AMERICAN JOURNAL OF OPHTHALMOLOGY VOLUME 88
NUMBER 4
OCTOBER, 1979
NATURAL HISTORY O F SEROUS D E T A C H M E N T S O F T H E RETINAL P I G M E N T E P I T H E L I U M T R A V I S A. M E R E D I T H , M.D., R I C H A R D E. B R A L E Y , AND T H O M A S M. A A R E R G , M.D. Milwaukee,
Serous detachment of the retinal pig ment epithelium from the underlying Bruch's membrane creates a distinctive clinical and angiographic appearance. Appearing as rounded domes beneath the neurosensory retina, serous detachments characteristically fill with dye early dur ing fluorescein angiography and retain the dye for long periods of time. 1 , 2 These serous detachments occur in a variety of disease processes including central se rous choroidopathy, age-related degener ative choroidopathy, angioid streaks, and choroidal tumors. 2 Gass 1 postulated that the formation of this space beneath the pigment epithelium in many diseases is complicated by ingrowth of new vessels with subsequent bleeding and organiza tion to form a fibrovascular scar. In a study of a small number of patients with drusen, Teeters and Bird 3 suggested that this occurred with great frequency in a short period of time after initial clinical diagnosis in these patients. Lewis 4 report ed in patients younger than age 55 years, both with and without drusen, that the From the Retina Service, Department of Ophthal mology, the Medical College of Wisconsin and Milwaukee County Medical Complex, Milwaukee, Wisconsin. Reprint requests to Travis A. Meredith, M.D., Department of Ophthalmology, Medical College of Wisconsin, 8700 W. Wisconsin Ave., Milwaukee, WI 53226.
M.D.,
Wisconsin
course of retinal pigment epithelial de tachments is benign and neovascularization of the subretinal space rarely oc curs. We report herein a clinical and fluores cein angiographic study undertaken to delineate the risk of vascular complica tions in initially avascular lesions, and define prognostic factors in patients with serous detachments not associated with choroidal tumors, severe myopia, or angi oid streaks. M A T E R I A L AND M E T H O D S
For the purposes of this study a serous detachment of the retinal pigment epithe lium was defined as a clinically detecta ble elevation of the retinal pigment epi thelium one-fourth disk diameter or greater in size. Each patient was studied shortly after clinical examination with stereoscopic color photography and fluo rescein angiography. Patients with serous retinal pigment epithelial detachment associated with severe myopia, angioid streaks, or choroidal tumors were not in cluded. Patients were excluded from the study if angiography revealed subretinal neovascularization or findings suggestive of subretinal neovascularization such as blocked fluorescence or focal bright spots of hyperfluorescence, or if subretinal blood or lipid suggested subretinal ves sels were present even though not detect-
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able by angiography. All patients seen by us between January 1972 and March 1977 who met these diagnostic criteria were enrolled in the study. The follow-up goal of the study was to observe each of these patients for at least one year with repeated clinical examinations. Stereoscopic color photography and fluorescein angiography were performed at selected intervals but were repeated at least once one year or longer after the initial angiography. Follow-up was considered complete, however, if subfetinal bleeding occurred or subretinal neovascularization was de tected by angiography before one year elapsed. Fifty eight eyes of 45 patients were diagnosed with serous retinal pigment epithelial detachment during the study period. Fifty eyes of 40 patients met the follow-up criteria. Therefore, 86% of the eyes and. 89% of the patients meeting the diagnostic criteria of the study could be followed up for a period sufficient to meet the natural history criteria, and these 50 eyes constitute the basis of this report. RESULTS
Of the 40 patients, 15 were men and 25 were women. The age range at diagnosis was 42 to 82 years with a median of 65 years. The data are summarized in Table 1. The end of the follow-up period was defined as either the occurrence of subret inal bleeding or subretinal neovasculari zation detected on angiography, or as the time when the patient was last studied with fluorescein angiography. The mean follow-up period was 22 months and ranged from two months (the earliest time of bleeding after clinical diagnosis of serous retinal pigment epithelial detach ment) to 59 months. The median followup was 16 months. Of 50 eyes, nine developed clinically detectable subretinal bleeding and five additional eyes showed subretinal new
OCTOBER, 1979
vessels by angiography (Figs. 1-4). Of all eyes in the study, therefore, 14 (28%) developed subretinal vascular changes. Five of the eyes (10%) developed sub retinal vascularity or bleeding within the first six months after clinical examination (Table 2). An additional three had these changes within the second six months; thus eight (16%) of the eyes developed vascular changes within the first year. Thirty-two eyes were followed up for more than one year and six (18.9%) addi tional eyes developed vascular complica tions. Age at time of diagnosis was important prognostically (Table 3). No patient younger than 56 years old at diagnosis developed subretinal new vessels. Of 39 patients who were 56 years or older, 14 (35.9%) developed these vascular compli cations. Slightly greater than nine of 31 (29%) of patients who were between 56 and 75 years old at diagnosis developed vascular complications, whereas five of eight (62.5%) of those over 75 years old at diagnosis developed bleeding or new ves sels. Of patients observed in this study, the youngest age at time of bleeding was 58 years, the same age reported by Gass 5 as the earliest development of a disciform lesion in his study of patients with drusen. Subretinal new vessels developed ex clusively in those serous detachments equal to or greater than one disk diameter in size (Table 4). Serous detachments smaller than one disk diameter occurred in six of 11 eyes in patients younger than age 55 years. In patients older than 55 years, bleeding occurred in 14 (41.2%) of those eyes containing a detachment greater than one disk diameter in size. Height of the detachment is difficult to quantitate but eight detachments showed high elevation of the center of the dome in addition to a diameter greater than one disk diameter and all eight of these devel oped bleeding or new vessels.
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TABLE 1 SUMMARY O F DATA*
Case No.
Age (yrs)
Initial Visual Acuity
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
77 60 56 73 64 76 76 70 70 73 73 61 61 70 74 69 74 63 74 80 82 76 74 58 62 76 82 64 66 66 70 64 61 57 57 67 67 56 66
6/9 (20/30) 6/7.5 (20/25) 6/21 (20/70) 6/12 (20/40) 6/18 (20/60) 6/60 (20/200) 6/7.5 (20/25) 6/9 (20/30) 6/9 (20/30) 6/24 (20/80) 6/9 (20/30) 6/6 (20/20) (3/120) 6/6 (20/20) 6/7.5 (20/25) 6/9 (20/30) 6/60 (20/200) 6/21 (20/70) 6/7.5 (20/25) 6/18 (20/60) 6/24 (20/80) Counting fingers 6/24 (20/80) 6/7.5 (20/25) 6/18 (20/60) 6/60 (20/200) 6/21 (20/70) 6/6 (20/20) 6/12 (20/40) 6/15 (20/50) 6/12 (20/40) 6/9 (20/30) 6/4.5 (20/15) 6/6 (20/20) 6/15 (20/50) 6/7.5 (20/25) 6/7.5 (20/25) 6/7.5 (20/25) 6/9 (20/30)
1 2 3 4 5 6 7 8 9 10 11
44 42 46 46 54 55 55 48 53 47 54
6/7.5 (20/25) 6/24 (20/80) 6/15 (20/50) 6/6 (20/20) 6/18 (20/60) 6/4.5 (20/15) 6/4.5 (20/15) Counting fingers 6/30 (20/100) 6/6 (20/20) 6/18 (20/60)
Fellow Eye
Associated Changes
Months Follow-up
Final Visual Acuity
I I RPEA
34 22 36 15 59 13 13 16 16 15 15 12 12 37 25 15 18 12 41 19 13 14 39 30 43 6 2 25 42 12 16 50 13 12 12 38 38 24 12
6/9 (20/30) 6/9 (20/30) Counting fingers Counting fingers Counting fingers 6/60 (20/200) 6/7.5 (20/25) 6/9 (20/30) 6/15 (20/50) 6/60 (20/200) 6/9 (20/30) 6/6 (20/20) 6/60 (20/200) 6/6 (20/20) 6/15 (20/50) 6/15 (20/50) 6/90 (20/300) 6/21 (20/70) 6/12 (20/40) Counting fingers Counting fingers Counting fingers 6/120 (20/400) 6/60 (20/200) Counting fingers Counting fingers Counting fingers 6/6 (20/20) 6/120 (20/400) 6/30 (20/100) 6/12 (20/40) Counting fingers 6/4.5 (20/15) 6/6 (20/20) 6/15 (20/50) 6/9 (20/30) 6/12 (20/40) 6/6 (20/20) 6/18 (20/60)
55 years or younger RPEA SRF, P F S D, SRF R D S SRF, P F R D, SRF, P F RPEA D, SRF, P F RPEA PF I D, P F RPEA PF I RPEA
49 12 12 12 14 21 21 22 20 12 12
6/9 (20/30) 6/18 (20/60) 6/6 (20/20) 6/6 (20/20) 6/18 (20/60) 6/4.5 (20/15) 6/4.5 (20/15) Counting fingers 6/9 (20/30) 6/6 (20/20) 6/12 (20/40)
Patients older than age 55 D, SRF, P F D, Disc D D, SRF, P F D, S P E D D, SRF, P F D, Disc D, P F D D, SRF D, SPED D, SRF, P F D, SPED D, SRF, PF D, S P E D D, SRF, P F D, SPED D, SRF, P F D, SPED D, SRF, P F D, SPED D, SRF D, SPED D, SRF, P F D, S P E D D, SRF, P F RPEA PF D, Disc D, PF D D, SRF D, Disc D, SRF D D, SRF D, SRF, PF D, G D, Disc D, SRF, P F D, SRF D D, SRF, P F D SRF, P F D,PF D D, PF D D, SRF, PF D, Disc D, SRF, P F Disc D, SRF D, SRF, P F Disc D, SRF Disc D D, SRF RPEA D, SRF RPEA D, S P E D D, RPEA D, SPED D, RPEA D, SPED D D, S P E D D SPED D D D, SRF Patients age RPEA RPEA D, S P E D D, S P E D SPED D, S P E D D, S P E D D SPED
Course years S RPEA Bled Bled Bled 1SRF JSRF S S RPEA S S RPEA RPEA RPEA SNV SNV SNV S Bled Bled SNV Bled RPEA G Bled Bled S Bled ISRF I SNV S
s sI
*G designates geographic atrophy; I, increased; S, stable; R, resolved; Disc, discifomi; SPED, serous pigment epithelial detachment; D, drusen; RPEA, retinal pigment epithelial atrophy; SRF, subretinal fluid; SNV, subretinal neovascularization; and PF, pigment figure.
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Fig. 1 (Meredith, Braley, and Aaberg). Case 27. Right eye, Classic cartwheel of subretinal neovascu larization developing beneath retinal pigment epi thelial detachment.
OCTOBER, 1979
Fig. 3 (Meredith, Braley, and Aaberg). Case 32. Right eye, Visual acuity of counting fingers; fundus photographs show only mild retinal pigment epithe lial changes but small area of subretinal lipid.
Involvement of the fovea (defined as an area roughly equivalent to the normal retinal avascular zone) by the serous de tachment was important prognostically in patients older than age 55 years (Table 5). In these older patients, 13 (39.4%) devel oped vascular complications as compared to one (16.7%) of those in which the fovea was not involved. Foveal involvement was present in only six of 11 eyes of patients age 55 years or younger.
Subretinal fluid was present in five of 11 eyes of patients 55 years or younger at diagnosis and in 28 of 39 eyes of patients age 56 years or older at diagnosis. Twelve of these 28 eyes (42.9%) developed vascu lar complications; two of 11 eyes without subretinal fluid (18.2%) developed these complications. These latter numbers are not statistically significantly different. Disciform detachment in the fellow eye
Fig. 2 (Meredith, Braley, and Aaberg). Case 29. Right eye, Disciform scar developing after retinal pigment epithelial detachment.
Fig. 4 (Meredith, Braley, and Aaberg). Case 32. Right eye, Diffuse subretinal neovascularization shown on fluorescein angiogram.
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SEROUS DETACHMENTS TABLE 2
TABLE 3
OCCURENCE OF BLEEDING OR SUBRETINAL NEOVASCULARIZATION RELATED TO FOLLOW-UP PERIOD
AGE AT DIAGNOSIS RELATED TO DEVELOPMENT OF SUBRETINAL NEOVASCULARIZATION OR BLEEDING
Follow-up (mos)
No. of Eyes
Subretinal Vessels or Bleeding
0-6 7-12 13-24 25-36 37-48 49-60 61-72
5 13 12 8 4 7 1
5 3 2 1 1 2 0
and the presence of a pigment figure associated with the detachment did not have a statistically significant influence on prognosis. Of eyes of patients older than age 55 years with a disciform lesion in the fellow eye, four of nine (44.4%) developed hemorrhagic complications, whereas ten of 30 (33.3%) of those with out disciform lesions did. A pigment fig ure was difficult to define precisely be cause pigment clumping existed over nearly all the detachments in the study. The presence of a definite pigment figure conferred no safety, however, since seven of 14 (50%) of the detachments that devel oped vascular complications had a marked pigment figure on initial photog raphy. In eyes that did not develop subretinal neovascularization, the retinal pigment epithelial detachment persisted or in creased in size in four of 11 eyes (36.4%) of patients younger than age 56 years and in 17 of 25 eyes (68%) of patients age 56
Age (yrs)
No. of Eyes
42-55 56-65 66-75 76-82
11 15 16 8
Subretinal Neovascularization or Bleeding No.
%
0 4 5 5
0 26.6 31.2 62.5
years or older. Of patients less than age 55 years, five of 11 had definite drusen, an incidence comparable to that noted by Lewis. 4 Of patients greater than age 55 years, 36 of 39 had definite drusen. One additional patient had drusen only in the fellow eye. Mild atrophy of the retinal pigment epithelium was almost universal after spontaneous resolution of serous retinal pigment epithelial detachments. In some cases this was shown only as trans mission defects on fluorescein angiography, while scarcely visible on ophthalmoscopic examination and color photogra phy. In only one case did this lead to the distinctive picture of geographic atrophy of the retinal pigment epithelium (Fig 5). One additional eye showed a clear-cut zone of atrophy that was of dimensions less than that usually seen in classic geo graphic atrophy. Visual outcome depend ed in part on the age of the patient at diagnosis. Patients age 55 years or young er lost more than one line of Snellen
TABLE 4 DEVELOPMENT OF BLEEDING OR SUBRETINAL NEOVASCULARIZATION RELATED TO SIZE OF RETINAL PIGMENT EPITHELIAL DETACHMENT
Size of Detatchment < 1 disk diameter > 1 disk diameter
Eyes of Patients 56-82 years old No. 0/5 14/34
All Eyes %
No.
%
0 41.2
0/11 14/39
0 35.9
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TABLE 5 D E V E L O P M E N T O F B L E E D I N G OR S U B R E T I N A L N E O V A S C U L A R I Z A T I O N R E L A T E D T O I N V O L V E M E N T O F F O V E A BY R E T I N A L P I G M E N T E P I T H E L I A L D E T A C H M E N T
Initial Retinal Pigment Epithelial detachment Fovea not involved Fovea involved
Eyes in Patients 56-82 years old No. % 1/6 13/33
acuity during the follow-up period in one case (9.1%) and improved in three (27.3%) (Table 6 and Fig. 6). In contrast, the older group of eyes showed improvement in only one of 39 (2.6%) of the cases and suffered a decline of greater than one line of Snellen acuity in 51.3% of the eyes. Of eyes of patients younger than 55 years, five of 11 (45.5%) had visual acuity of 6/12 (20/40) or better at the beginning of the study and seven of 11 (63.6%) achieved this level by the end of the study. Of the eyes of patients older than this group, 23 of 39 (59%) had visual acuity of 6/12 (20/40) or better at the beginning of the study and only 14 of 39 (35.9%) achieved this level of visual acu-
Ml Eyes
16.7 39.4
No.
%
1/12 13/38
8.3 34.2
ity at the end of the study. When visual acuity of 6/24 (20/80) is taken as a refer ence point, nine of 11 (81.8%) of the eyes of the younger group attained this level at the beginning of the study and ten of 11 (90.9%) of the eyes did so at the end of the study. In the older age group, 34 of 39 (87.1%) began with visual acuity of 6/24 (20/80) or better, but only 21 of 39 (53.8%) achieved this level at the completion of follow-up. DISCUSSION
The development of a serous detach ment of the retinal pigment epithelium often causes symptomatic loss of vision. Gass, Norton, and Justice 2 proposed that the prognosis for these detachments de pends on the underlying disease process, and that some patients may go on to develop vascularization beneath the reti nal pigment epithelium with subsequent disciform scarring. Retinal pigment epi thelial detachments in a younger age group may be part of the manifestation of
TABLE 6 VISUAL O U T C O M E
Age 42-55 yrs Age 56-82 yrs All No. % No. % No. % Fig. 5 (Meredith, Braley, and Aaberg). Case 25. Geographic retinal pigment epithelium atrophy de veloping after retinal pigment epithelial detach ment.
Better Same Worse
3 7 1
27.3 63.6 9.1
1 18 20
2.6 46.1 51.3
4 25 21
8 50 42
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SEROUS DETACHMENTS
NUMBER 4
OCTOBER, 1979
NATURAL HISTORY O F SEROUS D E T A C H M E N T S O F T H E RETINAL P I G M E N T E P I T H E L I U M T R A V I S A. M E R E D I T H , M.D., R I C H A R D E. B R A L E Y , AND T H O M A S M. A A R E R G , M.D. Milwaukee,
Serous detachment of the retinal pig ment epithelium from the underlying Bruch's membrane creates a distinctive clinical and angiographic appearance. Appearing as rounded domes beneath the neurosensory retina, serous detachments characteristically fill with dye early dur ing fluorescein angiography and retain the dye for long periods of time. 1 , 2 These serous detachments occur in a variety of disease processes including central se rous choroidopathy, age-related degener ative choroidopathy, angioid streaks, and choroidal tumors. 2 Gass 1 postulated that the formation of this space beneath the pigment epithelium in many diseases is complicated by ingrowth of new vessels with subsequent bleeding and organiza tion to form a fibrovascular scar. In a study of a small number of patients with drusen, Teeters and Bird 3 suggested that this occurred with great frequency in a short period of time after initial clinical diagnosis in these patients. Lewis 4 report ed in patients younger than age 55 years, both with and without drusen, that the From the Retina Service, Department of Ophthal mology, the Medical College of Wisconsin and Milwaukee County Medical Complex, Milwaukee, Wisconsin. Reprint requests to Travis A. Meredith, M.D., Department of Ophthalmology, Medical College of Wisconsin, 8700 W. Wisconsin Ave., Milwaukee, WI 53226.
M.D.,
Wisconsin
course of retinal pigment epithelial de tachments is benign and neovascularization of the subretinal space rarely oc curs. We report herein a clinical and fluores cein angiographic study undertaken to delineate the risk of vascular complica tions in initially avascular lesions, and define prognostic factors in patients with serous detachments not associated with choroidal tumors, severe myopia, or angi oid streaks. M A T E R I A L AND M E T H O D S
For the purposes of this study a serous detachment of the retinal pigment epithe lium was defined as a clinically detecta ble elevation of the retinal pigment epi thelium one-fourth disk diameter or greater in size. Each patient was studied shortly after clinical examination with stereoscopic color photography and fluo rescein angiography. Patients with serous retinal pigment epithelial detachment associated with severe myopia, angioid streaks, or choroidal tumors were not in cluded. Patients were excluded from the study if angiography revealed subretinal neovascularization or findings suggestive of subretinal neovascularization such as blocked fluorescence or focal bright spots of hyperfluorescence, or if subretinal blood or lipid suggested subretinal ves sels were present even though not detect-
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able by angiography. All patients seen by us between January 1972 and March 1977 who met these diagnostic criteria were enrolled in the study. The follow-up goal of the study was to observe each of these patients for at least one year with repeated clinical examinations. Stereoscopic color photography and fluorescein angiography were performed at selected intervals but were repeated at least once one year or longer after the initial angiography. Follow-up was considered complete, however, if subfetinal bleeding occurred or subretinal neovascularization was de tected by angiography before one year elapsed. Fifty eight eyes of 45 patients were diagnosed with serous retinal pigment epithelial detachment during the study period. Fifty eyes of 40 patients met the follow-up criteria. Therefore, 86% of the eyes and. 89% of the patients meeting the diagnostic criteria of the study could be followed up for a period sufficient to meet the natural history criteria, and these 50 eyes constitute the basis of this report. RESULTS
Of the 40 patients, 15 were men and 25 were women. The age range at diagnosis was 42 to 82 years with a median of 65 years. The data are summarized in Table 1. The end of the follow-up period was defined as either the occurrence of subret inal bleeding or subretinal neovasculari zation detected on angiography, or as the time when the patient was last studied with fluorescein angiography. The mean follow-up period was 22 months and ranged from two months (the earliest time of bleeding after clinical diagnosis of serous retinal pigment epithelial detach ment) to 59 months. The median followup was 16 months. Of 50 eyes, nine developed clinically detectable subretinal bleeding and five additional eyes showed subretinal new
OCTOBER, 1979
vessels by angiography (Figs. 1-4). Of all eyes in the study, therefore, 14 (28%) developed subretinal vascular changes. Five of the eyes (10%) developed sub retinal vascularity or bleeding within the first six months after clinical examination (Table 2). An additional three had these changes within the second six months; thus eight (16%) of the eyes developed vascular changes within the first year. Thirty-two eyes were followed up for more than one year and six (18.9%) addi tional eyes developed vascular complica tions. Age at time of diagnosis was important prognostically (Table 3). No patient younger than 56 years old at diagnosis developed subretinal new vessels. Of 39 patients who were 56 years or older, 14 (35.9%) developed these vascular compli cations. Slightly greater than nine of 31 (29%) of patients who were between 56 and 75 years old at diagnosis developed vascular complications, whereas five of eight (62.5%) of those over 75 years old at diagnosis developed bleeding or new ves sels. Of patients observed in this study, the youngest age at time of bleeding was 58 years, the same age reported by Gass 5 as the earliest development of a disciform lesion in his study of patients with drusen. Subretinal new vessels developed ex clusively in those serous detachments equal to or greater than one disk diameter in size (Table 4). Serous detachments smaller than one disk diameter occurred in six of 11 eyes in patients younger than age 55 years. In patients older than 55 years, bleeding occurred in 14 (41.2%) of those eyes containing a detachment greater than one disk diameter in size. Height of the detachment is difficult to quantitate but eight detachments showed high elevation of the center of the dome in addition to a diameter greater than one disk diameter and all eight of these devel oped bleeding or new vessels.
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TABLE 1 SUMMARY O F DATA*
Case No.
Age (yrs)
Initial Visual Acuity
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
77 60 56 73 64 76 76 70 70 73 73 61 61 70 74 69 74 63 74 80 82 76 74 58 62 76 82 64 66 66 70 64 61 57 57 67 67 56 66
6/9 (20/30) 6/7.5 (20/25) 6/21 (20/70) 6/12 (20/40) 6/18 (20/60) 6/60 (20/200) 6/7.5 (20/25) 6/9 (20/30) 6/9 (20/30) 6/24 (20/80) 6/9 (20/30) 6/6 (20/20) (3/120) 6/6 (20/20) 6/7.5 (20/25) 6/9 (20/30) 6/60 (20/200) 6/21 (20/70) 6/7.5 (20/25) 6/18 (20/60) 6/24 (20/80) Counting fingers 6/24 (20/80) 6/7.5 (20/25) 6/18 (20/60) 6/60 (20/200) 6/21 (20/70) 6/6 (20/20) 6/12 (20/40) 6/15 (20/50) 6/12 (20/40) 6/9 (20/30) 6/4.5 (20/15) 6/6 (20/20) 6/15 (20/50) 6/7.5 (20/25) 6/7.5 (20/25) 6/7.5 (20/25) 6/9 (20/30)
1 2 3 4 5 6 7 8 9 10 11
44 42 46 46 54 55 55 48 53 47 54
6/7.5 (20/25) 6/24 (20/80) 6/15 (20/50) 6/6 (20/20) 6/18 (20/60) 6/4.5 (20/15) 6/4.5 (20/15) Counting fingers 6/30 (20/100) 6/6 (20/20) 6/18 (20/60)
Fellow Eye
Associated Changes
Months Follow-up
Final Visual Acuity
I I RPEA
34 22 36 15 59 13 13 16 16 15 15 12 12 37 25 15 18 12 41 19 13 14 39 30 43 6 2 25 42 12 16 50 13 12 12 38 38 24 12
6/9 (20/30) 6/9 (20/30) Counting fingers Counting fingers Counting fingers 6/60 (20/200) 6/7.5 (20/25) 6/9 (20/30) 6/15 (20/50) 6/60 (20/200) 6/9 (20/30) 6/6 (20/20) 6/60 (20/200) 6/6 (20/20) 6/15 (20/50) 6/15 (20/50) 6/90 (20/300) 6/21 (20/70) 6/12 (20/40) Counting fingers Counting fingers Counting fingers 6/120 (20/400) 6/60 (20/200) Counting fingers Counting fingers Counting fingers 6/6 (20/20) 6/120 (20/400) 6/30 (20/100) 6/12 (20/40) Counting fingers 6/4.5 (20/15) 6/6 (20/20) 6/15 (20/50) 6/9 (20/30) 6/12 (20/40) 6/6 (20/20) 6/18 (20/60)
55 years or younger RPEA SRF, P F S D, SRF R D S SRF, P F R D, SRF, P F RPEA D, SRF, P F RPEA PF I D, P F RPEA PF I RPEA
49 12 12 12 14 21 21 22 20 12 12
6/9 (20/30) 6/18 (20/60) 6/6 (20/20) 6/6 (20/20) 6/18 (20/60) 6/4.5 (20/15) 6/4.5 (20/15) Counting fingers 6/9 (20/30) 6/6 (20/20) 6/12 (20/40)
Patients older than age 55 D, SRF, P F D, Disc D D, SRF, P F D, S P E D D, SRF, P F D, Disc D, P F D D, SRF D, SPED D, SRF, P F D, SPED D, SRF, PF D, S P E D D, SRF, P F D, SPED D, SRF, P F D, SPED D, SRF, P F D, SPED D, SRF D, SPED D, SRF, P F D, S P E D D, SRF, P F RPEA PF D, Disc D, PF D D, SRF D, Disc D, SRF D D, SRF D, SRF, PF D, G D, Disc D, SRF, P F D, SRF D D, SRF, P F D SRF, P F D,PF D D, PF D D, SRF, PF D, Disc D, SRF, P F Disc D, SRF D, SRF, P F Disc D, SRF Disc D D, SRF RPEA D, SRF RPEA D, S P E D D, RPEA D, SPED D, RPEA D, SPED D D, S P E D D SPED D D D, SRF Patients age RPEA RPEA D, S P E D D, S P E D SPED D, S P E D D, S P E D D SPED
Course years S RPEA Bled Bled Bled 1SRF JSRF S S RPEA S S RPEA RPEA RPEA SNV SNV SNV S Bled Bled SNV Bled RPEA G Bled Bled S Bled ISRF I SNV S
s sI
*G designates geographic atrophy; I, increased; S, stable; R, resolved; Disc, discifomi; SPED, serous pigment epithelial detachment; D, drusen; RPEA, retinal pigment epithelial atrophy; SRF, subretinal fluid; SNV, subretinal neovascularization; and PF, pigment figure.
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Fig. 1 (Meredith, Braley, and Aaberg). Case 27. Right eye, Classic cartwheel of subretinal neovascu larization developing beneath retinal pigment epi thelial detachment.
OCTOBER, 1979
Fig. 3 (Meredith, Braley, and Aaberg). Case 32. Right eye, Visual acuity of counting fingers; fundus photographs show only mild retinal pigment epithe lial changes but small area of subretinal lipid.
Involvement of the fovea (defined as an area roughly equivalent to the normal retinal avascular zone) by the serous de tachment was important prognostically in patients older than age 55 years (Table 5). In these older patients, 13 (39.4%) devel oped vascular complications as compared to one (16.7%) of those in which the fovea was not involved. Foveal involvement was present in only six of 11 eyes of patients age 55 years or younger.
Subretinal fluid was present in five of 11 eyes of patients 55 years or younger at diagnosis and in 28 of 39 eyes of patients age 56 years or older at diagnosis. Twelve of these 28 eyes (42.9%) developed vascu lar complications; two of 11 eyes without subretinal fluid (18.2%) developed these complications. These latter numbers are not statistically significantly different. Disciform detachment in the fellow eye
Fig. 2 (Meredith, Braley, and Aaberg). Case 29. Right eye, Disciform scar developing after retinal pigment epithelial detachment.
Fig. 4 (Meredith, Braley, and Aaberg). Case 32. Right eye, Diffuse subretinal neovascularization shown on fluorescein angiogram.
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SEROUS DETACHMENTS TABLE 2
TABLE 3
OCCURENCE OF BLEEDING OR SUBRETINAL NEOVASCULARIZATION RELATED TO FOLLOW-UP PERIOD
AGE AT DIAGNOSIS RELATED TO DEVELOPMENT OF SUBRETINAL NEOVASCULARIZATION OR BLEEDING
Follow-up (mos)
No. of Eyes
Subretinal Vessels or Bleeding
0-6 7-12 13-24 25-36 37-48 49-60 61-72
5 13 12 8 4 7 1
5 3 2 1 1 2 0
and the presence of a pigment figure associated with the detachment did not have a statistically significant influence on prognosis. Of eyes of patients older than age 55 years with a disciform lesion in the fellow eye, four of nine (44.4%) developed hemorrhagic complications, whereas ten of 30 (33.3%) of those with out disciform lesions did. A pigment fig ure was difficult to define precisely be cause pigment clumping existed over nearly all the detachments in the study. The presence of a definite pigment figure conferred no safety, however, since seven of 14 (50%) of the detachments that devel oped vascular complications had a marked pigment figure on initial photog raphy. In eyes that did not develop subretinal neovascularization, the retinal pigment epithelial detachment persisted or in creased in size in four of 11 eyes (36.4%) of patients younger than age 56 years and in 17 of 25 eyes (68%) of patients age 56
Age (yrs)
No. of Eyes
42-55 56-65 66-75 76-82
11 15 16 8
Subretinal Neovascularization or Bleeding No.
%
0 4 5 5
0 26.6 31.2 62.5
years or older. Of patients less than age 55 years, five of 11 had definite drusen, an incidence comparable to that noted by Lewis. 4 Of patients greater than age 55 years, 36 of 39 had definite drusen. One additional patient had drusen only in the fellow eye. Mild atrophy of the retinal pigment epithelium was almost universal after spontaneous resolution of serous retinal pigment epithelial detachments. In some cases this was shown only as trans mission defects on fluorescein angiography, while scarcely visible on ophthalmoscopic examination and color photogra phy. In only one case did this lead to the distinctive picture of geographic atrophy of the retinal pigment epithelium (Fig 5). One additional eye showed a clear-cut zone of atrophy that was of dimensions less than that usually seen in classic geo graphic atrophy. Visual outcome depend ed in part on the age of the patient at diagnosis. Patients age 55 years or young er lost more than one line of Snellen
TABLE 4 DEVELOPMENT OF BLEEDING OR SUBRETINAL NEOVASCULARIZATION RELATED TO SIZE OF RETINAL PIGMENT EPITHELIAL DETACHMENT
Size of Detatchment < 1 disk diameter > 1 disk diameter
Eyes of Patients 56-82 years old No. 0/5 14/34
All Eyes %
No.
%
0 41.2
0/11 14/39
0 35.9
648
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER, 1979
TABLE 5 D E V E L O P M E N T O F B L E E D I N G OR S U B R E T I N A L N E O V A S C U L A R I Z A T I O N R E L A T E D T O I N V O L V E M E N T O F F O V E A BY R E T I N A L P I G M E N T E P I T H E L I A L D E T A C H M E N T
Initial Retinal Pigment Epithelial detachment Fovea not involved Fovea involved
Eyes in Patients 56-82 years old No. % 1/6 13/33
acuity during the follow-up period in one case (9.1%) and improved in three (27.3%) (Table 6 and Fig. 6). In contrast, the older group of eyes showed improvement in only one of 39 (2.6%) of the cases and suffered a decline of greater than one line of Snellen acuity in 51.3% of the eyes. Of eyes of patients younger than 55 years, five of 11 (45.5%) had visual acuity of 6/12 (20/40) or better at the beginning of the study and seven of 11 (63.6%) achieved this level by the end of the study. Of the eyes of patients older than this group, 23 of 39 (59%) had visual acuity of 6/12 (20/40) or better at the beginning of the study and only 14 of 39 (35.9%) achieved this level of visual acu-
Ml Eyes
16.7 39.4
No.
%
1/12 13/38
8.3 34.2
ity at the end of the study. When visual acuity of 6/24 (20/80) is taken as a refer ence point, nine of 11 (81.8%) of the eyes of the younger group attained this level at the beginning of the study and ten of 11 (90.9%) of the eyes did so at the end of the study. In the older age group, 34 of 39 (87.1%) began with visual acuity of 6/24 (20/80) or better, but only 21 of 39 (53.8%) achieved this level at the completion of follow-up. DISCUSSION
The development of a serous detach ment of the retinal pigment epithelium often causes symptomatic loss of vision. Gass, Norton, and Justice 2 proposed that the prognosis for these detachments de pends on the underlying disease process, and that some patients may go on to develop vascularization beneath the reti nal pigment epithelium with subsequent disciform scarring. Retinal pigment epi thelial detachments in a younger age group may be part of the manifestation of
TABLE 6 VISUAL O U T C O M E
Age 42-55 yrs Age 56-82 yrs All No. % No. % No. % Fig. 5 (Meredith, Braley, and Aaberg). Case 25. Geographic retinal pigment epithelium atrophy de veloping after retinal pigment epithelial detach ment.
Better Same Worse
3 7 1
27.3 63.6 9.1
1 18 20
2.6 46.1 51.3
4 25 21
8 50 42
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