciform macular scarring, exuda- retinal pigment epithelial detach- our knowledge, the first such case of tion, subretinal fibrosis, RPE migra- ment (RPED) with accompanying an eye successfully treated with la- tion, and hyperplasia (Figure 1). choroidal neovascularization (CNV) ser photocoagulation for a serous The fluorescein angiogram of the in a 74-year-old woman with age- RPED with CNV and resorption of right fundus revealed a well- related macular degeneration (AMD). accompanying drusen. circumscribed area of early hypo- These findings were correlated with fluorescence with progressive hy- antemortem fluorescein and indocya- Report of a Case. A 74-year-old perfluorescence in the later phases nine green (ICG) angiographic stud- woman with AMD had a 2-month corresponding to the RPE eleva- ies. Histopathologic studies showed history of blurred central vision in tion seen clinically. Along the nasal that the serous RPED represented a her right eye. The vision in her left border of the lesion, a notched area separation of the retinal pigment epi- eye had been poor for 10 years be- was present in which there was de- thelium (RPE) and its basal lamina cause of exudative AMD. Her medi- layed filling and irregular late hy- from the remainder of the Bruch cal history was remarkable for hy- perfluorescence. Results of ICG membrane with no intervening CNV. pertension, coronary artery disease, angiography demonstrated well- Laser photocoagulation had suc- peripheral vascular disease, and co- demarcated hypofluorescence cor- cessfully closed the accompanying lon cancer. She did not smoke. responding to the RPED in the early sub-RPE (Gass type 1, presumed in- On examination, visual acuity and late phases. Within the nasal tra-Bruch) choroidal neovascular was 20/30 OD with no scotomata or notch of the RPED, an expanding membrane. The RPED resolved, leav- metamorphopsia by Amsler grid test- area of focal hyperfluorescence was ing a fairly well-preserved RPE mono- ing. Visual acuity OS was counting present (Figure 2). Another less Figure 1. Fundus photograph from a 74-year-old woman with a sharply circumscribed, dome-shaped elevation of the retinal pigment epithelium in the right eye with overlying serous retinal detachment (arrowheads) and a nasal notch (white arrowhead). Large drusen are scattered throughout the posterior pole, and a small patch of geographic atrophy is located temporal to the fovea (arrow).The left eye (OS)shows disciform macular scarring, exudation, subretinal fibrosis, retinal pigment epithelium migration, and hyperplasia. (REPRINTED) ARCH OPHTHALMOL / VOL 122, SEP 2004 WWW.ARCHOPHTHALMOL.COM 1383 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 A B C Early Phase Late Phase D E F F Early Phase Late Phase Figure 2. A-C, Fluorescein angiographic results of the right eye show a well-circumscribed area of early hypofluorescence with progressive hyperfluorescence in the later phases corresponding to the retinal pigment epithelium elevation seen clinically. Along the nasal border of the lesion, a notched area was present in which there was delayed filling and irregular late hyperfluorescence. D-F, Indocyanine green angiographic results of the right eye show well-demarcated hypofluorescence corresponding to the retinal pigment epithelial detachment (RPED) in the early and late phases. E, Within the nasal notch of the RPED, an expanding area of focal hyperfluorescence was present (arrowhead). F, Laser treatment results of the right eye. Argon green laser photocoagulation was applied to the area of choroidal neovascularization (arrow). Additionally, isolated laser applications were placed along the margin of the RPED (arrowheads). well-defined notch superior to the Twenty-one months after la- neurosensory retina was thinned, border of the RPED shows stippled ser photocoagulation and 5 months and the photoreceptor nuclear den- leakage in the later fluorescein after her most recent examination, sity was reduced. One to 3 layers of phases and staining in the late ICG the patient died following treat- cell nuclei were found in the outer angiography phases. ment for recurrent colon cancer. nuclear layer of this eye compared Argon green laser photocoagu- with 7 to 9 layers found in previ- lation (175 applications; 200-µm Results. The eyes were enucleated ously studied normal-aged reti- spot size; 0.2-second duration burns 3 hours post mortem and fixed 13 nas.6,7 A thin layer of hypocellular up to 220 mW) was applied to the hours thereafter in 4% buffered eosinophilic fibrous tissue was be- focal area of the presumed CNV at formaldehyde. The paraffin- neath the RPE. This material was dif- the nasal border of the RPED. Ad- embedded serial sections were cut ferent than its basal laminar de- ditionally, isolated laser applica- parallel to the pupil, optic nerve, and posit because it lacked the tions were placed along the margin macula plane, and the slides were anteroposterior striated appear- of the RPED (Figure 2). stained with hematoxylin-eosin. Us- ance described by Sarks and Sarks.8 The patient returned 1 month ing a microscope fitted with a cali- This region did not exhibit any dis- later. Visual acuity was 20/40 OD, brated reticule, histopathologic fea- tinguishing angiographic character- and the macula was flat. Fluores- tures were measured and plotted to istics. There was no transmission de- cein and ICG angiographic study re- yield a 2-dimensional cylindrical fect to suggest RPE atrophy. During sults revealed no leakage from the projection of the optic disc and tissue processing, serial sections did CNV and no hyperfluorescence in macula (Figure 5). This carto- not include the region superior to the the area of the RPED (Figure 3). graphic method has been described RPED. Therefore, no histopatho- The patient returned at 3, 5, and 8 previously.3-5 The histopathologic logic commentary could be made months with no evidence of CNV or and angiographic correlates are sum- about the corresponding area of RPED recurrence. marized in the Table. stippled leakage in the later fluores- Fifteen months after treat- We studied the following re- cein phases and staining in the late ment, visual acuity was 20/25 OD. gions: resolved RPED (Figure 6), ICG phases. Fundus examination results re- successfully photocoagulated CNV Good histopathologic correla- vealed a flat macula with a photo- (Figure 7 ), photocoagulation scars, tion was seen with the clinical and coagulation scar nasal to the fovea. and resorbed drusen (Figure 8). angiographic findings of success- When compared with pretreatment In the region of resolved RPED, fully treated CNV.9,10 Hypocellular photographs, drusen were fewer in a mildly disrupted RPE monolayer fibrous tissue was found beneath the posterior pole (Figure 4). apposed the Bruch membrane. The the RPE and its basal lamina. This (REPRINTED) ARCH OPHTHALMOL / VOL 122, SEP 2004 WWW.ARCHOPHTHALMOL.COM 1384 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 A B C Early OD Late OD D E Early OD Late OD Figure 3. A, One month posttreatment, fundus examination results show flattening of the retinal pigment epithelial detachment with a nasal laser scar. B and C, Fluorescein angiographic results show late staining without leakage in the areas of photocoagulation. D and E, The indocyanine green angiogram shows hypofluorescence in these areas. No focal or plaque hyperfluorescence was noted. A B Figure 4. Fundus photographs compare the right eye pretreatment (A) and 15 months posttreatment (B).The posttreatment photograph shows a flat macula, nasal laser scar, and reduction in drusen compared with the pretreatment photograph. treated CNV is a sub-RPE (Gass cence in early and late phases with inner nuclear, outer plexiform, and type 1, presumed intra-Bruch) mem- no leakage in both fluorescein and photoreceptor layers. There was hy- brane, which communicates with ICG angiography. perplasia of the retinal pigment epi- the choroid via 2 endothelium- The regions of photocoagula- thelial cells. Fibrocellular tissue was lined breaks in a layer presumed to tion at the nasal notch and at the found beneath the retina and in the be the outer layer of the Bruch margin of the RPED were charac- inner choroid, along with destruc- membrane (Figure
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