Choroidal folds and papilloedema

Abstract

Aims: To assess the clinical and fluorescein angiographic features of choroidal folds seen in association with papilloedema.

Methods: In a retrospective study, the clinical data from a database on patients with choroidal folds (1963-97), including fundus photography and fluorescein angiography, from 32 patients (64 eyes) with choroidal folds in association with papilloedema were reviewed. The clinical and fluorescein angiographic features and the clinical course of choroidal folds in these patients are described.

Results: 32 patients had choroidal folds associated with papilloedema. Folds of two distinct categories were observed, either coarse folds or wrinkles. The folds persisted in all cases, even after resolution of papilloedema. Follow up ranged from 1 month to 20 years. Only one patient suffered permanent visual impairment as a result of a choroidal fold.

Conclusions: Choroidal folds exist in two forms, coarse folds and wrinkles. They persist even after papilloedema has resolved. Final visual acuity did not appear to be affected by the presence of choroidal folds in the majority of patients.

Figure 1

Visual loss due to macular folds. Colour photograph of the left fundus of a patient (patient no 8, Table 3) who developed papilloedema and choroidal folds as a result of benign intracranial hypertension. A heavily pigmented choroidal fold, which can be seen passing through the fovea, is responsible for permanent visual impairment. Visual acuity in the left eye is 2/60, and the patient describes severe left metamorphopsia.

Figure 2

(A) Bilateral choroidal folds and unilateral papilloedema. Colour and fluorescein photographs demonstrating bilateral coarse choroidal folds and unilateral papilloedema in a patient (patient no 32, Table 3) with benign intracranial hypertension. (B) Distended nerve sheath and compressed globes. Computed tomograph scan of the same patient demonstrating dilated optic nerve sheaths. This patient presented with acquired hypermetropia. Examination revealed bilateral choroidal folds and a swollen left disc. The arrow denotes perineural cerebrospinal fluid.

Figure 3

Subclinical choroidal folds. Colour fundus photography showing no evidence of choroidal folds in a patient with benign intracranial hypertension. Fluorescein angiogram of the same patient demonstrating the presence of "subclinical" choroidal folds.

Figure 4

(A) Classic appearance of choroidal folds and papilloedema. This pattern of choroidal folding, where the folds curve around the nasal aspect of the disc, and then sweep superotemporally and inferotemporally, is the most common pattern of choroidal folding seen in association with papilloedema. Note the presence of both choroidal wrinkles (red arrow) and coarse choroidal folds (green arrow). (B) Histological section showing a wrinkle (arrow) involving only the retinal pigment epithelium and Bruch's membrane. The overlying retina is flat.

Figure 5

Persistence of choroidal folds. Fluorescein photographs showing the persistence of choroidal folds 7 years after resolution of papilloedema. This patient had a left optic nerve sheath fenestration for benign intracranial hypertension. Left: choroidal folds with papilloedema; right: 7 years after resolution.