Sir,
Rubella retinopathy is the most frequent ocular complication in children whose mothers contracted rubella during pregnancy.1 In these children, there are retinal pigment epithelium (RPE) alterations and visual acuity is usually not affected.2 However, severe vision loss may occur secondary to choroidal neovascularization (CNV).1, 2, 3 Herein, we report an unusual outcome of a case of CNV associated with rubella retinopathy, with emphasis on optical coherence tomography (OCT) features.
A 10–year-old girl was referred because of poor vision in her right eye for four weeks. Her mother contracted rubella during pregnancy. At birth, neither ocular nor systemic abnormalities were detected. At presentation, visual acuity was 20/200 in both eyes. A serohaemorrhagic elevation of the macula was seen in the right eye, and there was a whitish subretinal lesion in the left fovea. Mottling of the RPE was evident in both eyes. Fluorescein angiography showed an active subfoveal neovascular lesion in the right eye and staining of the subretinal lesion in the left (Figure 1). OCT revealed thickened and elevated retinal layers at the macula due to subretinal fluid and an extrafoveal protruding hyper-reflective mass in the right eye (Figure 2, left). After extensive discussions with her parents about the possible risks and benefits of the available treatments for CNV, including photodynamic therapy with verteporfin, a decision for observation was taken initially. Vision improved spontaneously to 20/20 in the right eye by 12 months of follow-up, and OCT revealed contraction of the mass and resolution of the fluid (Figure 2, right).
Few cases of CNV secondary to rubella have been reported and its natural history remains unclear, thus making the establishment of an appropriate treatment difficult, if any, for CNV in this setting. In this study we document with OCT, one case of CNV, which presented spontaneous involution during the course of one year. The underlying mechanisms related to the spontaneous involution of CNV, in particular of inflammatory causes, occasionally observed in the younger population remain unclear. Histopathologic examination performed by Gass, in a case of spontaneous type-2 CNV resolution associated with good visual acuity in a young woman with presumed ocular histoplasmosis, showed an atrophic layer of RPE ‘encircling’ the previously active neovascular lesion except where it communicated with the choroid.4 The morphological peculiarities observed at baseline on OCT, which were consistent with a type-2 (above the RPE) CNV emanating from the extrafoveal region with a relatively well-preserved pattern of reflectivity of the RPE/choriocapillaris complex at the fovea, coupled with fluorescein angiography findings suggesting the presence of an extrafoveal ingrowth site of the neovascular lesion,5 may provide clues when considering observation rather than treatment for CNV in a particular clinical setting.
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Veloso, C., Costa, R., Oréfice, J. et al. Spontaneous involution of choroidal neovascularization secondary to rubella retinopathy. Eye 21, 1429–1430 (2007). https://doi.org/10.1038/sj.eye.6702940
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DOI: https://doi.org/10.1038/sj.eye.6702940
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