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Novel optical coherence tomography findings in idiopathic choroidal folds

Chorio-retinal and choroidal folds are known to have different associations and may also be idiopathic. Although the prevalence of these folds may be up to one per cent in diseases like intracranial hypertension, the prevalence of idiopathic choroidal folds in the general population is not known. Advanced fundus imaging has provided valuable insight into their pathology. The use of optical coherence tomography (OCT) has been of particular utility but the current documentation focuses mostly on retinal findings and not much has been documented about the choroidal structural changes. This report presents novel OCT findings regarding the choroidal structure in a patient with idiopathic choroidal folds. A 55-year-old female presented for optometric review for near vision. There was no ocular, family, or systemic history. Bestcorrected visual acuity was 6/6 with a spherical error of +1.25 D in both eyes. Fundus examination revealed fine radially oriented and regularly placed choroidal folds involving the temporal macula of both eyes. The folds were limited within the vascular arcades. They symmetrically spared the fovea and appeared to be centripetally oriented toward it (Figure 1). Spectral domain OCT (SDOCT) imaging showed the foveal region to be normal. High-definition vertically oriented scans through the area of the presumed choroidal folds revealed the retinal pigment epithelium to be undulating along with the underlying choroid. The overlying outer retinal and underlying choroidal architecture seemed to be generally maintained although prominent large choroidal vessels and an absent capillary network were noted corresponding to the summit of some folds (Figure 2). Ultrasound of both orbits and magnetic resonance imaging of the head and orbits revealed no signs of raised intracranial tension or any other pathology. Hence the patient was diagnosed as having idiopathic choroidal folds. Choroidal folds are termed idiopathic as a diagnosis of exclusion after ruling out intracranial, ocular and intra-orbital pathologies. Lumbar puncture must be considered depending on clinical presentation. The grooves can assume a variety of orientations. The OCT findings of the choroidal vasculature seen at the ‘peaks’ of the idiopathic choroidal folds of this case have not been previously documented, and there is very scant literature on this topic. The largest series using conventional OCT in eight patients emphasised changes in the inner retina visualised in chorio-retinal folds, and variable OCT penetration through ‘valleys’ and ‘prominences’ of these folds. However, it did not reference choroidal luminal or stromal structures, possibly due to poor deeper penetration. Another study used enhanced-depth imaging OCT but included choroidal folds of variable causes in 11 patients. The authors commented only on the choroidal thickness but not on its vasculature. The choroidal thickness was found to depend upon the inherent cause of the folds. A case series of three patients of chorio-retinal folds analysed the choroid using OCT-angiography. The authors reported the presence of a ‘tigroid pattern’. This finding could have been due to legitimately altered blood flow or due to