Medical Retina & Posterior Segment:
                       Case 25


Figure 1

Figure 2

This 29 year-old woman presented to the eye casualty with a one-week history of distorted vision in both eyes. Her visual acuity was 6/12 in the right eye and 6/9 in the left with a myopic correction of -2.75 and -3.25 respectively. Slit-lamp examination of the anterior segment was normal and there was no vitritis. However, fundoscopy revealed multiple small white lesions. The blood tests including ACE, VDRL/TPHA and auto-antibodies were normal.  Her past medical history was unremarkable. The above pictures were taken five weeks later.

a. What is the most likely diagnosis?

Punctate inner choroidopathy.

This uncommon condition typically occurs in moderately myopic young females. The presentation is with blurred vision, photopsia and para-central scotoma in the absence of any systemic illnesses.  In the acute stage, fundoscopy revealed multiple discrete yellowish-white lesion at the level of choroid and retinal pigment epithelium measuring 100 - 300 um in diameter. There is absence of inflammation in the anterior segment and the vitreous. Over several weeks, the lesions evolve into chorioretinal scars with variable pigmentation.

b. What is the differential diagnosis?

The differential diagnosis include all types of multifocal choroidopathies in which there are multiple discrete lesions at the level of the choroid and the retinal pigment epithelium. These include:

Infectious causes:

  • presumed ocular histoplasmosis syndrome
  • pneumocystis carinii choroiditis
  • mycobacterial choroiditis
  • syphilitic choroiditis
Inflammatory causes:
  • multifocal choroiditis and panuveitis
  • birdshot retinochoroidopathy
  • sarcoid choroidopathy
  • sympathetic ophthalmia
  • acute posterior multifocal placoid pigment epitheliopathy
Neoplastic causes:
  • choroidal metastases

c. What complication may occur with this condition?

The main cause of visual loss is the development of choroidal neovascularization around the scars which occurs in about one third of patients.

d. How would you treat this condition?

Oral or subtenon steroid are recommended for this condition. Photocoagulation is used to treat sight-threatening choroidal neovascularization.
This patient did not receive any treatment and the eventual visual acuity was 6/9 in the right and 6/6 in the left with mild visual distortion in the right eye.

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