Multifocal Choroiditis Panuveitis - 32-year-old woman CNVM OS Recurrs 4 years after initial therapy (avastin)
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32-year-old woman in the office on February 21, 2008. I appreciate you sending along her old notes from 1999 when she had an episode of vision loss in the right eye associated with macular scarring and multifocal choroiditis. At that time she was not seen to have any active lesions in her macula and comes in now with the vision complaints lasting about two weeks of blurred vision in the left and good eye, obviously causing her concern.
She is not having any health problems. She does have a history of migraine and she also takes a multivitamin. She does not have any fevers, rashes, or arthritis. She has no evidence of any oral or genital sores, nor does she have any breathing problems.
VISUAL ACUITY: OD 20/400, OS 20/50. IOP: OD 15, OS 16.
SLIT LAMP EXAM: Normal clear lenses.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.1. There are multifocal chorioretinal scars with a foveal scar.
OS: Vertical C/D ratio is 0.1. There are multifocal chorioretinal scars. There is a focus of choroiditis just inferonasal to the fovea about 500 microns short of the fovea.
OCT SCAN: The right eye shows diffuse retinal atrophy. The left eye shows thickening of the retinal pigment epithelium with overlying retinal edema just nasal to the fovea. Photos confirm clinical findings.
FLUORESCEIN ANGIOGRAM: Shows increasing hyperfluorescence in the lesion of the macula of the left eye. There is, however, no definite vascularity to it. The right eye has staining macular scars.
IMPRESSION:
1. PIC – BOTH EYES
2. NEW LESION OF ACTIVE CHOROIDITIS THREATENING THE FOVEA – LEFT EYE
3. POSSIBLE CHOROIDAL NEOVASCULAR MEMBRANE – LEFT EYE
DISCUSSION: I explained to the patient given her history of multifocal scarring and the new lesion which appears to have no vascularity, no hemorrhage, very little overlying fluid, and is not associated with an old macular scar, I think this is most likely a focus of active inflammation and not an area of neovascularization. Patients with multifocal choroiditis rarely develop choroidal neovascular membranes, whereas patients with punctate inner choroidopathy do, but she does not look to have punctate inner choroidopathy. Because the lesion looks inflammatory, I am starting her on 60 mg of oral steroids daily. I asked her to return for a check in one week, sooner should she notice any problem. If we have no response at that time, I will probably try her with intravitreal Kenalog. If we do have response, we will need to do something about keeping her on anti-inflammatory medicines to prevent central vision loss in the left eye. If the lesion starts to look more vascular, I will treat her with intravitreal blood vessel inhibitors.
When she comes next time, I will also obtain blood tests from Dr. Miller’s office and see what testing needs to be obtained in her to rule-out possible pathologies for possible causes of multifocal choroiditis.
TWO MONTHS LATER:
Her vision in the left eye is doing a little bit better. Interestingly, the right eye is doing substantially better since I first encountered her. She since has had treatment in the left eye with a posterior sub-Tenon Kenalog in February and intravitreal Avastin in March.
VISUAL ACUITY: Vision OD is 20/30, OS is 20/40.
FU: 4 years later:
June 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining.
VISUAL ACUITY: OD 20/50, OS 20/80. IOP: OD 14, OS 17. There is 1+ nuclear sclerosis in both eyes.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.3. There is multifocal chorioretinal scars in the macula as well as nasal to the optic nerve. There is some hemorrhage nasal to the optic nerve.
OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
SPECTRALIS-SD-OCT SCAN: The OCT scan in the right eye shows the macula to be dry. The left eye shows macular edema. The photos confirm the retinal hemorrhage in the left eye.
FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography of the right eye shows multiple hyperfluorescence spots in the macula where the scarring is. The left eye shows an increasing hyperfluorescencent area under the fovea, which does look to be vascular, likely from a neovascular complex.
INDOCYANINE GREEN ANGIOGRAPHY: An indocyanine green angiogram was obtained in the both eyes, because of the multifocal chorioditis. The indocyanine green does show hypofluorescence centrally where the neovascular complex is and in the later frames there is a small hypofluorescence lesion. The right eye shows multifocal hypofluorescence spots corresponding to the macular scar.
IMPRESSION:
1. MULTIFOCAL CHOROIDITIS SUBRETINAL FIBROSIS – BOTH EYES
2. NEW FOVEAL HEMORRHAGE WITH A NEOVASCULAR MEMBRANE – LEFT EYE
3. ECCENTRIC HEMORRHAGE – RIGHT EYE
DISCUSSION: I explained to the patient the left macula does appear to have an area of scarring that is reactivated and there is a new blood vessel growth extending towards the fovea, which looks like it may at the moment be subfoveal. I treated the left eye with intravitreal injection of Avastin (1.25 mg/0.05 ml) without any difficulty today.
Vision returned to 20/40 after 3 treatments. Decision was made to treat every 3 months.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Macula OS 2 months post rx1012 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
2 months post-rx with posterior subtenons kenalog and intravitreal avastin - va os 20/30 and lesion has retracted and organized. It never subsequently grew over 2 years follow-up 
(1 votes)
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Montage Initial Visit793 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
2 months post-rx with posterior subtenons kenalog and intravitreal avastin - va os 20/30 and lesion has retracted and organized. It never subsequently grew over 2 years follow-up
(1 votes)
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 545 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 695 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 717 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 517 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 532 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 518 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 420 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye 470 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - FAF524 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - FAF500 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - SD OCT690 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - SD OCT593 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - SD OCT499 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram591 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram484 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram535 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram462 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram608 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram541 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram473 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram457 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram467 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram462 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram485 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram447 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Fluorescein Angiogram443 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Indocyanine Green Angiogram537 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Indocyanine Green Angiogram418 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Indocyanine Green Angiogram465 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Indocyanine Green Angiogram549 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Indocyanine Green Angiogram406 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Indocyanine Green Angiogram478 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - Indocyanine Green Angiogram410 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Punctate Inner Choroidopathy - Recurrent CNVM 4 years after initial treatment Left Eye - SDOCT469 viewsJune 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining. OD 20/50, OS 20/80. OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female New Lesion OS658 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Old Scar OD845 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Multifocal and macular scar OD1093 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Macula OS666 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Old Macular Scar OD881 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Multifocal Scars - PIC Like642 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Old Scar OD612 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female New Lesion OS572 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female New Lesion OS480 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female New Lesion OS482 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female New Lesion OS513 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female New Lesion OS475 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female New Lesion OS521 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Old Scar OD565 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female FA New Lesion OS563 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female FA Old Scar OS622 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female Line Scan New Lesion OS633 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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Multifocal Choroiditis and Subretinal Fibrosis - 32 yo Female OCT map771 views32-year-old woman vision loss in the right eye associated with macular scarring and multifocal choroiditis in 1999 with new vision loss in left eye: OD 20/400, OS 20/50.
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32-year-old woman in the office on February 21, 2008. I appreciate you sending along her old notes from 1999 when she had an episode of vision loss in the right eye associated with macular scarring and multifocal choroiditis. At that time she was not seen to have any active lesions in her macula and comes in now with the vision complaints lasting about two weeks of blurred vision in the left and good eye, obviously causing her concern.
She is not having any health problems. She does have a history of migraine and she also takes a multivitamin. She does not have any fevers, rashes, or arthritis. She has no evidence of any oral or genital sores, nor does she have any breathing problems.
VISUAL ACUITY: OD 20/400, OS 20/50. IOP: OD 15, OS 16.
SLIT LAMP EXAM: Normal clear lenses.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.1. There are multifocal chorioretinal scars with a foveal scar.
OS: Vertical C/D ratio is 0.1. There are multifocal chorioretinal scars. There is a focus of choroiditis just inferonasal to the fovea about 500 microns short of the fovea.
OCT SCAN: The right eye shows diffuse retinal atrophy. The left eye shows thickening of the retinal pigment epithelium with overlying retinal edema just nasal to the fovea. Photos confirm clinical findings.
FLUORESCEIN ANGIOGRAM: Shows increasing hyperfluorescence in the lesion of the macula of the left eye. There is, however, no definite vascularity to it. The right eye has staining macular scars.
IMPRESSION:
1. PIC – BOTH EYES
2. NEW LESION OF ACTIVE CHOROIDITIS THREATENING THE FOVEA – LEFT EYE
3. POSSIBLE CHOROIDAL NEOVASCULAR MEMBRANE – LEFT EYE
DISCUSSION: I explained to the patient given her history of multifocal scarring and the new lesion which appears to have no vascularity, no hemorrhage, very little overlying fluid, and is not associated with an old macular scar, I think this is most likely a focus of active inflammation and not an area of neovascularization. Patients with multifocal choroiditis rarely develop choroidal neovascular membranes, whereas patients with punctate inner choroidopathy do, but she does not look to have punctate inner choroidopathy. Because the lesion looks inflammatory, I am starting her on 60 mg of oral steroids daily. I asked her to return for a check in one week, sooner should she notice any problem. If we have no response at that time, I will probably try her with intravitreal Kenalog. If we do have response, we will need to do something about keeping her on anti-inflammatory medicines to prevent central vision loss in the left eye. If the lesion starts to look more vascular, I will treat her with intravitreal blood vessel inhibitors.
When she comes next time, I will also obtain blood tests from Dr. Miller’s office and see what testing needs to be obtained in her to rule-out possible pathologies for possible causes of multifocal choroiditis.
TWO MONTHS LATER:
Her vision in the left eye is doing a little bit better. Interestingly, the right eye is doing substantially better since I first encountered her. She since has had treatment in the left eye with a posterior sub-Tenon Kenalog in February and intravitreal Avastin in March.
VISUAL ACUITY: Vision OD is 20/30, OS is 20/40.
FU: 4 years later:
June 7, 2012. This pleasant 35-year-old woman noticed decreasing vision in the left eye recently. She returns now noticing the vision in the left eye is declining.
VISUAL ACUITY: OD 20/50, OS 20/80. IOP: OD 14, OS 17. There is 1+ nuclear sclerosis in both eyes.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.3. There is multifocal chorioretinal scars in the macula as well as nasal to the optic nerve. There is some hemorrhage nasal to the optic nerve.
OS: Vertical C/D ratio is 0.3. There is a scar just inferonasal to the fovea, which has grown some towards the fovea with a little blood just under the fovea.
SPECTRALIS-SD-OCT SCAN: The OCT scan in the right eye shows the macula to be dry. The left eye shows macular edema. The photos confirm the retinal hemorrhage in the left eye.
FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography of the right eye shows multiple hyperfluorescence spots in the macula where the scarring is. The left eye shows an increasing hyperfluorescencent area under the fovea, which does look to be vascular, likely from a neovascular complex.
INDOCYANINE GREEN ANGIOGRAPHY: An indocyanine green angiogram was obtained in the both eyes, because of the multifocal chorioditis. The indocyanine green does show hypofluorescence centrally where the neovascular complex is and in the later frames there is a small hypofluorescence lesion. The right eye shows multifocal hypofluorescence spots corresponding to the macular scar.
IMPRESSION:
1. MULTIFOCAL CHOROIDITIS SUBRETINAL FIBROSIS – BOTH EYES
2. NEW FOVEAL HEMORRHAGE WITH A NEOVASCULAR MEMBRANE – LEFT EYE
3. ECCENTRIC HEMORRHAGE – RIGHT EYE
DISCUSSION: I explained to the patient the left macula does appear to have an area of scarring that is reactivated and there is a new blood vessel growth extending towards the fovea, which looks like it may at the moment be subfoveal. I treated the left eye with intravitreal injection of Avastin (1.25 mg/0.05 ml) without any difficulty today.
Vision returned to 20/40 after 3 treatments. Decision was made to treat every 3 months.
