International Ophthalmology 8:217-220 (1985) 9 Dr W. Junk Publishers, Dordrecht. Printed in the Netherlands

Cases reported at the FAN club meeting, Bonn, November 1984 Case 2 P. Bonnin

Paris, France

M. Nath, aged 13 years, complains since October 10, 1984 of rapid decrease of the vision of the left eye. At previous school examinations visual acuity has always been normal. Later she will mention that she noticed the previous days a slight pain in the left orbit while moving the eyes. She is seen 3 days later. The right eye is completely normal both anatomically and functionally. Distant vision in the left eye is 1/10with sphere + 2,50, near vision Parinaud 10. The visual field presents a central scotoma and a superonasal defect. The anterior segment is normal with no signs of inflammation. The media are clear, the vitreous appears normal. Fundus examination reveals a white yellowish creamy subretinal exudate in the posterior pole associated with a bullous retinal detachment infero-temporal to the macula. The detached retina is mobile and transparent. No retinal tears are found. The history gives no indications of a local or generalized disease. The biological tests are and will remain normal. No signs of inflammation are found. Skull radiographies are normal. The fluorescein angiography performed on October 18 shows an extremely rapid and massive staining of the macular lesion, with no specific structure. The lesion is almost 3 DD large, the staining appears subretinal and the retinal vessels are unaffected. There is late staining of the subretinal fluid at the level of the detached retina, such as seen in inflammatory detachments. There is no late disc staining (Fig. la & b).

The echography performed the same day (Dr. Poujol) indicates clearly the macular lesion and also a choroidal excavation sign. The lesion is considered as 'a choroidal lesion resembling a tumour but possibly of infectious nature' (Fig. lc). A CT-scan performed on October 22 (Dr. E.A. Cabanis) shows hyperfixation of the contrast product at the posterior pole of the left eye. No other signs are observed (Fig. ld). On October 25, progressive resolution is observed without any treatment. Vision in 3/i0 with + 3,00 and Parinaud 5. The patient does not complain of pain and no inflammatory signs are observed. Fluorescein angiography confirms the regression of the lesions: the elevated area with late staining is limited to the infero temporal site of the macula. Elsewhere pigment epithelial changes are clearly visible. The retina has reattached. But also discrete inflammatory signs have appeared: abnormal staining of the optic disc and segmentary retinal phlebitis under the macula (Fig. 2a & b). Echography (Dr. Poujol) only shows a slight improvement (Fig. 2c). Systemic corticotherapy is started for 10 days. On November 15, uncorrected distant vision is 4/10, near vision Parinaud 2. The eye is quiet. Fluorescein angiography indicated pigmentary changes corresponding to the initial lesion, the persistance of a fluorescent area in the inferotemporal sector, normalization of the aspect of the optic disc and the disappearance of the signs of phlebitis. However arciform choroidal folds have appeared in the pa-

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Fig. 1. (A & B). Fluorescein angiography on October 18, 1984 at 242 and 252 s; (C) B-scan echography on October 18, 1984; (D) CT-scan on October 22, 1984.

pillo-macular region concentric to the initial lesion (Fig. 3a, b & c). The echography (Dr. Poujol) is almost normal (Fig. 3d). On December 17, uncorrected visual acuity is l~ and Parinaud 1,5. The posterior pole of the left eye only presents pigmentary changes. Biological tests are still normal. A pathogenic D streptococcus has been found in the throat. The child owns two cats and a dog.

Comments

Most likely we are dealing here with an acute posterior scleritis in a healthy 13-year-old girl. No definite etiology could be found. The condition rapidly improved. Different points are here characteristic of condition: the acquired hypermetropia, the fluoro angiographic aspect, the presence of an exsudative retinal detachment, the tomodensitometry. Also the echography indicates an inflammatory infiltrate of the posterior choroid. The initial echographic pattern similar to what is ob-

F A N club meeting, Bonn: Case 2

Fig. 2. (A & B). Fluorescein angiography on October 25, 1984at 20 and 260 s; (C) B scan echography on October 25~ 1984.

served in malignant m e l a n o m a of the choroid, is related to the choroidal infiltrate. The spontaneous regression in 8 days in suggestive as well as the secondary transient appearance of minor inflammatory signs of the optic disc and of retinal vessels. The pigment epithelial changes in the affected area and the choroidal folds around the lesion are an indication of the choroidal involvement. The choroidal infiltration has provoked a retinal detachment resulting in functional signs. A similar lesion situated outside the macular region might possibly have gone unnoticed.

Authors' address: Dr. P. Bonnin (CNO des XV-XX) 6, rue des Peupliers F-92270 Bois-Colombes France

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Fig. 3. (A, B & C). Fluorescein angiography on November 15, 1984 at 9.66 and 231 s, (B taken with 30~angle); (D) B-scan echography on November 15, 1984.