48.1 Features
Chorioretinal folds (CRFs) are anatomically characterized by undulations of the inner choroid, Bruch’s membrane, and overlying retinal pigment epithelium. This clinical appearance results from underlying choroidal alterations that push the overlying Bruch’s membrane into folds.
48.1.1 Common Symptoms
Usually, asymptomatic; metamorphopsia or blurry vision possible, depending on the underlying etiology.
48.1.2 Exam Findings
CRFs typically present as alternating yellow and dark bands, usually horizontally oriented and radiating from the optic nerve. The following exam findings can help determine etiology of the folds, including presence of a relative afferent pupillary defect (e.g., optic nerve head disorders, retrobulbar mass), abnormalities on external exam (e.g., proptosis for thyroid eye disease and orbital mass), anterior segment exam for wound leak (e.g., hypotony), and posterior segment exam for optic nerve edema, drusen, choroidal detachment, choroidal mass, and scleral buckle.
48.2 Key Diagnostic Ophthalmic Tests and Findings
48.2.1 Optical Coherence Tomography
May reveal subtle to significant CRFs. Rarely, intraretinal fluid may be present.
48.2.2 Fluorescein Angiography or Ultra-Widefield Fluorescein Angiography
Can be particularly helpful in cases where folds are suspected but exam findings are mild or difficult to discern. Typical findings include the early increase in background choroidal fluorescence and alternating bands of hyper- and hypofluorescence corresponding to crests and valleys of CRF. In uveal effusion syndrome, fluorescein angiography can demonstrate leopard spots of hyper- and hypofluorescence.
48.2.3 Indocyanine Green Angiography
Possible granular choroidal hyperfluorescence in uveal effusion syndrome.
48.2.4 Ultrasonography
Thickening and occasional flattening of the sclera on B-scan. May facilitate identification of a retrobulbar mass.
48.3 Critical Work-up
Patient history should investigate any recent trauma, surgery, headaches, blurry vision, metamorphopsia, and medications. In addition to clinical exam and key diagnostics, consider magnetic resonance imaging brain and orbits to evaluate retrobulbar or intracranial process and systemic imaging (CT chest/abdomen/pelvis) for suspected metastasis. There are many differential diagnoses to consider: hypotony following glaucoma surgery, wound leaks, and cyclodialysis cleft (▶ Fig. 48.1); uveal effusion syndrome (idiopathic exudative detachment of choroid, ciliary body, and retina usually associated with scleral thickening and hyperopia); retrobulbar/orbital mass lesions (benign or malignant tumors and orbital abscess) (▶ Fig. 48.2); idiopathic folds (diagnosis of exclusion, usually seen in young hyperopic patients) (▶ Fig. 48.3); inflammatory from thickening and inflammation of the sclera (e.g., posterior scleritis); Vogt–Koyanagi–Harada syndrome; thyroid eye disease, autoimmune etiologies; scleral buckle; intraocular neoplastic conditions (e.g., choroidal metastasis); choroidal neovascularization (CNV) with fibrotic contraction; optic nerve head disorders (e.g., papilledema); medications associated with choroidal folds, including topiramate and bimatoprost; and space flight-associated neuro-ocular syndrome (i.e., reported during and after long-duration space flights, which includes optic disc edema, choroidal and retinal folds, hyperopia, and retinal nerve fiber infarcts).
Fig. 48.1 Widefield image demonstrates choroidal folds 2 weeks after trabeculectomy.
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