Case Presentation

1.3.2002

SINGLETON HOSPITAL

HistoryGP referral RE visual loss R 9/6 L6/6

?RP

16.11.01• 54yr old myopic Caucasian male • 2/7 distorted vision

• POH Myope since childhood• PMHunremarkable

16.11.01

• No medical Treatment

• Penicillin Allergy

• FH Mother had cataract

16.11.01

• VA R 6/6 L 6/5

• Near R N/10 L N/5

(distorted)

• Normal Anterior Segment

• Posterior segment– lytic lesions, distributed in peripapillary – foveal fluid & marginal hg

16.11.01

• DD– Old /new CSCR– central CNVM 2 to ?POHS

• FFA on 28.11.01

Differential Diagnosis

• Myopic degeneration

• MIC (multifocal inner choroidopathy)

• PIC (punctate inner choroidopathy)

• POHS (Presumed ocular histoplasmosis syndrome)

• Idiopathic CNVM

Differential Diagnosis

• Birdshot Chorioretinopathy

• APMPPE (acute posterior multiple placoid pigment epitheliopathy)

MIC

• Age: 20 - 50 yrs

• F:M 3:1

• Young healthy moderately myope

• C/O– Subacute blurred vision– Floaters

MIC

Examination• 50% - AAU• Vitritis + multiple grey -white/ yellow lesions at RPE/

inner choroid• New lesions & recurrences occur

Prognosis Fair– Visual loss: CMO/CNVM

Treatment– Periocular steroid

PIC

• Young healthy myope

• Commoner in female

• Unknown etiology

• C/O– acute decreased VA/ central Scotoma

PIC• Exam

– Quiet Anterior segment– Multiple white/yellow lesion in peripapillary region/ fovea in

RPE/IC level +/- serous elevation of NSR– No vitritis– 1/3 rd develop CNVM

• Prognosis Good• Treatment Controversial

– Steroid– Submacular surgery

POHS

• Endemic area of Ohio-Missisipi river valley

• Exam– Histo spots

• atrophic punched out lesions around the disc

• maculopathy : pigment ring with overlying NSR det.

• Maculopathy develops in 2nd decade

• NO vitritis

POHS

• Treatment– early stages: steroids– CNVM: Photocoagulation/ Submacular sx

• Prognosis Variable– Without treatment 59% with VA worse than 6/60– Histo spots in macular area 25% chance of attack

over next 3yrs– No spots in macular area 2% chance of attack

Birdshot chorioretinopathy

• Uncommon

• F>M past 4th decade

• HLA- A29 (50-80%)

• C/O– Reduced VA, nyctalopia– Colour VA disturbed

Birdshot chorioretinopathy

• Exam– Minimal/No Anterior segment inflamm– Cream coloured depigmented spots throughout

fundus (birdshot from a shotgun)– attenuated & sheathed vessel, disc oedema, OA– CMO– Reduced ERG

• Treatment– Periocular / systemic steroids

APMPPE

• Young adults• F:M 1:1• Assoc. HLA DR2 & HLA B7

• C/O– Unilateral visual loss– prodromal flu-like symptomps 50%– few has CNS vasculitis

APMPPE

• Exam– Deep placoid cream-coloured lesions Post-

equatorally– Vascular sheathing / Disc oedema– Tends to affect One eye few days before the

other eye is affected

• Prognosis Generally Good

• Treatment None effective

30.11.01

• Review

• Noticed improvement

• RVA 6/5 LVA 6/4

• Diag: CSCR

• review 5/52

11.1.02

• Sudden loss of VA 2/52

• RVA 6/18 LVA 6/5

• -4.0/-1.5x90 -3.75/-1.25x105

• FFA

15.1.02

• PIC

• MIC

• Idiopathic CNVM

• Oral pred 40 mg od

• f/u 3/52

5.2.02

• No change in VA

• Distortion gone

• Developed Diabetes

A.Acute White spots Vanishing later on

• MEWDS

• Cat-scratch disease

• AIDS Microangiopathy

• CW spots

• Acute Vitelliform maculopathy

B. Acute white spots with coalescence & diffuse scarring

• APMPPE

• Serpiginous choroiditis

• Herpes Retinitis

C. Acute white spots becoming white scars with variable

pigmentation• Multifocal choroiditis - classical form

– a) PIC– b) Difuse subretinal fibrosis

• Toxoplasma retinochoroiditis

• Tuberculous chorioretinitis

• Syphilitic chorioretinitis

• Lyme disease

C. Acute white spots becoming white scars with variable

pigmentation• Sarcoidosis

• Sympathetic Ophthalmia

• VKH

• Bacterial retinochoroiditis

• Fungal retinochoroiditis

• Pneumocystis carinii choroiditis

D. Late white spots with or without initial orange spots

• Birdshot choroidopathy