multi focal choroid it is final

8/8/2019 Multi Focal Choroid It Is Final

1/23

A case of bilateral multifocal

choroiditis

Bucharest Ophthalmology Emergency Hospital

Author: Alexandru Dieaconescu


2/23

I will present a case of a 33 years female, who

came to hospital accusing in left eye:

- decrease visual acuity - photopia- blurring of vision - blind spot

symptoms that appeared in only few days.

The patient has no significant personal or

heredocolateral pathology.

Clinical symptoms


3/23

History

The patient presented the same symptoms in the right

eye 3 weeks ago, and she was diagnosed with

multifocal choroiditis in right eye, based on clinical

exam, fundus aspect, OCT test and visual field.

The patient followed a medication with systemic and

local steroids and antibiotics and the visual acuity

improved.

After 3 weeks of good visual acuity the same

symptoms appeared under medication in the left eye

so she came to a new examination.


4/23

History

Optical coherence tomography on RE

17.08.2009 Best corr. RE Visual acuity 1/24

The patient presented the Right Eye OCT made three weeks ago, before

treatment administration , that shows macular edema ( 637 um),

neurosensory detachement and multiple yellowish oval lesions


5/23

History

Right Eye Visual Field

We can see in righteye a narrowed

visual field and a

central scotoma.


6/23

Clinical evaluation

General examination:

- Cardiovascular system in normal limits:Blood pressure= 100 /70 mm Hg

Pulse = 74

- Respiratory system in normal limits

- Normal neurological examination

- Normal gastroenterological exam


7/23

Clinical evaluation

Ophthalmological examination :

Best corr. visual acuity : Right eye = 0,7 (after 3 weeks treatment)

Left eye = pmm

Slit lamp exam reveals a normal anterior pole.

The fundus examination shows multiple yellowish to grayround and oval lesions that vary in size in both eyes, with righteye peripapilaredema and LE normal optic disc.

Clinical evaluation with a 90-D aspheric lens reveals areas ofretinal thickening and macular edema in LE, and depigmentatedmacular area in RE without edema.


8/23

OCT in RE at initially hospital presentation,

after 3 weeks treatment

After 3 weeks of systemic and local treatment wesee the resolution of macular edema with a macular

thickness of 207 um compared with 637 um and an

improved visual acuity ( 0,7 Compared with 1/24).


9/23

Optical coherence tomography on LE

at initially hospital presentation

07.09.2009

Best corr. Visual Acuity = pmm

OCT Shows macular edema ( 1073 um) and yellowish oval lesions .


10/23

The fundus examination shows multiple yellowish to gray round

and oval lesions that vary in size, with normal optic disc.

LE fundus aspect at initially hospital

presentation


11/23

Differential diagnosis

Clinical exam and ancillary tests reveals an inflammatory

disease, and the possible diagnosis are:

Punctate inner choroidopathy

Ocular histoplasmosis syndrome

Sarcoidosis

VogtKoyanagiHarada syndrome

Sympathetic uveitis

Subretinal fibrosis and uveitis syndrome Serpiginous choroiditis

Birdshot retinochoroidopathy

Myopic degeneration maculopathy


12/23

Positive diagnostic

Based on symptoms, clinical examination,

fundus aspect and OCT, the main diagnosis is

multifocal choroiditis in both eyes.

This diagnosis is supported by:

- Sex and age: female in forth decade

- Symptoms

- Fundus clinical aspect ( multiple yellowish lesions,vary in size )

- OCT and visual field aspect


13/23

Diagnosis

To exclude the possibility of a certain etiology for the

inflammation, the patient made some tests to identify the

etiology:

Sarcoidosis - negative Toxoplasmosis negative

Citomegalovirus IGG +, IGM

FR negative

Lupus cell negative

ANCA negative

This negative results support the main diagnosis multifocal

choroiditis, which is an inflammatory disease with an obscure

etiology.


14/23

Systemic associations

Multifocal choroiditis with panuveitis is a common

inflammatory disease with an obscure etiology.

An association between multifocal choroiditis and

EpsteinBarr virus systemic infection has been

suggested.

It has been suggested that EpsteinBarr virus triggers

an immune response that results in persistentintraocular inflammation.

The patient had an Epstein-Barr test


15/23

Treatment

Systemic - steroids : Medrol -first week 2cp/day,

then 1,5 cp of 16 mg/day

- antibiotic : Lekoclar - 2cp/day one week

Local - steroids : Maxitrol 4 times / day


16/23

Intravitreal Triamcinolone acetonide injection

. The patient visual acuity decreased in the left eye,after she forgot to take her steroids doses for a few daysand the LE OCT showed an important macular edema ,so we decided to do, beside the treatment above, anintravitreal injection with triamcinolone acetonide.

In left eye, for macular edema we do intravitrealinjection with triamcinolone acetonide, using 30Gneedle, injecting the dose supero-temporal throughpars plana at 4 mm from limbus , under checking thecentral retinal artery perfusion.


17/23

OCT in LE one day after treatment

One day after the

intravitreal injection the

OCT still shows a

significant macular edema,

but decreasing ( 845 umcompared with 1073 um),

and we decided to make a

control clinical examination

and OCT test in a 2 weeks

to see the efficiency of this

treatment.

Best corr VA one day

after injection : 0,1

(compared with pmm)


18/23

Treatment efficiency one week

administration


19/23

Treatment efficiency one week

administration

RE best corr VA = 0,9

Macular thickness = 206 um

LE best corr VA = 0,7

Macular thickness = 186 um


20/23

Evolution

Without treatment

The normal course of this disease is with

recurrent inflammatory episodes, inactive lesions with

pigmented borders and association of CNV (choroidalneovascularization) and occasionally diffuse subretinal

fibrosis, determining an important decrease in visual

acuity.

With treatmentTreatment with systemic and local steroids is

effective in at least 50% of cases, when administered

early.


21/23

Prognosis

Prognosis is variable because the disease has

a wide spectrum varying between those with few

lesions and short periods of activity to patients

with progressive scarring and visual loss due tomaculopathy or diffuse subretinal fibrosis.

However because the medication wasadministrated early the evolution of this case may

be favorably.


22/23

Particularity of the case

The particularity of this case is that after the patient

forgot to take some steroids doses the visual acuity in

LE decreased under systemic medication, but one

triamcinolone acetonide intravitreal injection, and thestraight administration of the local and systemic

medication had a significant improvement of visual

acuity.

The obscure etiology of the inflammatory lesions,

which according with clinical exam and OCT aspect

are suggestive for multifocal choroiditis .


23/23

Thank you!

multi focal choroid it is final

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