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ARTICLE
Year : 1968  |  Volume : 16  |  Issue : 1  |  Page : 37-41

Juxtapapillary retinochoroiditis


Department of Ophthalmology, Sawai Man Singh Medical College and Hospital, Jaipur, India

Date of Web Publication22-Dec-2007

Correspondence Address:
B N Consul
Department of Ophthalmology, Sawai Man Singh Medical College and Hospital, Jaipur
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Consul B N, Chhabra H N, Singh S. Juxtapapillary retinochoroiditis. Indian J Ophthalmol 1968;16:37-41

How to cite this URL:
Consul B N, Chhabra H N, Singh S. Juxtapapillary retinochoroiditis. Indian J Ophthalmol [serial online] 1968 [cited 2020 Feb 20];16:37-41. Available from: http://www.ijo.in/text.asp?1968/16/1/37/37492

Table 1

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Table 1

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Juxtapapillary retinochoroiditis (Jensen) is a clinical entity of special interest- and has been widely discus­sed in literature. Besides the juxta­papillary placement which may also be seen to exist in other forms of choroiditis, there is an out of propor­tion involvement of the neuroretinal elements resulting in a varying degree of papillitis and a typical sector shap­ed field defect which are so charac­teristic that the disease fairly justi­fies the merit of being classified as an entity.

The clinical picture of choroiditis may quite often be masked or domi­nated by the association of varying degrees of papillitis and its field de­fects confused with those of glau­coma, DUKE-ELDER .[2] LERMAN, [10] The aetiology of the condition has also been controversial and is yet undecided. The present case is of interest in as much as that it had a relatively unusual age and mode of presentation as well as aetiological association.


  Case report Top


S. Devi, 40 year old female was admitted to Eye ward of S. M. S. Hospital, Jaipur on 13.6.67 with the chief complaint of cloudiness of vi­sion in the left eye of one week's duration. She was a known hyper­tensive and used to get occasional attacks of vertigo for the last two years. Seven days earlier she got vertigo during which she had tran­sient loss of vision from both the eyes. She had no other ocular or general accompaniments such as uncon­sciousness, convulsions and motor or sensory defects. The whole event lasted for a few moments. While the vision seemed to return to prevertigo state in the right eye, cloudiness of vision persisted in the left eye and was more appreciable in the upper field of this eye. There was consi­derable fall of vision to the extent of seeing hand movements only.

She never had such complaints be­fore, nor was there any history of a significant general or ocular disease. Family history was not revealing ex­cept that she had two abortions among the first few conceptions. There was no history of contracting any venereal disease. She was known to have hypertension for the last two years.

General Examination

She was a well built and well nourished lady, had no anemia or adenopathy. There was no cyanosis but some edema on her feet at the time of admission. Examination of other systems did not reveal any sig­nificant finding. The B.P. was 170/ 100 nom of Hg.

Local Ocular Examination

The Examination of the right eye did not reveal any abnormality. The visual acuity, fundus and fields were all within normal limits.

In the left eye, the pupil was 5 mm round and showed a poorly sus­tained reaction to light. The lens was clear. Fundus examination showed fairly clear media. The disc was livvpcraemic. There was blurring of upper, nasal and lower margin. The physiological cup looked full. Along the inferior vessels the retina show­ed a relatively pale ground. The pal­lor started close to the lower border of the disc, being contiguous with it and spread down and out for a dis­tance of 3 to 4 disc diameters. The margins of this area merged indis­tinctly into the surrounding retina [Figure - 1]. The vessels specially the artery and its distal branches looked appreciably narrowed. The upper branches of retinal vessels did not show any abnormality. The macular region also showed some pallor and reflexes suggesting oedema. The foveal reflex was absent. The A. V. crossings showed no changes nor were there any exudates or hemorr­hages. The arterial pulsation could be elicited on global pressure in both, the upper and lower arterial branches.

The visual acuity was finger count­ing at two feet and limited only to the lower field. Projection of light was absent on the upper and tem­poral sides. The ocular movements were full and painless but the eye ball was tender on deep pressure. The peripheral field [Figure - 2] of left eye showed a generalised narrowing by 10° to 20° with an absolute sec­torial scotoma in the lower part with its apex touching the central spot. The central field also showed an ab­solute sectorial defect corresponding to that seen in the peripheral field.[Table - 1]

Screening chest, E. N. T. and Den­tal examination revealed no abnor­mality. The gynaecological examina­tion showed cervicitis.

Treatment and Progress

The patient was put on systemic and retrobulbar corticoids (Decadron 0.5 mg. Tablets, 2 hourly and retrobulbar Decadron ½ cc. daily). In­jection of PAM (Penicillin, Alumi­nium monosterate) 1,000,000 units in­tramuscular was started on the 4th day of admission (on receipt of a positive Kahn's test report). The whole treatment was continued for 10 days. The systemic corticoids were gradually tapered in 3 weeks time and retrobulbar Decadron and PAM injections stopped after 10 in­jections each.

The visual acuity improved to finger counting at 5 feet on the 4th day of admission but the improvement was limited to lower field only. It reached to 6/60 in this field by the time she was discharged (3 weeks after admission) from the hospital. The fundus picture showed interest­ing changes. The diffuse retinal pal­lor gave place in about 9 days time following therapy (16 days from on­set) to a circumscribed and well de­ned plain patch of exudate of the size of a disc [Figure - 3]. It was seen at a little distance from the disc and under the inferior retinal vessels which showed narrowing over the exudate and beyond it. On the 14th day of admission (21 days after on­set) the disc began to show some temporal pallor. The exudative patch became more defined. By the end of third week some pigmentary change could be seen bordering the patch. The visual fields showed no appreciable change except some ge­neral improvement in the peripheral field.


  Discussion Top


In view of the sudden cloudiness of vision, objective signs of ill sus­tained pupil and oedematous disc the patient was admitted with a pro­visional diagnosis of papillitis. The appearance of pallor in a segment of the retinal ground with narrowing of arteries and sector shaped field defect however, could not be fitted in this diagnosis.

An arterial branch occlusion was considered as the next possibility. The sudden onset, the association of hypertension and the episode of tran­sient loss in the other eye also sup­ported this possibility as also the nar­rowing of the artery and a segmental pallor of retina. The appearance of the disc however did not fit into the picture of occlusion nor has the field a strictly sectorial shape in branch occlusion.-ELWYN. [3]

With the subsidence of retinal pal­lor into more or less a defined patch of exudate close to the disc the diag­nosis of Juxtapapillary retinochoroidi­tis became strongly probable. The un­usual features which led us away from this diagnosis were the patient's age, the mode and type of onset, a rather sudden and gross dimness of vision and absence of clinically dis­cernable vitreous haze. A relatively larger area of retinal pallor and nar­rowing of the arterial branches in this area were also misleading al­though these have been commonly observed in this condition.-FUCHS. [4] The timely appearance of a relativ­ely more definite patch of exudate close to the disc, the associated papil­litis and sectorial field defect, how­ever, completed the characteristic triad for an authentic diagnosis of Jensen's Juxtapapillary retinochoroi­ditis. The absence of appreciable vitreous haze was rather unexplain­able.

The aetiology of the condition has been controversial and is still not settled. JENSEN [9] thought that pos­sibly the infection which involves the choroid and retina, starts from the posterior end of the optic nerve sheaths. He did not express opinion on the character of the infection. GOMPARTS [5] and ABRAHAM [1] con­sidered it to be due to nonspecific infection. NEWELL [11] and DUKE­ELDER [2] believed that any type of choroiditis if severe may cause papil­litis as a toxic phenomenon, specially when situated close to the papilla. Others have attributed the condition to syphilis (IGERSHEIMER [8] ) or tuberculosis (FUCHS [4] ; GILBERT [7] ). GREER [6] mentions toxoplasmosis as one of the causes of juxtapapillary re­tinochoroiditis.

The present case had history sug­gestive of syphilis and showed a po­sitive serological test for the same. Although it is quite possible that in a luetic, the retinochoroiditis may be of different aetiology, its oetiological significance in this case cannot be ruled out. Neuritis papulosa, a cli­nical entity ascribed to syphilis also gives rise to a clinical triad of vitre­ous opacities, exudation of the optic disc and chorioretinitis. Often a sec­torial field defect is also present in this condition. However, the exudate in this condition appears right on the disc although it may extend beyond it, towards the retina or anteriorly into the vitreous. In addition there are multiple foci of chorioretinitis elsewhere in the retina. Retinal and preretinal hemorrhages are also not uncommon in this condition.

It may therefore, be implied that the Jensen's retinochoroiditis juxtapa­pillaris as pointed out by earlier wor­kers (4, 6, 7, 8) array well be due to any of the specific diseases includ­ing syphilis provided it conforms to the characteristic clinical picture described by JENSEN [9] . The pecularities of this case were:

(a) A sudden onset simulating papil­litis and/or an arterial branch occlusion. The latter was diffi­cult to rule out from the early clinical picture specially in the presence of systemic hyperten­sion.

(b) The relatively unusual age of presentation, because the disease has been observed commonly in the young people.

(c) The association of syphilis, show­ing that the condition may as well be due to this or for that purpose due to any specific dis­ease.


  Summary Top


A case of Retinochoroiditis Juxtapapillaries (Jensen) with unusual cli­nical presentation is reported.[13]

 
  References Top

1.
ABRAHAM, S. V. `Chorioretinitis Jux­tapapillaries (Jensen) first histologic report, Arch. Ophth., 8: 503, 1932.  Back to cited text no. 1
    
2.
DUKE-ELDER, 'System of Ophthal­mology' Vol. IX, Henry Kimpton, Lon­don, P. 212, 1966.  Back to cited text no. 2
    
3.
ELWYN, H. 'Diseases of retina' Phi­ladelphia. The Blakiston Co. P. 196, 1946.  Back to cited text no. 3
    
4.
FUCHS, IL E., 'Diseases of the eye' 10th Edition. J. 13. Lippincott Co., London, P. 315, 1933.  Back to cited text no. 4
    
5.
GOMPERTS. C. E. `Relation between Jensen chorioretinitis and toxoplasma infection', Ophthalmologica, 120, 178­-1950.  Back to cited text no. 5
    
6.
GREER, C. H., Ocular Pathology, Ed. I Blackwill Scientific Publications Ox­ford, P. 48, 1963.  Back to cited text no. 6
    
7.
GILBERT, NV. Discussion to Fleis­cher, Bar.u.d. Versanmild deutach. Ophth. Gesellsch, 43: 145, 1922.  Back to cited text no. 7
    
8.
IGERSHEIMER, J. Spirochwtal In­fections - Modern Ophthalmology Vol. 2, Systemic aspects, Butterworth, London P. 220, 1963.  Back to cited text no. 8
    
9.
JENSEN, E. 'Retinochoroiditis Juxta­papillaris, Arch. f. Ophthal, 69: 41, 1908.  Back to cited text no. 9
    
10.
LERMAN, S. `Basic Ophthalmology' Me Graw Hill Book Company N. Y. P. 321, 1966.  Back to cited text no. 10
    
11.
NEWELL, F. W. 'Ophthalmology­-Principles and Concepts' Mosby Com­pany St. Louis P. 235, 1965.  Back to cited text no. 11
    
12.
Posthumus, R. G. 'Chorioretinitis Juxtapapillaris (Jensen) Brit. J. Ophthal. 26: 23, 1942.  Back to cited text no. 12
    
13.
Tower, P. `Differential Diagnosis of Common eve diseases of Eye ground' Grune and Stratton, N. Y. P. 131, 1953.  Back to cited text no. 13
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1]



 

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