Case of the Month
Edited by Robert N. Johnson, MD
Case #11, Sept, 2018
Joseph Alsberge, MD
A 50-year-old man with an 8-month history of worsening vision in his left eye.
Figures 1 and 2: Color photo montage of the right and left retina. Note the extensive areas of chorioretinal scarring in the posterior pole. The left eye has an area of subretinal hemorrhage and serous exudation in the macula.
A 50-year-old Middle Eastern man presented with the complaint of worsening vision in the left eye of 8 months duration.
On examination, visual acuity was 20/200 in the right eye and 3’/200 in the left eye. The anterior segment examination was unremarkable. Dilated examination revealed geographic atrophic chorioretinal scars projecting from the optic nerve and involving the macula in both eyes, and subfoveal hemorrhage in the left eye (Figures 1 and 2). Fluorescein angiography revealed early hypofluorescence of the atrophic scars secondary to choriocapillary loss with late staining in both eyes, as well as findings consistent with subfoveal choroidal neovascularization in the left eye (Figures 3-5). Optical coherence tomography revealed retinal atrophy with disruption of the photoreceptors and retinal pigment epithelium in the right eye and subfoveal hyper-reflective material in the left eye (Figures 6 and 7).
Figures 3-5: Fluorescein angiograms of the left and right eye. The early phase of the left eye shows lacy hyperfluorescence in the macula and in the late phases, there is significant leakage. Multiple areas of chorioretinal scarring show hypofluorescence early with some mild late staining.
Figures 6 and 7: OCT-SD studies of the right and left macula. Areas of outer retinal and RPE atrophy are noted in both eyes. In the left macula, note the area of subretinal fluid and hyperreflective material corresponding to hemorrhage on the color photo (Figure 2), and area of choroidal neovascularization seen on the fluorescein angiogram (Figures 3 and 4).
What is your Diagnosis?
Serpiginous choroiditis, tuberculous serpiginous-like choroiditis, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), relentless placoid chorioretinitis, sarcoidosis, syphilis.
Additional History and Diagnosis
The patient reported a several-year history of episodic blurry vision in both eyes. A prior provider had performed an extensive work up for infectious and systemic inflammatory etiologies, which was negative. He had been previously treated with systemic steroids and noncorticosteroidal immunosuppressives, though he was no longer on these agents. Given this history, and the pattern and location of the chorioretinal scars, the diagnosis of inactive serpiginous choroiditis with choroidal neovascularization was made. He was given an intravitreal injection of bevacizumab in the left eye and asked to return in one month’s time for ongoing monitoring for recurrent inflammation and to monitor response to the bevacizumab injection.
Take Home Points
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