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Research Letters |

Eales Disease Associated With Serpiginous Choroiditis FREE

Adrian T. Fung, MBBS, MMed, FRANZCO; Massimo Nicolò, MD; Susanne Yzer, MD, PhD; Carlo Enrico Traverso, MD; Lawrence A. Yannuzzi, MD
[+] Author Affiliations

Author Affiliations: Vitreous-Retina-Macula Consultants of New York and LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear, and Throat Institute (Drs Fung, Yzer, and Yannuzzi) and Department of Ophthalmology, Columbia University (Drs Yzer and Yannuzzi), New York; and Fondazione per la Macula Onlus (Dr Nicolò) and Department of Neuroscience, Ophthalmology, and Genetics, University of Genova (Drs Nicolò and Traverso), Genova, Italy.


Arch Ophthalmol. 2012;130(11):1484-1486. doi:10.1001/archophthalmol.2012.683.
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Published online

Eales disease is an idiopathic, usually bilateral, inflammatory, retinal vascular occlusive disorder.1 Serpiginous choroiditis is an idiopathic, usually bilateral, recurrent acute progressive inflammation of the inner choroid and retinal pigment epithelium.2 To our knowledge, we describe the first case of Eales disease followed by serpiginous choroiditis.

A 49-year-old immunocompetent white man had gradual vision loss in his left eye. Visual acuity was 20/20 OD and 20/100 OS. Anterior segment examination of the left eye demonstrated small, white, central keratic precipitates but no cells or flare. Fundus examination revealed left temporal retinal vascular occlusive disease, arteriolar and venous sheathing, and peripheral retinal ischemia with neovascularization (Figure, A). The right eye was normal. Complete blood cell count, thrombophilia screen, antinuclear antibody, syphilis serology, and QuantiFERON results were normal. An anterior chamber paracentesis was negative for herpes simplex virus, varicella-zoster virus, and cytomegalovirus by polymerase chain reaction. Chest radiograph and tuberculin skin testing results were normal. Eales disease was diagnosed, scatter laser photocoagulation was applied to areas of ischemic retina, and systemic corticosteroids (60 mg/d) and mycophenolate mofetil (1.5 g/d) were prescribed.

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Bilateral Eales disease and right serpiginous choroiditis. The patient had left temporal retinal vascular occlusion and neovascularization (A), followed 9 months later by right peripapillary serpiginous choroiditis (B) and peripheral retinal vascular occlusion and neovascularization (C). Peripheral scatter argon laser photocoagulation was applied judiciously to ischemic retina in both eyes to minimize any proinflammatory effects. The area of peripapillary serpiginous choroiditis slowly expanded during the following 7 years, visible on color photographs (D), fluorescein angiography (E), and fundus autofluorescence imaging (F).

After 9 months, slowly progressive lobular peripapillary choroiditis (Figure, B), peripheral temporal retinal vascular occlusive disease with vitritis, and keratic precipitates developed in the right eye (Figure, C). Visual acuity remained 20/20. On fluorescein angiography, the area of peripapillary choroiditis revealed hyperfluorescent transmission defect and periphlebitis. Retinal neovascularization was detected at the edge of the capillary closure temporally. Bilateral Eales disease and right serpiginous choroiditis were diagnosed and the ischemic areas were photocoagulated.

During the following 7 years, the capillary closure and retinal neovascularization progressed bilaterally, with development of cataract, rubeotic glaucoma, cystoid macular edema, and progressive serpiginous choroiditis with vitritis in the right eye (Figure, D-F). For this reason, bilateral intravitreal bevacizumab and triamcinolone acetonide injections and right intravitreal dexamethasone implants (Ozurdex), peribulbar triamcinolone injections, phacoemulsification with intraocular lens implantation, and pars plana vitrectomy were performed. Polymerase chain reaction results from the vitreous for Mycobacterium tuberculosis, herpes simplex virus, and varicella-zoster virus were negative.

Although tuberculous infection and/or hypersensitivity has been associated with both Eales disease and serpiginous choroiditis, the evidence remains inconclusive.1M tuberculosis has been detected by polymerase chain reaction from vitreous biopsies in patients with Eales disease, but the same biopsies were negative for mycobacterial cultures.3 In patients with systemic tuberculosis, the development of Eales disease is uncommon.4 A positive QuantiFERON result was detected in 11 of 21 patients with serpiginous-like choroiditis.5 Choroidal tuberculous lesions mimicking serpiginous choroiditis have been described and named tubercular serpiginous-like choroiditis.2 Previous authors6 believe that tubercular serpiginous-like choroiditis may be distinguishable from classic serpiginous choroiditis by the presence of vitritis and smaller, multifocal lesions in the fundus of patients from tuberculosis endemic regions.

To our knowledge, the coexistence of Eales disease and serpiginous choroiditis has been reported only once before, in a 35-year-old Pakistani man with bilateral ampiginous chorioretinitis followed by unilateral Eales disease.7 Mantoux skin test results were positive with no active tuberculosis infection. Although an association between serpiginous choroiditis and retinal periphlebitis and/or vein occlusions was previously reported, testing for tuberculosis in these cases was either not performed or had negative results.8 Furthermore, in our patient, the area of Eales disease was distinct from the peripapillary serpiginous choroiditis.

Our patient does not fit into either category of serpiginous disease previously described.6 Unlike patients with tubercular serpiginous-like choroiditis, he had a solitary, peripapillary lesion and negative results on extensive investigation for tuberculosis; unlike patients with classic serpiginous choroiditis, he exhibited bilateral intraocular inflammation with vitritis in the right eye and keratic precipitates in both eyes. Because it is improbable that these 2 rare conditions would coexist, it is possible that Eales disease and serpiginous choroiditis represent manifestations of the same underlying inflammatory disease.

Correspondence: Dr Massimo Nicolò, Clinica Oculistica, Di.N.O.G.Mi, Università di Genova, Viale Benedetto XV, n.5 16132 Genova, Italy (massimo.nicolo@unige.it).

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by The Macula Foundation, Inc and Stichting Wetenschappelijk Onderzoek Oogziekenhuis Rotterdam, Rotterdamse Blindenbelangen, Stichting Blindenhulp, Gelderse Blinden Stichting, Landelijke Stichting voor Blinden.

Biswas J, Sharma T, Gopal L, Madhavan HN, Sulochana KN, Ramakrishnan S. Eales disease: an update.  Surv Ophthalmol. 2002;47(3):197-214
PubMed   |  Link to Article
Gupta V, Gupta A, Arora S, Bambery P, Dogra MR, Agarwal A. Presumed tubercular serpiginouslike choroiditis: clinical presentations and management.  Ophthalmology. 2003;110(9):1744-1749
PubMed   |  Link to Article
Madhavan HN, Therese KL, Gunisha P, Jayanthi U, Biswas J. Polymerase chain reaction for detection of Mycobacterium tuberculosis in epiretinal membrane in Eales' disease.  Invest Ophthalmol Vis Sci. 2000;41(3):822-825
PubMed
Biswas J, Badrinath SS. Ocular morbidity in patients with active systemic tuberculosis.  Int Ophthalmol. 1995-1996;19(5):293-298
PubMed   |  Link to Article
Mackensen F, Becker MD, Wiehler U, Max R, Dalpke A, Zimmermann S. QuantiFERON TB-Gold: a new test strengthening long-suspected tuberculous involvement in serpiginous-like choroiditis.  Am J Ophthalmol. 2008;146(5):761-766
PubMed   |  Link to Article
Vasconcelos-Santos DV, Rao PK, Davies JB, Sohn EH, Rao NA. Clinical features of tuberculous serpiginouslike choroiditis in contrast to classic serpiginous choroiditis.  Arch Ophthalmol. 2010;128(7):853-858
PubMed   |  Link to Article
Wong R, Graham E, Scoppettuolo E, Moin M, Stanford MR. Case report: ampiginous chorioretinopathy associated with Eales disease in a patient with presumed tuberculosis.  Retin Cases Brief Rep. 2011;5:249-250
Link to Article
Friberg TR. Serpiginous choroiditis with branch vein occlusion and bilateral periphlebitis: case report.  Arch Ophthalmol. 1988;106(5):585-586
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Bilateral Eales disease and right serpiginous choroiditis. The patient had left temporal retinal vascular occlusion and neovascularization (A), followed 9 months later by right peripapillary serpiginous choroiditis (B) and peripheral retinal vascular occlusion and neovascularization (C). Peripheral scatter argon laser photocoagulation was applied judiciously to ischemic retina in both eyes to minimize any proinflammatory effects. The area of peripapillary serpiginous choroiditis slowly expanded during the following 7 years, visible on color photographs (D), fluorescein angiography (E), and fundus autofluorescence imaging (F).

Tables

References

Biswas J, Sharma T, Gopal L, Madhavan HN, Sulochana KN, Ramakrishnan S. Eales disease: an update.  Surv Ophthalmol. 2002;47(3):197-214
PubMed   |  Link to Article
Gupta V, Gupta A, Arora S, Bambery P, Dogra MR, Agarwal A. Presumed tubercular serpiginouslike choroiditis: clinical presentations and management.  Ophthalmology. 2003;110(9):1744-1749
PubMed   |  Link to Article
Madhavan HN, Therese KL, Gunisha P, Jayanthi U, Biswas J. Polymerase chain reaction for detection of Mycobacterium tuberculosis in epiretinal membrane in Eales' disease.  Invest Ophthalmol Vis Sci. 2000;41(3):822-825
PubMed
Biswas J, Badrinath SS. Ocular morbidity in patients with active systemic tuberculosis.  Int Ophthalmol. 1995-1996;19(5):293-298
PubMed   |  Link to Article
Mackensen F, Becker MD, Wiehler U, Max R, Dalpke A, Zimmermann S. QuantiFERON TB-Gold: a new test strengthening long-suspected tuberculous involvement in serpiginous-like choroiditis.  Am J Ophthalmol. 2008;146(5):761-766
PubMed   |  Link to Article
Vasconcelos-Santos DV, Rao PK, Davies JB, Sohn EH, Rao NA. Clinical features of tuberculous serpiginouslike choroiditis in contrast to classic serpiginous choroiditis.  Arch Ophthalmol. 2010;128(7):853-858
PubMed   |  Link to Article
Wong R, Graham E, Scoppettuolo E, Moin M, Stanford MR. Case report: ampiginous chorioretinopathy associated with Eales disease in a patient with presumed tuberculosis.  Retin Cases Brief Rep. 2011;5:249-250
Link to Article
Friberg TR. Serpiginous choroiditis with branch vein occlusion and bilateral periphlebitis: case report.  Arch Ophthalmol. 1988;106(5):585-586
PubMed   |  Link to Article

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