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 remained 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 lation, 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 hyperfluorescence. 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.

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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

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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 9). This re- terized by thinning of the neurosen- tion of adjacent choroidal vessels. gion corresponded to hypofluores- sory retina with destruction of the This area corresponded to well-

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101

111

161

211

261

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Purple: Laser Photocoagulation Yellow Spots: Drusen Green: Treated CNV (Intra-Bruch, Type 1, Sub-RPE) Yellow Rings: Areas of Resorbed Drusen Red Spot: CNV Perforating Outer Bruch Membrane Bright Red: Retinal Arterioles Map Legend: Black Cross: Fovea Dark Red: Retinal Veins Pink: Eosinophilic Material Intra-Bruch Red Stripes: RPE Atrophy Pale Blue: Reduced Outer Nuclear Density

Figure 5. Histopathologic map of the left eye. CNV indicates choroidal neovascularization; RPE, retinal pigment epithelium.

Correlation of Histopathologic Features With Angiographic Findings

Ophthalmoscopic Indocyanine Finding Map Color Histologic Findings Fluorescein Finding Green Finding Resolved RPED Pale blue Mildly disrupted RPE monolayer apposes Bruch membrane; No discerning features No discerning features thinned neurosensory retina; reduced photoreceptor nuclear density Pink Thin hypocellular eosinophilic fibrous tissue underlay the RPE Photocoagulated Green Hypocellular fibrous tissue between RPE and basal lamina Early and late Early and late CNV (intra-Bruch; Gass type 1) hypofluorescence hypofluorescence Red spots Perforation from choroid through outer layer of Bruch membrane Photocoagulation Purple Thinned neurosensory retina; destruction of inner nuclear, Early hypofluorescence; Early and late scar outer plexiform, and photoreceptor layers; RPE late staining of edges hypofluorescence hyperplasia; fibrocellular tissue beneath retina and in the inner choroids Resorbed drusen Yellow rings Bruch membrane separation into inner layer (RPE and basal No discerning features No discerning features lamina) and outer layer (elastic layer, choriocapillaris basal lamina); calcification in intra-Bruch space

Abbreviations: CNV, choroidal neovascularization; RPE, retinal pigment epithelium; RPED, retinal pigment epithelial detachment.

demarcated hypofluorescence in outer layer, whose elastic layer was tral vision in patients with AMD.11,12 early phases with staining of the undulated. Calcification was evi- Serous RPEDs have been qualified edges in the late phases on the fluo- dent in this presumed intra-Bruch as avascular or vascularized to de- rescein angiogram. On the ICG an- space. No basal laminar deposit was note the absence or presence of as- giogram, the photocoagulation scars present in this area. This region dis- sociated CNV. corresponded with well-demar- played no distinguishing angio- Avascular serous RPEDs, some- cated hypofluorescence in both the graphic features. times referred to as drusenoid RPEDs, early and late phases. presumably form as soft drusen pro- Examination of the area of dru- Comment. Serous RPEDs from the gressively accumulate, enlarge, and sen resorption disclosed separation Bruch membrane have distinctive coalesce. These elevations of RPE of the Bruch membrane into an in- clinical and angiographic features typically develop slowly and ini- ner layer (RPE basal lamina) and an and often contribute to loss of cen- tially may cause milder complaints of

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Figure 7. The photocoagulated choroidal neovascularization (asterisk) resides between the plane of the retinal pigment epithelium (arrowhead) and the presumed outer layers of the Bruch membrane (arrow). Note the scarring of the inner choroid, absence of choriocapillaris, and loss of retinal pigment epithelial cells and outer nuclear layer as a result of laser photocoagulation (hematoxylin-eosin, original magnification ϫ200).

A B

Figure 6. In the region of resolved retinal pigment epithelial detachment, the photoreceptor nuclear density is attenuated (arrowhead). Hypocellular, eosinophilic fibrous tissue remains between the retinal pigment epithelium and its basal lamina and the presumed outer layers of the Bruch membrane (arrows). A mildly disrupted retinal pigment epithelial monolayer has reapproximated the Bruch membrane (hematoxylin-eosin, original magnification ϫ100 (A); original magnification ϫ200 [B]).

Figure 8. Resorbed soft drusen. Sub–retinal pigment epithelium (presumed intra-Bruch) calcification present in areas where drusen resorbed (arrows). No basal laminar deposit is seen. The outer nuclear layer is attenuated (arrowheads) (hematoxylin-eosin, original magnification ϫ200).

blurring and metamorphopsia. An- With vascularized RPEDs, pa- lished data, 1998). If the detach- giographic results outline these lobu- tients tend to experience acute vi- ment occurs at the edge of the CNV, lar or scalloped lesions as the mate- sion loss as they develop sharply de- a reniform detachment results. In rial beneath the RPE stains with marcated, dome-shaped elevations of these lesions, the sub-RPE material fluorescein. The late staining may be the RPE, often accompanied by el- within the dome stains slowly and un- irregular depending on the density of evation of the overlying neurosen- evenly. Irregular early hyperfluores- the material beneath the RPE. In the sory retina. In AMD, serous RPEDs cence and evidence of late staining absence of CNV, vision loss may be are usually accompanied by angio- may or may not occur in the area of minimal or progress slowly. Occa- graphic evidence of CNV and consti- CNV that lies in the notch.13,14 sionally, the detachment may spon- tute approximately 15% of eyes with In 1984, Gass13 presented the taneously flatten.13,14 neovascularization (M.L.K., unpub- concept that notched serous RPEDs

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Figure 10. Soft drusen. Localized detachment of the retinal pigment epithelium with underlying amorphous eosinophilic material (asterisk) and basophilic calcifications (arrowheads) (hematoxylin-eosin, original magnification ϫ200). sory detachment in a patient with AMD. In 1976, Small et al21 reported a patient (case 2) with a serous RPED accompanied by an adjacent subfoveal CNV and correlated the fluorescein angiographic features with the histopathologic features also using cartographic reconstruction. In this patient, the subfoveal CNV, composed of fibro- vascular tissue, resided beneath the RPE within a split in the Bruch membrane (Gass type 1) and was adja- Figure 9. A choroidal vessel perforated the presumed outer layer of the cent to serous separation of the RPE. Bruch membrane (arrow) to communicate with the photocoagulated By correlating both fluorescein sub–retinal pigment epithelium (RPE) (Gass type 1, presumed intra-Bruch) and ICG angiographic features with choroidal neovascularization (CNV) (asterisk). The CNV resided in the same histopathologic characteristics and plane and adjacent to the RPE detachment, between the plane of the RPE (arrowhead) and the outer layers of the Bruch membrane cartographic reconstruction, we (hematoxylin-eosin, original magnification ϫ200). demonstrated in this case that iden- tification and ablation of extrafo- are often caused by occult, flat sub- served,18,19 as happened in this case. veal CNV with argon laser treat- RPE CNV lying within the notch A basic assumption in treating such ment allowed the adjacent serous outside the margin of the serous eyes is that the adjacent CNV is con- RPED to resolve, enabling the RPED and reported the case of suc- fined to an area identified on fluo- patient to maintain a visual acuity cessful treatment of these lesions rescein or ICG angiography and not of 20/25 OD. with focal laser directed to the area also located under the serous RPED. Another unique feature of this of the notch with or without laser This study illustrates the histopatho- study was the histopathologic find- of the margin of the RPED. He also logic basis for successful treatment ings of resorbed drusen. Although demonstrated the clinical and his- of CNV associated with a serous resorption of drusen has been rec- topathologic findings of flat, focal, RPED, which is the absence of CNV ognized clinically following laser occult sub-RPE CNV lying within in the area under the collapsed photocoagulation,22-27 no informa- the notch causing a large hemor- RPED. To our knowledge, only 2 tion has been reported describing the rhagic RPED. Since then, the term other clinicopathologic cases of se- histopathologic findings in an eye in notched serous RPED has gained wide rous RPED with cartographic recon- which this has occurred. usage in describing these com- struction have been reported.20,21 In In this eye, soft drusen were monly occurring, potentially treat- both cases, the serous RPEDs were characterized by a localized RPED able lesions.14 not treated and were represented his- with underlying amorphous eosino- For the last 20 years, the value topathologically as a serous separa- philic material and basophilic cal- of laser photocoagulation in such tion of the RPE and its basal lamina cifications (Figure 10). Areas of cases has been unclear. Investiga- from the remainder of the Bruch drusen resorption were identified us- tors have reported that laser treat- membrane. Frank et al20 in 1973 cor- ing cartographic correlation. In these ment is of no value.12,15-17 Others re- related the fluorescein angio- areas, calcification was present port that if the CNV is identified and graphic and histopathologic fea- within the Bruch membrane and no treated, flattening of the RPED will tures of drusen, serous RPED basal laminar deposit was evident occur and vision can be pre- without CNV, and serous neurosen- (Figure 9). There was also separa-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Figure 11. Diagrammatic representation.13,14 An extrafoveal sub–retinal pigment epithelium (RPE) (Gass type 1, presumed intra-Bruch) choroidal neovascularization adjacent to a serous RPE detachment was treated with laser photocoagulation. In this case, successful treatment resulted in closure of the choroidal neovascularization, resolution of the RPE detachment, relative preservation of the RPE monolayer, and preservation of good vision for 21 months.

tion of the presumed inner and outer tain basal laminar deposits were pres- CNV with laser allows the resolu- layers of the Bruch membrane with ent in the area of resorbed drusen. tion of the RPED (Figure 11).13,14 an undulating contour. Although the Basal laminar deposits were pres- In areas of resorbed drusen, there is separation may be an artifact of tis- ent elsewhere, primarily nasal to the a relatively normal relationship be- sue processing, it does suggest the optic nerve head. This suggests that tween the RPE and the overlying prior presence of some material in resorption of clinically apparent dru- photoreceptors. areas where drusen have resorbed. sen may serve as a marker for re- Additionally, in this region, the outer sorption of basal laminar deposits. Andreas K. Lauer, MD nuclear layer is attenuated indicat- The RPE in the area of drusen re- Jonathan Yoken, MD ing photoreceptor loss. sorption remained intact. Al- Michael L. Klein, MD The phenomena of disappear- though there was some reduction in David J. Wilson, MD ing neighboring drusen after flat- the thickness of the outer nuclear Portland, Ore tening both vascularized and non- layer, there was clearly an intact pho- vascularized RPEDs is seen toreceptor-RPE complex in the area The authors have no relevant finan- frequently.14 This observation was of drusen resorption. cial interest in this article. partly responsible for the interest in In conclusion, when corre- This study was supported by an using focal photocoagulation of lated with both fluorescein and ICG unrestricted fund from Research to some drusen to clear the macula of angiographic findings, this study il- Prevent Blindness, New York, NY, and drusen. In this case, it is unclear lustrates histopathologic evidence the Heed Ophthalmic Foundation, whether disappearance of drusen for 2 important points. Eyes with se- Cleveland, Ohio (Dr Yoken). was as a consequence of the devel- rous RPED and adjacent CNV may Thisstudywaspreviouslypresent- opment and flattening of the RPED be successfully treated if the CNV ed at the Verhoeff Society annual meet- itself or due to photocoagulation at can be completely identified and ing; April 23, 1999; Portland, Ore, and the nasal notch and at the margin of photocoagulated. With closure of the the Association for Research in Vision the RPED. Histopathologic clues to CNV, the serous RPED can resolve, and Ophthalmology annual meeting; resorption of drusen seen in this the RPE monolayer is relatively pre- May 10, 1999; Fort Lauderdale, Fla. study have implications for trials served, and vision can improve if the Correspondence: Dr Lauer, Ca- such as the Complications of Age- CNV is outside the fovea. Serous sey Eye Institute, Oregon Health and related Macular Degeneration Pre- RPEDs probably develop because of Science University, 3375 SW Terwil- vention Trial28 in which a standard- a cleavage plane between the elas- liger Blvd, Portland, OR 97239. ized grid of laser photocoagulation tic portion of the Bruch membrane 1. Lauer AK, Wilson DJ, Klein ML. Clinicopatho- is applied to the macula in hopes of and the RPE and underlying basal logic correlation of fluorescein and indocya- reducing drusen and preventing laminar deposits. Fluid leaking out nine green angiography in exudative age- CNV. Although there are no clini- of adjacent CNV is able to dissect related macular degeneration. Retina. 2000;20: 492-499. cal features that correspond to basal along this cleavage plane resulting 2. Chang TS, Freund KB, de la Cruz Z, Yannuzzi laminar deposits, it is almost cer- in the serous RPED. Closure of the LA, Green WR. Clinicopathologic correlation

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 of choroidal neovascularization demonstrated Prevention Trial Research Group. Ophthalmol- are designated as allergic mucin be- by indocyanine green angiography in a pa- ogy. 1999;106:1367-1373, 1974 (discussion). tient with retention of good vision for almost 23. Olk RJ, Friberg TR, Stickney KL, et al. Thera- cause of the abundance of eosino- four years. Retina. 1994;14:114-124. peutic benefits of infrared (810-nm) diode la- phils and their degradation prod- 3. Borodkin MJ, Thompson JT. Retinal cartogra- ser macular grid photocoagulation in prophy- ucts within the mucus.1 Although phy: an analysis of two-dimensional and three- lactic treatment of nonexudative age-related dimensional mapping of the retina. Retina. 1992; macular degeneration: two-year results of a ran- standardized treatment for AFS is not 12:273-280. domized pilot study. Ophthalmology. 1999;106: well defined, surgical debridement 4. Snyder JP. Map Projections: A Working Manual, 2082-2090. and systemic corticosteroid therapy USGS Professional Paper. Washington, DC: US 24. Figueroa MS, Regueras A, Bertrand J, Aparicio Government Printing Office; 1987. MJ, Manrique MG. Laser photocoagulation for are commonly recommended. 5. Muehrcke P. Map Use: Reading, Analysis and In- macular soft drusen: updated results. Retina. The typical patient with AFS is terpretation. Madison, Wis: JP Publications; 1997;17:378-384. 1986. 25. Frennesson IC, Nilsson SE. Laser photocoagu- young and immunocompetent with 2 6. Kornzweig AL. The eye in old age, V: diseases lation of soft drusen in early age-related macu- a history of asthma or atopy. Or- of the macula, a clinicopathologic study. Am J lopathy (ARM): the one-year results of a pro- bital involvement in AFS is caused by Ophthalmol. 1965;60:835-843. spective, randomised trial. Eur J Ophthalmol. 7. Green WR. Retina. In: Spencer WH, ed. Oph- 1996;6:307-314. the direct extension of sinus inflam- thalmic Pathology: An Atlas and Textbook. 4th 26. Little HL, Showman JM, Brown BW. A pilot ran- mation and can result in compres- ed. Philadelphia, Pa: WB Saunders Co; 1996: domized controlled study on the effect of laser sive ocular symptoms. Although well 669-676. photocoagulation of confluent soft macular dru- 8. Sarks SH, Sarks JP. Age related maculopathy: sen. Ophthalmology. 1997;104:623-631. described in the medical literature, nonneovascular age related macular degenera- 27. Sigelman J. Foveal drusen resorption one year AFS has rarely been described with tion and the evolution of geographic atrophy. after perifoveal laser photocoagulation. Oph- In: Ryan SJ, Schachat AJ, eds. Retina. 3rd ed. thalmology. 1991;98:1379-1383. ophthalmic involvement. We found St Louis, Mo: Mosby Inc; 2001:1070-1077. 28. Complications of Age-Related Macular Degen- only 5 such patients discussed in the 9. Green WR. Clinicopathologic studies of treated eration Prevention Trial (CAPT). National In- ophthalmologic literature and take choroidal neovascular membranes: a review and stitutes of Health National Eye Institute Web report of two cases. Retina. 1991;11:328-356. site. November 6, 2001. Available at: http: this opportunity to add our case se- 10. Meyer D, Harris WP, Fine SL, Green WR. Clini- //www.nei.nih.gov/neitrials/static/study70 ries to this list.2-5 copathologic correlation of argon-laser photo- .htm. Accessed December 13, 2003. coagulation of an idiopathic choroidal neovascular membrane in the macula. Retina. 1984; Report of Cases. Case 1. A 15-year- 4:107-114. old African American boy came to 11. Gass JD. Pathogenesis of disciform detach- Allergic Fungal Sinusitis ment of the neuroepithelium. Am J Ophthal- our clinic with mild proptosis, pain mol. 1967;63(suppl):1-139. With Unilateral Eye and tearing of the left eye, and a his- 12. Braunstein RA, Gass JD. Serous detachments Involvement tory of having been “elbowed” in that of the retinal pigment epithelium in patients with senile macular disease. Am J Ophthalmol. eye 4 months previously (Figure 1). 1979;88:652-660. We describe 2 patients with ocular Medications included ibuprofen, 13. Gass JD. Serous retinal pigment epithelial detachments with a notch. Retina. 1984;4:205- signs and symptoms who were sub- fexofenadine hydrochloride, and an 220. sequently diagnosed as having al- artificial tear preparation. Medical 14. Gass JD. Stereoscopic Atlas of Macular Dis- lergic fungal sinusitis (AFS). This and family histories were noncon- eases: Diagnosis and Treatment. 4th ed. St Louis, Mo: Mosby; 1997:24-32, 80-87, 1032-1045. disease is characterized primarily by tributory. His visual acuity was 20/20 15. Baumal CR, Duker JS, Wong J, Puliafito CA. In- chronic rhinosinusitis, nasal polyp- OU. Slight hypoglobus and 5-mm docyanine green hyperfluorescence associ- osis, allergic mucin, and the pres- proptosis were present in the left eye. ated with serous retinal pigment epithelial detachment in age-related macular degeneration. ence of fungal organisms according The remainder of the ocular exami- Ophthalmology. 1997;104:761-769. to a culture and/or histologic examination results were unremarkable. 16. Bird AC, Marshall J. Retinal pigment epithe- 1 lial detachments in the elderly. Trans Ophthal- nation. Clinical features are those An otolaryngologic consultation pro- mol Soc UK. 1986;105(pt 6):674-682. associated with chronic rhinosinus- vided findings of erythematous na- 17. Slakter JS, Yannuzzi LA, Sorenson JA, Guyer itis, which include facial pressure, res, congestion, a deviated nasal sep- DR, Ho AC, Orlock DA. A pilot study of indo- 2 cyanine green videoangiography-guided laser nasal obstruction, and rhinorrhea. tum, and polyps in the left nasal photocoagulation of occult choroidal neovas- Proptosis, ptosis, and diplopia are cavity. An orbital computed tomo- cularization in age-related macular degenera- the most common ocular symp- graphic (CT) scan revealed exten- tion. Arch Ophthalmol. 1994;112:465-472. 18. Lim JI, Aaberg TM, Capone A Jr, Sternberg P toms; however, these conditions sive sinus soft tissue opacification Jr. Indocyanine green angiography-guided pho- rarely represent the initial manifes- with sinus expansion and multifo- tocoagulation of choroidal neovascularization associated with retinal pigment epithelial de- tation of the disease. The nasal mu- cal erosion with lytic destruction of tachment. Am J Ophthalmol. 1997;123:524- cus specimens of patients with AFS bone along the paranasal sinuses. In 532. 19. Maguire JI, Benson WE, Brown GC. Treat- ment of foveal pigment epithelial detachments with contiguous extrafoveal choroidal neovascular membranes. Am J Ophthalmol. 1990;109:523-529. 20. Frank RN, Green WR, Pollack IP. Senile macular degeneration: clinicopathologic correlation of a case in the predisciform stage. Am J Ophthalmol. 1973;75:576-586. 21. Small ML, Green WR, Alpar JJ, Drewry RE. Se- nile macular degeneration: a clinicopathologic correlation of two cases with neovascularization beneath the retinal pigment epithelium. Arch Ophthalmol. 1976;94:601- 607. 22. Ho AC, Maguire MG, Yoken J, et al. Laser- induced drusen reduction improves visual func- Figure 1. A 15-year-old African American boy with proptosis, hypoglobus, and mild blepharoptosis of the tion at 1 year: Choroidal Neovascularization left eye.

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