Focal Choroidal Elevations: Localized Pigment Epithelial Contour Alterations due to Isolated Choroidal Vessels

Abstract

Purpose: The objective of this case series was to describe the clinical and imaging features of focal choroidal elevations (FCE), which are chorioretinal contour changes induced by individual choroidal vessels within an overall thin-appearing choroid.

Methods: A total of 787 enhanced depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT) patient images were initially screened for the presence of FCE. Prospective imaging analysis of 38 patients with FCE was done. Mean central macular choroidal thickness (CMCT), FCE location, FCE vessel lumen diameter, patient demographics, cycloplegic autorefraction, ophthalmoscopic findings, and presence of choroidal neovascularization (CNV) in the fellow eye were recorded.

Results: FCE were observed in 25 patients with age-related macular degeneration (ARMD), in 5 patients with high myopia, and in 8 patients with age-related choroidal atrophy (ARCA). Mean patient age was 80 ± 9.4 years. Mean CMCT was 86 ± 40 μm. Mean lumen diameter of the vessels inducing FCE was 131 ± 33 μm.

Conclusions: FCE are relatively frequently encountered morphologic features of elderly patients with ARMD, high myopia, and ARCA, and have a distinct clinical and imaging morphology which differs from classically described chorioretinal folds. The lesions may commonly be mistaken for pigment epithelial detachments on ophthalmoscopy, may be associated with CNV in fellow eyes, and have a characteristic SD-OCT appearance.

Figure 1

Spectral-domain optical coherence tomography findings in focal choroidal elevations and chorioretinal folds. (a) Left eye of a 79-year-old male with age-related choroidal atrophy, but no additional eye pathology demonstrating a focal chorioretinal contour change overlying a large choroidal vessel (arrow) or focal choroidal elevation; mean central macular choroidal thickness = 48 μm. (b) Right eye of a patient with idiopathic uveal effusion syndrome demonstrating chorioretinal folds overlying a relatively thick choroid that do not correspond to specific choroidal vessels. (c) Right eye of a patient with chorioretinal folds due to external globe compression from a lacrimal adenocarcinoma. Chorioretinal folds do not correspond to specific choroidal vessels as in (d) the right eye of patient with an encircling scleral buckle and chorioretinal folds.

Figure 2

Metamorphopsia and focal choroidal elevations in a patient with atrophic age-related macular degeneration. (a) Amsler grid demonstrating metamorphopsia drawn by this 86-year-old female patient. (b) Right eye fundus autofluorescence with no evidence of geographic atrophy but showing a faint pinpoint area of relative hypoautofluorescence (arrowhead) corresponding to focal choroidal elevation in (c) scanning laser ophthalmoscopic image with green arrow showing raster position for SD-OCT in (d) focal choroidal elevation (arrow) without overlying drusen or atrophy corresponds to the location of metamorphopsia; there is subtle disruption of the ellipsoid portion of photoreceptor outer segments (IS/OS line) overlying this region (arrowhead).

Figure 3

Imaging features of a small focal choroidal elevation in a patient with early atrophic age-related macular degeneration. (a) Color fundus photograph demonstrating drusen and the position of a subtle pigment epithelial elevation (arrowhead) observed on ophthalmoscopy. (b) Fundus autofluorescence reveals no specific abnormality in the region. (c) Scanning laser ophthalmoscopic image; green arrow corresponding to SD-OCT raster in (d). There is a subfoveal drusenoid pigment epithelial detachment and a focal choroidal elevation (FCE) corresponding to the region observed in (a); mean macular choroidal thickness = 105 μm; FCE lumen diameter = 126 μm.

Figure 4

Imaging characteristic of a large focal choroidal elevation simulating a pigment epithelial detachment in atrophic age-related macular degeneration. (a) Color fundus photograph demonstrating drusen and an orange-red foveal lesion which appeared elevated on ophthalmoscopy. (b) Scanning laser ophthalmoscopic image with green arrow corresponding to raster position for SD-OCT in (c) revealing a large focal choroidal elevation (FCE); lumen = 239 μm which corresponds to the lesion in (a). (d) Adjacent raster scan reveals evidence of a posterior ciliary vessel continuous with the FCE (arrow).

Figure 5

Imaging characteristics of a focal choroidal elevation in a patient with pathologic myopia. (a) Scanning laser ophthalmoscopic image; green arrow corresponds to SD-OCT in (b) demonstrating a focal choroidal elevation in an overall thin choroid (mean macular choroidal thickness = 24 μm). (c) Color fundus photograph reveals dusky red-colored lesion that resembles a pigment epithelial detachment on ophthalmoscopy corresponding to the FCEs in (b). (d) Laminar phase fluorescein angiogram reveals a complete fill of this choroidal vessel which appeared to originate from the location of the FCEs, indicating its probable direct continuation from a short posterior ciliary artery.