acta ophthalmol scand 2000 feigl-1
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—
ACTA OPHTHALMOLOGICA SCANDINAVICA 2000
Optical coherence tomography
OCT) n acute macular
neuroretinopathy
Beatrix Feigl
and
Anton Haas
Department of Ophthaltnology, University of Graz, Austria
ABSTRACT.
Purpose: To evaluate the value of ocular coherence tomography (OCT) concern-
in;̂ diagnosis and pathogenesis of acute macular neuroretinopathy.
Methods: A 33-year old woman complained of sudden onset of central scotomas
in her right eye hecause of acute niacutar neuroretinopathy. We performed a
direct ophthalmoscopy, a visual Held testing, a fluorescein angiography (FA) a
multifocal ERG (mf-ERG) and an OCT.
Re sults:
We found typical paracentral scotoma in visual field testing, a normal
FA and nif-KRG in her right eye. In OC T there was a hand of higher reflectivity
(115 ^m) overlying an intact hand corresponding to the retinal pigment epithel-
ium (RPE)/ choriocapillaris complex. Retinal thickness was within the normal
range.
Conclusion: OCT can he an additional valuahle tool in acute macular neuroreti-
nopathy us it is a disease with discrete pathology and often normal results in
other diagnostic tests.
Key words: optical coherence tomography - OCT - acute macular neuroretinopathy
Acta Ophthalmol. Scand. 2000: 78: 714-716
Copyright SI
cta
Ophlhalmot
Scard
2000
tSSN
1395 3907
A
cule macular neuroretinopathy was
.first discribed
by Bos and
Deut-
matin in 1975 and is a rare uni-or bilat-
eral tTiaculopathy of unknown etiology
itivolving mainly young women between
the ages
of
20 and 30 years. Most patients
experience sudden onset
of
paracentral
scototnas with preserved good visual acu-
ity, often with a preceding flu-like disease
(Bos Deutmann 1975; Miller et al.
1989).
Opiilhalmoscopy shows wedge-
shaped, red-brown lesions arranged radi-
ally in the macula. The lesions are sug-
gested
to be
located
in the
outer retina,
FA and standard electroretinography
(Sieving et al. 1984) typically are nor tnal .
whereas Amsler grid
and
visual fields
re-
veal parafoveal scotomas. Visual deficit
does
not
improve
as
persistance
of
macul-
opathy and scotomas have been de-
scribed up to 9 years (Desai et al . l993)
(e.g steroids) has not been proven to
date.
Case Report
A 33-year-old female patient complained
about sudden visual disturbances with
central, greyish, swirling scotomas
on her
right eye. A week before she had suffered
from a flu-Uke disease with fever, swelling
of
the
left subma ndi bula r lytnph nodes,
and pain in her joints. Othe r than taking
oral antibiotics after
the
onset
of
v'isual
problems, she did not receive any treat-
ment.
Visual acuity was 20/20 on her right
eye;
on her
left
eye she had a
decreased
visual acuity (20/100) because
of
squint-
ing as a child and amblyopia. Amsler
right eye. Direct ophthalmoscopy
vealed red-brown lesions (Fig. 1) in
macula area
and
visual field test
(Octopus
M2.
Interzeag. Switzerlan
showed paracentral scotomas (Fig
while the results on her left eye w
within the norm al range. First order K
nels
of
mf-ERG (Reti scan. Roland
C
suU. Wiesbaden. Germany) were norm
Fig, 1. Fundus examiniition showed a
reddish-brown lesion on the right eye.
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ACTA OPHTHALMOLOGICA SCANDINAVICA
2000
Fig. 3. a. OCT resu lts (longitu dinal scan and a rea showed on Fig. 1) on her right eye revealed a hyperrefleciivity (arrow ) above an und isturbe d Rl 'E/
chorio capillaris b and wh ich spares the foveal depression, b. Longitud inal O CT scan thro ugh the fovea on her left eye was within the norm al ran ge.
on her right eye and could not be per-
formed on her left eye because of ambly-
opia and difficulties in central fixation.
The horizontal OCT scan through the
tnacula (Humphrey Instruments. Zeiss.
Obcrkochen. Germany) on her right eye
showed a batid of hyp er reflectivity of 115
j^m overlying an intact RPE/choriocapil-
laris complex sparing the foveal de-
pression, and normal results on her left
eye (Fig. 3a. b).
Discussion
The lypica hallmarks of acute macular
neuroretinopathy are a younger age of
onset, female gender, paracentral scot-
omas and reddish-brown macular lesions,
but the pathogenesis is still unknown. It
is not clear cither why the lesions appear
red. A thin retinal blood layer has been
discussed but seems unlikely due to nor-
mal angiographic findings in most ofthe
patients, except a very slight hypolluo-
rescencc and not a dramatically blocked
flourescencc that would be expected from
blood (Kalina 1999). Nonetheless, a vas-
cular etiology has been discussed as pa-
tients with acute hypertension caused by
intravenous sytnpathomimetics (O'Brien
ct ai. 1989). patients receiving a contrast
agent for computed tomography (Guzak
ct al, 1983). as well as patients with ec-
lampsia (Kalina 1999) and oral contra-
ceptive use (Desai et al. 1993) have been
described to resetiible AMN. Recently.
heavy calTeitie con sum ptio n as well as hy-
potension have been published as ad-
ditional causes in AMN (Kerrison et al.
2000).
sensory retina with intact RPE and reti-
nal blood vessels, although an affection
of the inner layers of the retina causing
temporal disc pallor has been postulated
(Kerrison etal. 2000).
Standard electroretinography is nor-
mal, but early receptor potentials are re-
duced, confirming assignment of the
pathology to the photoreceptors (Sieving
et al. 1984). Therefore, one would expect
also reduction in mf-ERG as it refiects
photoreceptor function in well defined
small areas. We could not tind any path-
ology in mf-ERG. but maybe the area
was too small to be detected. As we used
a 61 hexagonal stimulus perhaps the use
of more stimulus segments, for example
of 103 or 206 hexagons, would have been
of greater diagnostic value.
In our patient we found n orma l thick-
ness of the retinal layers including the
nerve fibre layer (NFL) and a stnall area
of hyper reflectivity overlying an undi s-
turbed RPE/choriocapillaris complex in
OCT Hyperreflectivity in OCT is found
in several disorders including inflamma-
tory processes, chorioretinal neovascu-
larisations. hard exudates. fibrosis. and
hemorrhages,
Considering hyperreflectivity due to an
inflammatory process maybe our findings
could reflect a swelling ofthe photorecep-
tor ceils or an increase ofth e intercellular
matrix because of inflammatory cells in
the outer layer of the retina.
As in many patients with acute macu-
lar neuroretinopathy a preceding flu-like
disease can be found and an autoitnmune
response to retinal antigens may also play
a causative role in this entity.
There are several antigens from the
agent for an autoimmune response in-
ducing blast transformation of lympho-
cytes,
causing an immune memory and
therefore ati inllamniatory reaction (Nus-
senblatt et al,1980).
So possibly an initial process like a
viral infection with subsequent exposure
of normally sequestered antigens from
the retinal photoreceptors to the immune
system and sensitization may be the incit-
ing cause in AMN.
Nevertheless, whether hyperrefiectivity
in our pa tient is due to an inflamm atory
or a preceding vascular event which leads
to a small hemorrhagic lesion that would
explain the reddish-brown colour i.s still
unclear and canno t be differentiated with
OCT. But our observations may under-
line the the location of AMN in the outer
retinal layer.
References
Bos PJ & Deutmann AF (1975): Acute macu-
lar neuroretinopathy. Am J Ophthalmol 80;
573-584 .
Desai UR. Sudhamathi K & Natarajan S
(1993); Intravenous epinephrine and acute
macular neuroretinopathy (Letter). Arch
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Gu zak SV, Kalinii RE & Chenoweth RG
(1983); Acute macular neuroretinopathy fol-
lowing adverse reaction lo intravenous con-
trast media. Reiina 3; 312-317.
Kalina RE (1999); Acute macular neiirorclino-
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Kerrison JB. Pollock SC. Biousse V New-
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— ACTA OPHTHALMOLOGICA SCANDINAVICA 2000
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Received on May 29th, 2000.
Accepted on July
1
hh . 2000 .
Corresponding author:
Beatrix Feigl. M.D.
Deparlment ot Ophthalmology
Univ. Augenklinik
Auenbruggerplaiz 4
8036 Graz
Austria
Tel: 0316 385 2394
Fax: 0316 385 3261
e-mail; [email protected]
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