History of present illness
A 32-year-old healthy female patient presented at 22 weeks’ gestation with abdominal pain and acute vision loss in the left eye (OS). Past medical history was remarkable for treated hypothyroidism with no personal or family ocular history.
Ocular examination findings
On examination, visual acuity was 20/20 right eye (OD) and 20/30 OS. Intraocular pressure and anterior chambers of both eyes (OU) were within normal limits. Dilated fundus examination demonstrated normal optic nerve and vessels with a clear vitreous OU; however, a serous retinal detachment was noted OS.
Imaging
Spectral-domain optical coherence tomography (SD-OCT) demonstrated extrafoveal subretinal fluid OD and central subretinal fluid OS with no evidence of retinal pigment epithelium (RPE) detachment or RPE mottling OU ( Fig. 35.1 ).
Questions to ask
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What medications does the patient take?
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Only levothyroxine. Steroid use in any form (e.g., oral, nasal, topical) is an important risk factor for central serous chorioretinopathy (CSC), which must be excluded.
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Does the patient have any neurological symptoms (e.g., meningismus), headaches, hearing abnormalities such as tinnitus, or skin color changes or hair loss?
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No. Vogt-Koyanagi-Harada (VKH) disease can cause bilateral multifocal serous retinal detachments due to inflammatory choroidal infiltration.
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Does the patient have any current evidence or history of high blood pressure? Hypertensive choroidopathy and preeclampsia can be the cause of subretinal fluid especially in a pregnant patient.
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No. The patient’s blood pressure was normal.
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Does the patient have any remarkable obstetrical history?
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Yes, this patient endorsed a history of three pregnancy losses (9–13 weeks), and, given her abdominal pain, suspicion for pregnancy complication should be investigated.
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Assessment
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This is a case of a 32-year-old pregnant woman with a history of three pregnancy losses who presented with acute abdominal pain and unilateral vision loss. SD-OCT demonstrated bilateral serous retinal detachment.
Differential diagnosis
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Central serous chorioretinopathy (CSC)
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VKH disease
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Hypertensive choroidopathy
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Macular (i.e., choroidal) neovascularization or macular neovascularization (MNV) (possible causes in this demographic include idiopathic, myopia, multifocal choroiditis)
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Optic disc pit or coloboma
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Posterior scleritis
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Choroidal tumor (e.g., choroidal hemangioma or metastasis)
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Idiopathic uveal effusion syndrome
Working diagnosis
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Pregnancy-related HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). These patients may also have evidence of antiphospholipid syndrome (APS).
Multimodal testing and results
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SD-OCT
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As mentioned, SD-OCT showed extrafoveal subretinal fluid superotemporally OD and macular detachment with subretinal fluid centrally OS. Serous retinal detachment can complicate HELLP syndrome in 3.7% of cases.
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The SD-OCT failed to show any evidence of pigment epithelial detachment typical of CSC or type 1 MNV.
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Wide-field fluorescein angiography (WF-FA)
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WF-FA illustrated superotemporal choroidal hypoperfusion OD and severe central choroidal ischemia OS with subretinal leakage temporal to the macula OS ( Fig. 35.2 ). Choroidal ischemia, leading to vascular permeability and RPE pump impairment, is the cause of serous retinal detachment and subretinal fluid in patients with HELLP syndrome.
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