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BRIEF COMMUNICATION
Year : 2014  |  Volume : 62  |  Issue : 4  |  Page : 506-507

Increased choroidal thickness in patient with high-altitude retinopathy


1 Kyorin Eye Center, Kyorin University School of Medicine, Tokyo, Japan
2 Kyorin Eye Center, Kyorin University School of Medicine; Heiwa Eye Clinic, Tokyo, Japan

Date of Submission23-May-2012
Date of Acceptance30-Aug-2012
Date of Web Publication8-May-2014

Correspondence Address:
Makoto Inoue
Kyorin Eye Center, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611
Japan
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Source of Support: None, Conflict of Interest: None


Read associated Erratum: Erratum with this article

DOI: 10.4103/0301-4738.116483

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  Abstract 

We report a case of high-altitude retinopathy with increased choroidal thickness detected by spectral-domain optical coherence tomography (SD-OCT). A 36-year-old Japanese man developed an acute vision decrease in his left eye after he had trekked at an altitude of 4600 m in Tibet for 1 week. His visual acuity was 20/20 OD and 20/200 OS with refractive errors of − 0.25 diopters (D) OD and − 0.50 D OS 3 weeks after the onset of the visual decrease. Funduscopic examinations revealed multiple intraretinal hemorrhages bilaterally and a macular hemorrhage in the left eye. SD-OCT showed that the thickness of choroidal layer at the fovea was 530 μm OD and 490 μm OS which is thicker than that in normal subjects of approximately 300 μm. We suggest that the increase in the retinal blood flow under hypoxic conditions may be associated with an increase in the choroidal blood flow resulting in an increase in choroidal thickness.

Keywords: Choroidal thickness, enhanced depth imaging, high-altitude retinopathy, optical coherence tomography


How to cite this article:
Hirukawa-Nakayama K, Hirakata A, Tomita K, Hiraoka T, Inoue M. Increased choroidal thickness in patient with high-altitude retinopathy. Indian J Ophthalmol 2014;62:506-7

How to cite this URL:
Hirukawa-Nakayama K, Hirakata A, Tomita K, Hiraoka T, Inoue M. Increased choroidal thickness in patient with high-altitude retinopathy. Indian J Ophthalmol [serial online] 2014 [cited 2020 Apr 8];62:506-7. Available from: http://www.ijo.in/text.asp?2014/62/4/506/116483

High-altitude illness is characterized by acute mountain sickness, high-altitude retinopathy (HAR), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema. The ocular signs of HAR are dilated retinal veins and arteries, diffuse or punctate pre-retinal hemorrhages usually located peripherally but occasionally in the macula, vitreous hemorrhages, papillary hemorrhages, peripapillary hyperemia, and papilledema. [1] Fluorescein angiography shows no leakage, and the retinal hemorrhages are located superficially. The development of HAR is the first sign of HACE which can progress to death. [2] We describe a patient with HAR whose choroidal thickness determined by spectral-domain optical coherence tomography (SD-OCT) was thicker than normal.


  Case Report Top


A 36-year-old Japanese man was referred to us for the evaluation of bilateral retinal hemorrhages. He had been a healthy adult without any medical history. He developed an acute vision decrease in his left eye, pain in his right chest area, and headache after he had trekked at an altitude of 4600 m in Tibet for 1 week. Because of the illness, he descended 3 days later, and he felt better at that time but the visual impairment remained.

Our examination showed that his visual acuity was 20/20 OD and 20/200 OS with refractive errors of − 0.25 diopters (D) OD and − 0.50 D OS measured 3 weeks after the onset of the visual decrease. Funduscopic examination revealed multiple intraretinal hemorrhages bilaterally and a macular hemorrhage in the left eye [Figure 1]. SD-OCT (Spectralis, Heidelberg Engineering, Heidelberg, Germany) showed that the macular hemorrhage was in the superficial layer of the retina beneath the inner limiting membrane of the left eye [Figure 2]. The SD-OCT image shown was the average of 100 images. The thickness of the choroidal layer at the fovea was 530 μm OD and 490 μm OS which was thicker than the mean subfoveal choroidal thickness in normal subjects of approximately 300 μm in the enhanced depth images obtained by Spectralis SD-OCT. [3] Most recent studies report that the average subfoveal choroidal thickness is 287 μm in Caucasians of an average age of 50.4 years [4] and 272.6 μm in the Japanese of an average age of 30.5 years obtained by the enhanced depth imaging of the Spectralis SD-OCT. [5]
Figure 1: Fundus photographs at the first visit of a patient with high-altitude retinopathy. Fundus photograph of the right eye (a) and the left eye (b) showing multiple intraretinal hemorrhages and a macular hemorrhage in the left eye

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Figure 2: Optical coherence tomographic images at the first visit. The choroidal layers (white arrowheads) are thick in both eyes (a: Right eye, b: Left eye). A macular hemorrhage located in the superficial retina beneath the inner limiting membrane of the left eye (white arrow) can be seen

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  Discussion Top


Individuals with acute mountain sickness present with lethargy, nausea, headache, insomnia, anorexia, and disorientation. The proposed mechanism for the symptoms of acute mountain sickness is respiratory alkalosis from hyperventilation and increased cerebral blood flow. In HACE, there is a breakdown of the blood-brain barrier which can lead to the edema and hemorrhage in the brain. [6] HAR is relatively benign and the hemorrhage usually resolves spontaneously. However, HACE can lead to long-lasting severe neurological and psychiatric disorders and even death in some cases. Wiedman and Tabin examined 40 climbers who had ascended to altitudes of over 4870 m whether they developed signs of HAR, symptoms of acute mountain sickness, and clinically signs of HACE. [2] All patients who had HACE also had HAR. Thus, they concluded that when advanced HAR is recognized, treatment should be initiated for HACE with oxygen, steroids, or diuretics, and immediate descent to prevent further progression of HACE.

A pronounced increase in retinal blood flow in mountaineers with retinal hemorrhage and dilated epipapillary network has been detected with Heidelberg retina flowmeter after acute hypoxic stress at high altitudes. [7] The increase in retinal blood blow and cerebral blood flow under hypoxic conditions may also be associated with an increase in choroidal blood flow resulting in an increase in choroidal thickness. The pathogenesis of the increased choroidal thickness may be similar to that of HACE, namely a breakdown of the blood-brain barrier and edema.

It is difficult to draw strong conclusions from a single case; however, we suggest that measurements of the choroidal thickness may be useful in evaluating the status of HACE. Currently, data are not available from population-based studies on the normal values for the choroidal thickness of a large number of Caucasians or Asians. Further studies are needed to evaluate the choroidal thickness in mountaineers with acute mountain sickness.


  Acknowledgment Top


The authors received no grant support in reporting these clinical observations.

 
  References Top

1.
Wiedman M. High altitude retinal hemorrhage. Arch Ophthalmol 1975;93:401-3.  Back to cited text no. 1
    
2.
Wiedman M, Tabin GC. High-altitude retinopathy and altitude illness. Ophthalmology 1999;106:1924-6.  Back to cited text no. 2
    
3.
Spaide RF, Koizumi H, Pozzoni MC. Enhanced depth imaging spectral-domain optical coherence tomography. Am J Ophthalmol 2008;146:496-500.  Back to cited text no. 3
    
4.
Margolis R, Spaide RF. A pilot study of enhanced depth imaging optical coherence tomography of the choroid in normal eyes. Am J Ophthalmol 2009;147:811-5.  Back to cited text no. 4
    
5.
Yamashita T, Yamashita T, Shirasawa M, Arimura N, Terasaki H, Sakamoto T. Repeatability and reproducibility of subfoveal choroidal thickness in normal eyes of Japanese using different SD-OCT devices. Invest Ophthalmol Vis Sci 2012;53:1102-7.  Back to cited text no. 5
    
6.
Hackett PH, Yarnell PR, Hill R, Reynard K, Heit J, McCormick J. High-altitude cerebral edema evaluated with magnetic resonance imaging: Clinical correlation and pathophysiology. JAMA 1998;280:1920-5.  Back to cited text no. 6
    
7.
Müllner-Eidenböck A, Rainer G, Strenn K, Zidek T. High-altitude retinopathy and retinal vascular dysregulation. Eye (Lond) 2000;14:724-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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