|Year : 1968 | Volume
| Issue : 1 | Page : 37-41
BN Consul, HN Chhabra, Shyam Singh
Department of Ophthalmology, Sawai Man Singh Medical College and Hospital, Jaipur, India
|Date of Web Publication||22-Dec-2007|
B N Consul
Department of Ophthalmology, Sawai Man Singh Medical College and Hospital, Jaipur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Consul B N, Chhabra H N, Singh S. Juxtapapillary retinochoroiditis. Indian J Ophthalmol 1968;16:37-41
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 . LERMAN,  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|| |
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.
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|| |
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. 
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.  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  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  and ABRAHAM  considered it to be due to nonspecific infection. NEWELL  and DUKEELDER  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  ) or tuberculosis (FUCHS  ; GILBERT  ). GREER  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  . 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|| |
A case of Retinochoroiditis Juxtapapillaries (Jensen) with unusual clinical presentation is reported.
| References|| |
ABRAHAM, S. V. `Chorioretinitis Juxtapapillaries (Jensen) first histologic report, Arch. Ophth., 8: 503, 1932.
DUKE-ELDER, 'System of Ophthalmology' Vol. IX, Henry Kimpton, London, P. 212, 1966.
ELWYN, H. 'Diseases of retina' Philadelphia. The Blakiston Co. P. 196, 1946.
FUCHS, IL E., 'Diseases of the eye' 10th Edition. J. 13. Lippincott Co., London, P. 315, 1933.
GOMPERTS. C. E. `Relation between Jensen chorioretinitis and toxoplasma infection', Ophthalmologica, 120, 178-1950.
GREER, C. H., Ocular Pathology, Ed. I Blackwill Scientific Publications Oxford, P. 48, 1963.
GILBERT, NV. Discussion to Fleischer, Bar.u.d. Versanmild deutach. Ophth. Gesellsch, 43: 145, 1922.
IGERSHEIMER, J. Spirochwtal Infections - Modern Ophthalmology Vol. 2, Systemic aspects, Butterworth, London P. 220, 1963.
JENSEN, E. 'Retinochoroiditis Juxtapapillaris, Arch. f. Ophthal, 69: 41, 1908.
LERMAN, S. `Basic Ophthalmology' Me Graw Hill Book Company N. Y. P. 321, 1966.
NEWELL, F. W. 'Ophthalmology-Principles and Concepts' Mosby Company St. Louis P. 235, 1965.
Posthumus, R. G. 'Chorioretinitis Juxtapapillaris (Jensen) Brit. J. Ophthal. 26: 23, 1942.
Tower, P. `Differential Diagnosis of Common eve diseases of Eye ground' Grune and Stratton, N. Y. P. 131, 1953.
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]