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Bilateral solar retinopathy. Autofluorescence and optical coherence tomography
Retinopatía solar bilateral. Autofluorescencia y tomografía de coherencia óptica
P. Rocha Cabrera
, L. Cordovés Dorta, M. González Hernández
Corresponding author
Sección de Retina Médica, Servicio de Oftalmología, Hospital San Juan de Dios, Santa Cruz de Tenerife, Spain
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A new ophthalmological disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "397" "paginaFinal" => "399" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "«Maculopatía por <span class="elsevierStyleItalic">poppers</span>» en España. Una nueva enfermedad oftalmológica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 660 "Ancho" => 990 "Tamanyo" => 361269 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Right eye spectral domain optical coherence tomography showing the rupture of the ellipsoid line at the foveal level.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. García-Bella, J. Donate, R. Gallego-Pinazo, J.M. Benítez del Castillo" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "García-Bella" ] 1 => array:2 [ "nombre" => "J." 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Autofluorescence and optical coherence tomography" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "391" "paginaFinal" => "396" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Rocha Cabrera, L. Cordovés Dorta, M. González Hernández" "autores" => array:3 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Rocha Cabrera" "email" => array:1 [ 0 => "procha975@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Cordovés Dorta" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "González Hernández" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Retina Médica, Servicio de Oftalmología, Hospital San Juan de Dios, Santa Cruz de Tenerife, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Retinopatía solar bilateral. Autofluorescencia y tomografía de coherencia óptica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1468 "Ancho" => 1500 "Tamanyo" => 288107 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">After performing fluorescein angiography, hyperfluorescence can be seen at the level of the previously described macular lesions in all times. The upper image shows angiography at 1:02<span class="elsevierStyleHsp" style=""></span>min, while the lower part is at 8:30. The periphery does not exhibit significant angiographic alterations.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The noxious effects of sunlight are well known: it causes thermal and photochemical damage in the retina pigment epithelium and photoreceptors. Lesions are produced by temperature increases in said area and by near-UVA ultraviolet radiations (320–400<span class="elsevierStyleHsp" style=""></span>nm), which account for photochemical damage. In addition, histological damage takes place at the level of the retina pigment epithelium melanosomae and photoreceptor external segment.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Particularly, the fovea is not protected by the ganglion layer, making it more vulnerable to solar radiation. Feared maculopathies can be caused by a single or also recurring exposure.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Solar retinopathy differential diagnostic must include hereditary diseases such as retinal or pattern dystrophies, inflammatory diseases such as acute retinal epithelitis, toxic causes (chlorokine and derivatives), traumatic causes, initial macular hole stages and central serous chorioretinopathy.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The latter condition is well described in patients with mental disorders, in those who participate in religious rituals, the military and individuals who sunbathe or watch a solar eclipse without adequate ocular protection.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Macular alteration depends directly on the intensity, duration and range of exposure. There is a certain degree of individual susceptibility, particularly with patients having dilated pupils, transparent media, albinos, individuals with good fixation capacity, emmetropes when radiations are transmitted directly to the fovea, and individuals living in geographic areas with high atmospheric transmission of ultraviolet radiation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Clinic case of a patient who visited due to diminished bilateral visual acuity caused by solar retinopathy (SR), with a diagnostic based on autofluorescence and macular optical coherence tomography (OCT).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinic case</span><p id="par0025" class="elsevierStylePara elsevierViewall">Male, 33, referred due to possible best macular dystrophy. The patient referred diminished bilateral visual acuity since 5 years ago. Being in the military profession, the patient referred significant solar exposure secondary to his activity, and admitted not using ocular protection. Irrelevant personal and familial history.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Visual acuity was of 0.1 in right eye (RE) and 0.15 in left eye (LE), emmetrope, normal intraocular pressure and bilateral biomicroscopy, with bilateral iris hypochromia. Ocular fundus revealed bilateral yellowish pigmented macular lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Macular OCT evidenced disruption in the ellipsoid layer and bilateral alteration in the retinal pigment epithelium (RPE) of the foveal area (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Autofluorescence was performed, which revealed hypo-autofluorescence with atrophy areas in RPE matching anomalous macular pigmentation areas of the retinography (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Fluorescein angiography was performed, which showed sustained bilateral hyperfluorescence since early times, matching the macular lesions (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Visual macular field confirmed said lesions due to the existence of a central scotoma, consistent with the findings (<a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5 and 6</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the poor prognostic concerning recovery, the patient was informed and advised to use ocular protection.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">In the acute phase of SR, ocular fundus generally exhibits foveal yellowish lesions surrounded by minor grayish granular pigmentation which in time turns reddish.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Hyperfluorescence is produced due to the light-induced stimulation of lipofuscin contained in the RPE which is being used with great interest in the various fields of the retina as it supplies important activity information for various types of uveitis,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> central serous chorioretinopathy, ARMD, macular hole, macular tumors and dystrophies, among others. Hyper-autofluorescence is due to increased metabolic activity in the external photoreceptor segments or to RPE inability to process photoreceptor metabolites, whereas hypo-autofluorescence translates into diminished, if any, photoreceptor activity with or without RPE atrophy, associated in many cases to apoptosis of said cells as in the present case. This is of great help in the differential diagnostic of other retinopathies due to the defect occurring in the ellipsoid layer.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The present patient exhibits a typical hypo-autofluorescence of this defect at the macular level, which supports the diagnostic.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The pathological changes observed in OCT are lesions of the RPE and of the disruption of external photoreceptor segments, evidencing damage in the ellipsoid layer and RPE hypo-reflectiveness in the foveal area.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Frequently, SR is bilateral although unilateral cases have been described.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">There is no treatment for SR as corticoids have not demonstrated benefits. Accordingly, prevention and education is vitally important to make the population aware that they should never gaze at the sun directly with the naked eye.</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is concluded that the profession of the patient induced suspicion about possible macular damage due to solar exposure. The physical activity inherent in said profession, enhanced by increased temperatures, the absence of ocular protection and iris hypochromia were the causes of SR. The main diagnostic should be based mainly on anamnesis and funduscopic, angiographic characteristics, together with autofluorescence and OCT to facilitate SR diagnostic.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors state that they do not have commercial interests and have not received financial support. In addition, no conflict of interests has been reported.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres693582" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec702575" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres693581" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec702576" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-29" "fechaAceptado" => "2016-01-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec702575" "palabras" => array:5 [ 0 => "Retinopathy" 1 => "Solar" 2 => "OCT" 3 => "Autofluorescence" 4 => "Military" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec702576" "palabras" => array:5 [ 0 => "Retinopatía" 1 => "Solar" 2 => "OCT" 3 => "Autofluorescencia" 4 => "Militar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case report</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 33-year-old man referred decreased bilateral visual acuity for five years, with no history of interest. Military profession and probably previous sun exposure. Focal pigmented lesions in the macular area of the fundus were observed, with impairment of the photoreceptor layer in the fovea, observed by optical coherence tomography (OCT), in various sectors of the fovea.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Solar retinopathy is associated with professions at risk of sun exposure. The diagnosis is based on autofluorescence and macular OCT, that later will provide key data to establish the cause.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Caso clínico</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Varón de 33 años, que refiere disminución de agudeza visual bilateral desde hace 5 años. No presenta antecedentes de interés. Militar de profesión y probable exposición ocular solar previa. Se aprecian en el fondo de ojo lesiones pigmentadas focales maculares, con alteración de la capa de los fotorreceptores a nivel foveal, evidenciada por tomografía de coherencia óptica (OCT) en varios sectores de la fóvea.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La retinopatía solar está asociada a profesiones con exposición solar de riesgo. El diagnóstico está basado en la autofluorescencia y OCT macular que nos va a aportar datos fundamentales para establecer la causa.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rocha Cabrera P, Cordovés Dorta L, González Hernández M. Retinopatía solar bilateral. Autofluorescencia y tomografía de coherencia óptica. Arch Soc Esp Oftalmol. 2016;91:391–396.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 722 "Ancho" => 1500 "Tamanyo" => 177927 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Bilateral retinography, showing multiple yellowish lesions at the macular/foveal area in both eyes.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1050 "Ancho" => 1602 "Tamanyo" => 251034 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">OCT taken with Topcon 3D OCT-2000 FA Plus<span class="elsevierStyleSup">®</span>, showing an ellipsoid layer disruption and subfoveal RPE alteration in both eyes. The upper part of the figure shows right eye macular OCT, while the lower part shows left eye macular OCT.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 753 "Ancho" => 1500 "Tamanyo" => 138610 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Autofluorescence taken with Topcon 3D OCT-2000 FA Plus<span class="elsevierStyleSup">®</span>: hypoautofluorescence showing RPE atrophy areas matching the anomalous pigmentation areas at the macular level in the retinography of both eyes.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1468 "Ancho" => 1500 "Tamanyo" => 288107 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">After performing fluorescein angiography, hyperfluorescence can be seen at the level of the previously described macular lesions in all times. The upper image shows angiography at 1:02<span class="elsevierStyleHsp" style=""></span>min, while the lower part is at 8:30. The periphery does not exhibit significant angiographic alterations.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 4120 "Ancho" => 3173 "Tamanyo" => 556231 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Right eye macular visual field, showing central campimetric defects compatible with solar maculopathy.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 4117 "Ancho" => 3167 "Tamanyo" => 547910 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Left eye macular visual field, showing the central scotoma that accounts for the visual loss of the patient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Photochemical damage of the retina" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. 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