aCase 5

by Dr. Chua

This 34-year-old multigravida (gravida 2 abortion 1) woman was referred by the obstetrician because of seeing patches of darkness in her vision and trouble with seeing at night for the past few days. She underwent termination of pregnancy one week ago at 22-weeks because of  eclampsia. Prior to the termination, her urine showed 3+ albumin with blood pressure of 160/110 despite medical treatment. She denied any previous history of ocular problems.

Right fundus

　

Left fundus

a. What is the most likely diagnosis?

Choroidal ischaemia caused by hypertensive choroidopathy. The mechanism being fibrinoid necrosis of the choroidal vessels from acute hypertension.

Eclampsia is diagnosed when a pregnant woman with pre-eclampsia develops comma or seizure. The syndrome of pre-eclampsia consists of hypertension, proteinuria and oedema in the absence of an underlying microvascular disorder.

b. Can you explain the appearance seen on the fundi?

The fundi show patches of yellowish lesions deep in the retina. These are patches of disturbed retinal pigment epithelium overlying occluded choriocapillaris.

On fluorescein angiography, the choroidal vasculature shows delayed filling or non-perfusion and the yellowish areas will leak fluorescein due to the breakdown of the RPE barrier.

 
c. What other conditions may be responsible for poor vision in eclampsia?

Apart from hypertensive choroidopathy, decreased vision in eclampsia¹ (also in preeclampsia) are usually caused by:

• serous retinal detachment (from the breakdown of the retinal pigment epithelium barrier)

• occipital cortex involvement (this may be caused by vasospasm, ischaemia or oedema from increased vascular permeability, most cases of cortical blindness resolved within 4 hours to 8 days)

Less common causes include:

• acute ischaemic optic neuropathy

• retinal vasospasm or oedema

　

d. What is the visual prognosis in this patient?

The visual prognosis is good. Termination of the pregnancy usually improves all the signs of eclampsia. The retinal pigment epithelium changes resolve within 3 weeks in 80% of the cases². As these lesions heal, the RPE may become hyperpigmented surrounded by halo of hypopigmentation (Elschnig's spots).

　

Reference:

1. Dinn RB, Alon Harris A, Marcus PS. Ocular Changes in Pregnancy. Obsterical and Gynecological Survey. Volume 58, Number 2. 137-144.

　

2. Saito Y, Tano Y. Retinal pigment epithelial lesions associated with choroidal ischemia in preeclampsia. Retina 1998;18:103–108.

　

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