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Uncovered Undulations

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 53-year-old man presented to his ophthalmologist for a newly noticed bulging left eye. He reported several eyeglass prescription changes in the left eye over the past 2 years and frequent ipsilateral tearing. He denied ocular discomfort, headaches, or double vision. He had a distant history of right temple melanoma that was excised with clean margins and accompanied by a negative sentinel lymph node biopsy result.

On examination, he was found to have a best-corrected visual acuity of 20/20 OD and 20/40 OS, with a normal pupillary response and intact color vision bilaterally. He had a mild limitation of left abduction and supraduction. He had 5 mm of relative left proptosis, with moderate resistance to retropulsion of the left globe. No change in globe position was appreciated with systolic pulsations or the Valsalva maneuver. Anterior segment examination results were normal bilaterally. Dilated fundus examination results of the left eye revealed an abnormality of the posterior pole (Figure 1A), which was confirmed on fluorescein angiography (Figure 1B).

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Choroidal folds secondary to an orbital cavernous hemangioma

C. Magnetic resonance imaging of orbits

Choroidal folds are formed by corrugations of the choroid and retinal pigment epithelium (RPE), which appear clinically as alternating light and dark bands. This clinical finding most commonly appears in the posterior pole.1 Choroidal folds are further accentuated on fluorescein angiography and optical coherence tomography. B-scan ultrasonography may additionally demonstrate retinal and choroidal thickening with a flattening of the posterior globe. Choroidal folds should be differentiated from retinal folds, which are lighter and less distinct on fluorescein angiography and are commonly associated with optic disc edema (ie, Patton lines) or areas of retinal traction, as in epiretinal membranes or proliferative vitreoretinopathy.2

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Article Information

Corresponding Author: Natalie Homer, MD, TOC Eye and Face, 3705 Medical Pkwy, Ste 120, Austin, TX 78705 (nhomer@tocaustin.com).

Published Online: August 29, 2019. doi:10.1001/jamaophthalmol.2019.3090

Conflict of Interest Disclosures: Dr Nakra is a shareholder of Global Beauty Science, Inc. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Newell  FW.  Fundus changes in persistent and recurrent choroidal folds.  Br J Ophthalmol. 1984;68(1):32-35. doi:10.1136/bjo.68.1.32PubMedGoogle ScholarCrossref
2.
Norton  EWD.  A characteristic fluorescein angiographic pattern in choroidal folds.  Proc R Soc Med. 1969;62(2):119-128.PubMedGoogle Scholar
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Gasperini  J, Elliot  D, Cunningham  ET.  How to recognize and treat chorioretinal folds.  Rev Ophthalmol. https://www.reviewofophthalmology.com/article/how-to-recognize-and-treat-chorioretinal-folds. Accessed December 16, 2018.Google Scholar
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von Winning  CH.  Fluography of choroidal folds.  Doc Ophthalmol. 1972;31(2):209-249. doi:10.1007/BF00160792PubMedGoogle ScholarCrossref
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Cohen  SM, Gass  JD.  Bilateral radial chorioretinal folds.  Int Ophthalmol. 1994-1995-95;18(4):243-245. doi:10.1007/BF00951806PubMedGoogle ScholarCrossref
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Steuhl  KP, Richard  G, Weidle  EG.  Clinical observations concerning choroidal folds.  Ophthalmologica. 1985;190(4):219-224. doi:10.1159/000309521PubMedGoogle ScholarCrossref
7.
Johnson  RN, Schatz  H, McDonald  HR.  Photic maculopathy: early angiographic and ophthalmoscopic findings and late development of choroidal folds: case report.  Arch Ophthalmol. 1987;105(12):1633-1634. doi:10.1001/archopht.1987.01060120031010PubMedGoogle ScholarCrossref
8.
Kalina  RE, Mills  RP.  Acquired hyperopia with choroidal folds.  Ophthalmology. 1980;87(1):44-50. doi:10.1016/S0161-6420(80)35279-2PubMedGoogle ScholarCrossref
9.
Newell  FW.  Choroidal fold: the seventh Harry Searls Gradle Memorial lecture.  Am J Ophthalmol. 1973;75(6):930-942. doi:10.1016/0002-9394(73)91080-5PubMedGoogle ScholarCrossref
10.
Dailey  RA, Mills  RP, Stimac  GK, Shults  WT, Kalina  RE.  The natural history and CT appearance of acquired hyperopia with choroidal folds.  Ophthalmology. 1986;93(10):1336-1342. doi:10.1016/S0161-6420(86)33577-2PubMedGoogle ScholarCrossref
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