Peripheral Exudative Hemorrhagic Chorioretinopathy
Download
Report
Transcript Peripheral Exudative Hemorrhagic Chorioretinopathy
Grand Rounds
Peripheral Exudative Hemorrhagic Chorioretinopathy
Mark Sherman MD
University of Louisville
Department of Ophthalmology and Visual Sciences
08/01/2014
Subjective
CC: Decreased vision in the right eye for four months
HPI: 70 year old white female presented to the retina
clinic with a four month history of painless decreased
vision in her right eye. Patient denied any other ocular
symptoms. No history of trauma. No recent illness.
POH: None
PMH: IDDM, HTN
Exam
BCVA:
OD
CF @ Face
OS
20/30
Pupils:
53
53
No APD
IOP:
EOM:
14
14
Full OU
Anterior Segment Exam
SLE:
L/L
Conjunctiva
K
AC
I/L
OD
OS
WNL
WNL
WNL
WNL
WNL
WNL
WNL
WNL
2+ NS
2+ NS
(No NVI OU)
DFE
OD: Dense vitreous hemorrhage, unable to
view
disc or fundus
OS: Disc WNL, attenuated vessels, few
scattered microaneurysms
(No NVD/NVE)
B-Scan OD
Dense vitreous hemorrhage; retina flat
Assessment/Differential Diagnosis
Assessment: 70 year old diabetic white female
with a dense vitreous hemorrhage OD x ~4
months
DDx:
1) Proliferative Diabetic Retinopathy
2) Retinal Tear/Break
3) Exudate age-related macular
degeneration
Plan:
Pars Plana Vitrectomy OD
Surgical Video
1 Week Follow-Up
S: Vision markedly improved, no complaints
O: BCVA: 20/30 OD, Anterior segment: Unchanged
DFE OD: retina flat, ~25% air bubble,
large sub-retinal clot inferior to inferior
arcade surrounded by laser,
peripheral laser 360 degrees
A: Peripheral Exudative Hemorrhagic Chorioretinopathy
Peripheral Exudative Hemorrhagic
Chorioretinopathy
Thought to be a variant of age related macular
degeneration
Characterized by blood in the subretinal or sub-retinal
pigment epithelial space in the peripheral retina
More common in older (70-80) Caucasians (~90%)
Often confused on presentation for vitreous hemorrhage
secondary to retinal detachment or break, choroidal
melanoma, or retinal artery macroaneurysm
Peripheral Exudative Hemorrhagic
Chorioretinopathy
Three characteristic lesion types
Hemorrhagic: subretinal or sub-pigment epithelium blood
present in the absence of exudate (60%)
Exudative: subretinal exudates in the absence of clinically
detectable blood (10%)
Exudative-Hemorrhagic: both blood and exudates present
(30%)
Treatment is usually not required unless secondary
complications occur (persistent vitreous
hemorrhage, retinal detachment, extension into the
macula)
Peripheral Exudative Hemorrhagic Chorioretinopathy
Simulating Choroidal melanoma in 173 eyes
Retrospective chart review of 173 eyes (146 patients)
Mean age: 80
145 (99%) Caucasian
98 (67%) Female
171 (99%) were referred for the diagnosis of choroidal
melanoma
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating
Choroidal Melanoma in 173 eyes. Ophthalmology. 2009;116:529-35.
Peripheral Exudative Hemorrhagic Chorioretinopathy
Simulating Choroidal melanoma in 173 eyes
Common clinical features:
Subretinal hemorrhage: 78%
Serous RPE detachment: 28%
Vitreous hemorrhage: 24%
Retinal exudation: 21%
Associate macular changes:
RPE changes: 23%
Drusen: 17%
Choroidal neovascularization: 8%
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating
Choroidal Melanoma in 173 eyes. Ophthalmology. 2009;116:529-35.
Peripheral Exudative Hemorrhagic Chorioretinopathy
Simulating Choroidal melanoma in 173 eyes
15 months of observation
90% stabilized or regressed
10% progressed
7% of patients developed exudative macular changes
Features found to differentiate from melanoma:
Retinal exudation
Hypofluorescence on FA
Lack of sentinel vessels
Cleft separating clot from from choroid on ultrasound
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic Chorioretinopathy Simulating
Choroidal Melanoma in 173 eyes. Ophthalmology. 2009;116:529-35.
Intravitreal Bevacizumab Injection for Peripheral
Exudative Hemorrhagic Chorioretinopathy
Case report of 74 year female referred for suspicion of choroidal
melanoma OD
Patient presented with 20/50 vision OD, WNL anterior segment,
mild vitreous hemorrhage, and a serous retinal detachment with
retinal and subretinal hemorrhages in the inferior periphery
B-Scan:
8mm x 3mm
infero-temporal lesion
Socorro, MA, Sabater N, et al. Intravitreal
Bevacizumab Injection for Peripheral Exudative
Hemorrhagic Chorioretinopathy. Jpn J Ophthalmol. 2011;55(4)425-7
Intravitreal Bevacizumab Injection for Peripheral
Exudative Hemorrhagic Chorioretinopathy
Patient was given a diagnosis of peripheral exudative
hemorrhagic chorioretinopathy and was observed
2 months later the patient returned with decreased vision
(20/100) and complaints of metamorphopsia
Exam showed increased vitreous hemorrhage and extension of
the serous retinal detachment into the macula
Patient was given an intravitreal injection of bevacizumab
One week follow-up: vision had improved to 20/40,
improvement of vitreous heme and complete resolution of
serous detachment
Socorro, MA, Sabater N, et al. Intravitreal Bevacizumab Injection for Peripheral Exudative
Hemorrhagic Chorioretinopathy. Jpn J Ophthalmol. 2011;55(4)425-7
References
Annesley, WH JR: Peripheral exudative hemorrhagic retinopathy. Trans Am
Ophthalmol Soc 78:321-364, 1980
BCSC: Retina and Vitreous. Peripheral Retinal Neovascularization. Pgs: 121-22
Mantel I, Uffer S, Zografos. Peripheral Exudative Hemorrhagic
Chorioretinopathy: A Clinical, Angiographic, and Histologic Study. Am J
Ophthalmol. 2009;148:932-38
Pinarci EY, Kilic, et al. Clinical Characteristics of Peripheral Exudative
Chorioretinopathy and its Response to Bevacizumab Therapy. Eye.
2013;27:111-12
Shields CL, Salazar PF, et al. Peripheral Exudative Hemorrhagic
Chorioretinopathy Simulating Choroidal Melanoma in 173 eyes. Ophthalmology.
2009;116:529-35.
Socorro, MA, Sabater N, et al. Intravitreal Bevacizumab Injection for
Peripheral Exudative Hemorrhagic Chorioreintopathy. Jpn J Ophthalmol.
2011;55(4)425-7