PSEUDOVASCULITIS ASSOCIATED WITH VITREORETINAL TRACTION Paris G. Tranos, PhD, FRCS,*† Marie-Helene Errera, MD,* Athanasios N. Vakalis, MD,† Solon G. Asteriades, MD, FRCS,† Carlos Pavesio, MD*
Purpose: The purpose of this study was to report a case of vitreoretinal traction masqueraded as retinal vasculitis. Methods: An 81-year-old woman with exudative age-related macular degeneration was treated with intravitreal injections of ranibizumab. During routine follow-up, angiographic evidence of focal, segmental, retinal vasculitis, involving both arteries and veins, was noticed in the fellow eye. Clinical examination revealed no sign of ocular inflammation in either eye. Results: Spectralis optical coherence tomography revealed partial posterior vitreous detachment with multiple areas of persisting vitreoretinal adhesion. Focal vasculitis on fluorescein angiography showed absolute correspondence with sites of vitreoretinal traction on optical coherence tomography. Patient was managed by observation and 6 months later, despite persisting fluorescein leak, she was still asymptomatic with no evidence of anterior chamber or vitreous activity. Conclusion: This is an exceptional case of pseudovasculitis associated with mechanical traction, representing a variant of vitreomacular traction syndrome. Clinicians should be aware of this unusual manifestation, which may mimic true vasculitis associated with uveitis. RETINAL CASES & BRIEF REPORTS 6:219–221, 2012
From the *Moorfields Eye Hospital, London, United Kingdom; and †Thessaloniki Retina Consultants, Thessaloniki, Greece.
Case Report An 81-year-old woman with left exudative age-related macular degeneration was treated with 4 intravitreal injections of ranibizumab. One month after the last injection, fundus fluorescein angiography was performed to evaluate the status of the choroidal neovascular membrane. Despite the patient being asymptomatic,
V
itreoretinal traction syndrome is characterized by traction on the retinal internal limiting membrane by adherent vitreous fibrils. It is the consequence of anomalous posterior vitreous detachment, which is associated with gel liquefaction without sufficient dehiscence at the vitreoretinal interface.1 Anomalous posterior vitreous detachment may result in a variety of adverse sequelae including cystoid macular edema and macular hole, as well as epiretinal membrane and tractional macular detachment.2,3 We report a case of abnormal vitreoretinal separation simulating true vasculitis.
The authors declare no conflict of interest. Reprint requests: Paris G. Tranos, PhD, FRCS, Moorfields Eye Hospital, City Rd, London EC1V 2PD, United Kingdom; e-mail: [email protected]
Fig. 1. Fundus fluorescein angiography showing multiple focal sites of leaking along the temporal vascular arcades of the right posterior pole.
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there was angiographic evidence of right focal segmental retinal vasculitis, involving both arteries and veins, predominantly at the posterior pole (Figure 1). On examination, her visual acuity was 80/100 and 20/400 in the right and the left eyes, respectively. Her anterior chambers and vitreous showed no sign of inflammation, and fundoscopy revealed only mild pigmentary macular changes on the right and a disciform choroidal neovascular membrane on the left. Spectralis (Heidelberg engineering) optical coherence tomography revealed partial poste-
Fig. 2. Sequel of red-free and OCT images at four sites of vascular leakage. A and B illustrate the same OCT section, with the cursor placed at two different leaking points, showing absolute correspondence with persistent vitreoretinal traction (vertical lines). Similarly, (C and D) demonstrate vascular leak due to vitreoretinal traction inferior and superior to optic disk, respectively. OCT, optical coherence tomography.
rior vitreous detachment with multiple areas of persisting vitreoretinal adhesion. Focal vasculitis on fundus fluorescein angiography showed absolute correspondence with sites of vitreoretinal traction on optical coherence tomography (Figure 2). Moreover, vitreopapillary adhesion was also evident (Figure 3), accompanied by mild optic disk leakage demonstrated on fundus fluorescein angiography (Figure 1). In view of the mechanical etiology of her vasculitis, the latter was managed by observation and no topical or systemic steroids
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Fig. 3. Red-free and OCT image demonstrating persisting vitreomacular and vitreopapillary adherence. OCT, optical coherence tomography.
were prescribed at any time. Her left choroidal neovascularization required one further intravitreal injection of LUCENTIS. Six months later, fundus fluorescein angiography and optical coherence tomography were repeated, showing no change at the vitreoretinal traction and the leaking sites compared with baseline. Despite persisting leak on fluorescein angiography, the patient was still asymptomatic and there was no evidence of anterior chamber or vitreous activity.
Discussion The vitreous is most firmly attached along the major retinal vessels, the macula, the optic disk, and the vitreous base.2 Persisting traction at the vitreoretinal interface can be the result of an anomalous posterior vitreous detachment.1 When the latter involves the optic disk, the vitreopapillary adhesion may infrequently result in optic nerve dysfunction or macular edema.4 Recent studies have also demonstrated that the presence of vitreopapillary adhesion may influence the subsequent course and vectors of traction, increasing the risk of macular hole development. In our case, despite vitreopapillary adhesion (Figure 3), there was no evidence of optic nerve or macular disease within a 6-month follow-up. Abnormal vitreoretinal traction at the retinal vessels may be associated with retinal hemorrhage or aggravation of retinal neovascularization.2 More rarely, persistent vitreous adherence may trigger disruption of the inner blood–retinal barrier, resulting in focal vascular leak on fluorescein angiography.
Improved imaging modalities such as spectral domain high-resolution optical coherence tomography provide further information facilitating better understanding of subtle pathophysiologic events.5 Vascular leak associated with mechanical traction could be named “pseudovasculitis,” and it represents a variant of vitreomacular traction syndrome, which is expected to improve with elimination of the tractional vectors. Clinicians should be aware of this unusual manifestation, which may mimic true vasculitis associated with uveitis. Key words: fluorescein leakage, high-resolution optical coherence tomography, pseudovasculitis, uveitis, vitreoretinal traction, vitreomacular traction syndrome, vitreopapillary adhesion. References 1. Sebag J. Anomalous posterior vitreous detachment: a unifying concept in vitreo-retinal disease. Graefes Arch Clin Exp Ophthalmol 2004;242:690–698. 2. Johnson MW. Tractional cystoid macular edema: a subtle variant of vitreomacular traction syndrome. Am J Ophthalmol 2005;140:184–192. 3. Sebag J, Wang MY, Nguyen D, Sadun AA. Vitreo-papillary adhesion in macular diseases. Trans Am Ophthalmol Soc 2009;107:35–46. 4. Wang MY, .Nguyen D, Hinduan N, et al. Vitreo-papillary adhesion in macular hole and macular pucker. Retina 2009;29:644–650. 5. Gallemore RP, Jumper JM, McCuen BW, et al. Diagnosis of vitreoretinal adhesions in macular disease with optical coherence tomography. Retina 2000;20:115–120.
Purpose: The purpose of this study was to report a case of vitreoretinal traction masqueraded as retinal vasculitis. Methods: An 81-year-old woman with exudative age-related macular degeneration was treated with intravitreal injections of ranibizumab. During routine follow-up, angiographic evidence of focal, segmental, retinal vasculitis, involving both arteries and veins, was noticed in the fellow eye. Clinical examination revealed no sign of ocular inflammation in either eye. Results: Spectralis optical coherence tomography revealed partial posterior vitreous detachment with multiple areas of persisting vitreoretinal adhesion. Focal vasculitis on fluorescein angiography showed absolute correspondence with sites of vitreoretinal traction on optical coherence tomography. Patient was managed by observation and 6 months later, despite persisting fluorescein leak, she was still asymptomatic with no evidence of anterior chamber or vitreous activity. Conclusion: This is an exceptional case of pseudovasculitis associated with mechanical traction, representing a variant of vitreomacular traction syndrome. Clinicians should be aware of this unusual manifestation, which may mimic true vasculitis associated with uveitis. RETINAL CASES & BRIEF REPORTS 6:219–221, 2012
From the *Moorfields Eye Hospital, London, United Kingdom; and †Thessaloniki Retina Consultants, Thessaloniki, Greece.
Case Report An 81-year-old woman with left exudative age-related macular degeneration was treated with 4 intravitreal injections of ranibizumab. One month after the last injection, fundus fluorescein angiography was performed to evaluate the status of the choroidal neovascular membrane. Despite the patient being asymptomatic,
V
itreoretinal traction syndrome is characterized by traction on the retinal internal limiting membrane by adherent vitreous fibrils. It is the consequence of anomalous posterior vitreous detachment, which is associated with gel liquefaction without sufficient dehiscence at the vitreoretinal interface.1 Anomalous posterior vitreous detachment may result in a variety of adverse sequelae including cystoid macular edema and macular hole, as well as epiretinal membrane and tractional macular detachment.2,3 We report a case of abnormal vitreoretinal separation simulating true vasculitis.
The authors declare no conflict of interest. Reprint requests: Paris G. Tranos, PhD, FRCS, Moorfields Eye Hospital, City Rd, London EC1V 2PD, United Kingdom; e-mail: [email protected]
Fig. 1. Fundus fluorescein angiography showing multiple focal sites of leaking along the temporal vascular arcades of the right posterior pole.
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there was angiographic evidence of right focal segmental retinal vasculitis, involving both arteries and veins, predominantly at the posterior pole (Figure 1). On examination, her visual acuity was 80/100 and 20/400 in the right and the left eyes, respectively. Her anterior chambers and vitreous showed no sign of inflammation, and fundoscopy revealed only mild pigmentary macular changes on the right and a disciform choroidal neovascular membrane on the left. Spectralis (Heidelberg engineering) optical coherence tomography revealed partial poste-
Fig. 2. Sequel of red-free and OCT images at four sites of vascular leakage. A and B illustrate the same OCT section, with the cursor placed at two different leaking points, showing absolute correspondence with persistent vitreoretinal traction (vertical lines). Similarly, (C and D) demonstrate vascular leak due to vitreoretinal traction inferior and superior to optic disk, respectively. OCT, optical coherence tomography.
rior vitreous detachment with multiple areas of persisting vitreoretinal adhesion. Focal vasculitis on fundus fluorescein angiography showed absolute correspondence with sites of vitreoretinal traction on optical coherence tomography (Figure 2). Moreover, vitreopapillary adhesion was also evident (Figure 3), accompanied by mild optic disk leakage demonstrated on fundus fluorescein angiography (Figure 1). In view of the mechanical etiology of her vasculitis, the latter was managed by observation and no topical or systemic steroids
221
PSEUDOVASCULITIS AND VITREORETINAL TRACTION
Fig. 3. Red-free and OCT image demonstrating persisting vitreomacular and vitreopapillary adherence. OCT, optical coherence tomography.
were prescribed at any time. Her left choroidal neovascularization required one further intravitreal injection of LUCENTIS. Six months later, fundus fluorescein angiography and optical coherence tomography were repeated, showing no change at the vitreoretinal traction and the leaking sites compared with baseline. Despite persisting leak on fluorescein angiography, the patient was still asymptomatic and there was no evidence of anterior chamber or vitreous activity.
Discussion The vitreous is most firmly attached along the major retinal vessels, the macula, the optic disk, and the vitreous base.2 Persisting traction at the vitreoretinal interface can be the result of an anomalous posterior vitreous detachment.1 When the latter involves the optic disk, the vitreopapillary adhesion may infrequently result in optic nerve dysfunction or macular edema.4 Recent studies have also demonstrated that the presence of vitreopapillary adhesion may influence the subsequent course and vectors of traction, increasing the risk of macular hole development. In our case, despite vitreopapillary adhesion (Figure 3), there was no evidence of optic nerve or macular disease within a 6-month follow-up. Abnormal vitreoretinal traction at the retinal vessels may be associated with retinal hemorrhage or aggravation of retinal neovascularization.2 More rarely, persistent vitreous adherence may trigger disruption of the inner blood–retinal barrier, resulting in focal vascular leak on fluorescein angiography.
Improved imaging modalities such as spectral domain high-resolution optical coherence tomography provide further information facilitating better understanding of subtle pathophysiologic events.5 Vascular leak associated with mechanical traction could be named “pseudovasculitis,” and it represents a variant of vitreomacular traction syndrome, which is expected to improve with elimination of the tractional vectors. Clinicians should be aware of this unusual manifestation, which may mimic true vasculitis associated with uveitis. Key words: fluorescein leakage, high-resolution optical coherence tomography, pseudovasculitis, uveitis, vitreoretinal traction, vitreomacular traction syndrome, vitreopapillary adhesion. References 1. Sebag J. Anomalous posterior vitreous detachment: a unifying concept in vitreo-retinal disease. Graefes Arch Clin Exp Ophthalmol 2004;242:690–698. 2. Johnson MW. Tractional cystoid macular edema: a subtle variant of vitreomacular traction syndrome. Am J Ophthalmol 2005;140:184–192. 3. Sebag J, Wang MY, Nguyen D, Sadun AA. Vitreo-papillary adhesion in macular diseases. Trans Am Ophthalmol Soc 2009;107:35–46. 4. Wang MY, .Nguyen D, Hinduan N, et al. Vitreo-papillary adhesion in macular hole and macular pucker. Retina 2009;29:644–650. 5. Gallemore RP, Jumper JM, McCuen BW, et al. Diagnosis of vitreoretinal adhesions in macular disease with optical coherence tomography. Retina 2000;20:115–120.
