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Bilateral serous retinal detachment in association with preeclampsia

Published:October 18, 2018DOI:https://doi.org/10.1016/j.jcjo.2018.07.003
      Preeclampsia is a multisystem disorder characterized by the onset of hypertension and often accompanied by significant edema and proteinurea.
      • Ober RR.
      Pregnancy-induced hypertension (preeclampsia-eclampsia).
      The clinical spectrum may range from mild to severe preeclampsia; eclampsia involving seizures and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome.

      Case Report

      We describe a case of a 33-year-old female who was seen by the ophthalmology service for complaint of decreased central vision bilaterally in the post-partum period in the setting of severe preeclampsia and low platelets.
      This patient underwent a spontaneous vaginal delivery. She was noted in the antenatal period to have severe preeclampsia and low platelets. She also experienced significant postpartum hemorrhage with blood loss of 2 L. This required an oxytocin infusion, a dose of carboprost tromethamine, and misoprostol. Following her delivery, she complained of decreased vision with central loss of visual field, floaters, and metamorphopsia.
      The patient had no previous ocular concerns and was not on any ocular medications. She was given labetalol to control her blood pressure in the antenatal period. She had no other significant past medical history. Her bedside physical examination revealed a best corrected visual acuity with a hand-held Rosenbaum screener of 20/400 in the right eye and 20/200+1 in the left eye. Pupils were equal and reactive to light with no relative afferent pupillary defect. Intraocular pressure in both eyes was 13. A gross anterior segment examination of both eyes was unremarkable. A dilated fundus examination of the right eye revealed no vitreous opacification with a cup-to-disc ratio of 0.3 and subretinal fluid in the macular region consistent with a serous retinal detachment. The vessels were within normal limits and no retinal hemorrhages were noted. Examination of the left eye revealed a cup-to-disc ratio of 0.3 with a similar serous retinal detachment involving the temporal aspect of the retina and extending into the macula. The vessels were again within normal limits, with no hemorrhages or tears noted.
      A diagnosis of bilateral serous retinal detachments in the setting of preeclampsia was made. The patient was observed, as this condition is usually self-resolving and carries a favorable prognosis. The patient was seen 1 week later by the retina service in outpatient follow-up with intravenous fluorescein angiogram and optical coherence tomography imaging (Figs. 1,2).
      Fig 1
      Fig. 1A. colour fundus photographs of right and left eye showing presence of macular deep subretinal hypopigmented placoid lesions. B, early intravenous fluorescein angiography images showing presence of hypoflouresence in macular region corresponding to placoid lesions. C, late intravenous fluorescein angiography images showing presence of hyperfluorescence at margin of placoid lesions likely consistent with staining. D, optical coherence tomography images of right and left eye revealing evidence of subretinal fluid.
      Fig 2
      Fig. 2A. colour fundus photographs of right and left eye showing smaller resolving placoid lesions. B, red free imaging of right and left eye in optical coherence tomography, revealing normalizing macular anatomy and thickness. C, optical coherence tomography images of right and left eye revealing evidence of no subretinal fluid.

      Discussion

      In preeclampsia, the underlying abnormality is thought to be severe generalized vasospasm, postulated to be secondary to increased sensitivity to circulating prostaglandins.
      • Ober RR.
      Pregnancy-induced hypertension (preeclampsia-eclampsia).
      The exact mechanism of serous retinal detachment in cases of preeclampsia is unknown. It is hypothesized that choroidal dysfunction occurs following arteriolar vasospasm. This choroidal dysfunction, particularly choriocapillaris ischemia, leads to damage of the retinal pigment epithelium and breakdown of the blood-retinal barrier. The compromised fluid and ion-transport leads to accumulation of subretinal fluid and subsequent serous detachment.
      • Spaide RF
      • Goldbaum M
      • Wong DWK
      • Tang KC
      • Iida T
      Serous detachment of the retina.
      • Saito Y
      • Tano Y
      Retinal pigment epithelial lesions associated with choroidal ischemia in preeclampsia.
      • Mohan AK
      • Al-Senawi RN
      • Mathew M
      • Ganesh A
      • Al-Mujaini A
      Exudative retinal detachment in eclampsia: a management dilemma.
      In the case of HELLP syndrome, hemolysis of the red blood cells may further contribute to focal ischemia caused by way of capillary obstruction.
      The overall choroidal thickness in preeclampsia associated malperfusion remains the same. However, the yellow-white focal lesions occur at the level of the retinal pigment epithelium presumably secondary to choriocapillaris infarction. Following resolution, these focal lesions diminish in size. The postulated mechanism for this would be return to baseline autoregulation of the retinal and choroidal vasculature. Scholfield et al. discussed the role of calcium ions in vessel tone and permeability with an excitatory role in initiating signals that regulate vessels.
      • Scholfield CN
      • Mcgeown JG
      • Curtis TM
      Cellular physiology of retinal and choroidal arteriolar smooth muscle cells.
      Vigil-De Gracia et al. described the largest review of 28 cases between 1990 and 2010 of serous retinal detachments in the setting of preeclampsia/eclampsia/HELLP syndrome. All patients in this series had full spontaneous resolution of their serous detachment within 2-12 weeks without any adverse sequelae.
      • Gracia Vigil-De
      • L Ortega-Paz
      Retinal detachment in association with pre-eclampsia, eclampsia, and HELLP syndrome.
      These patients require observation, and medical treatment with systemic antihypertensive drugs may be helpful. Vision loss following delivery in the setting of preeclampsia should arise suspicion for possible serous retinal detachment.

      Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.

      Appendix. Supplementary materials

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