Title: Episcleritis Associated with Lyme Disease, Case Report
Author: Eliza Barnwell, MSCR
Keywords / Main Subjects: Episcleritis; scleritis; conjunctival inflammation
Description of Image: This patient is a 24–year-old male with a one year history of Lyme disease who presented with 2 months of light sensitivity, redness and irritation in the right eye. Slit-lamp examination of the right eye revealed mild ptosis, 2+ sectoral injection of the conjunctiva in the superior and nasal regions with dilated episcleral vessels and 3 cells per high-powered-field in the anterior chamber. Examination of his left eye was normal. Topical application of 2.5% phenylephrine blanched the injected vessels. He was started on prednisolone drops 4 times a day and the episcleritis resolved shortly thereafter.
Episcleritis is typically an idiopathic, autoimmune condition causing dilation and inflammation of the superficial layers of the eye.1 Although usually idiopathic, episcleritis can also be associated with a variety of systemic diseases such as rheumatoid arthritis, Systemic Lupus Erythematous (SLE) and Inflammatory bowel diseases (IBD).3 Though uncommon, a number of studies have described episcleritis as an ocular manifestation of Lyme disease, both in late and early stages of the disease.4,5,6 In one case report, initiation of intravenous ceftriaxone therapy aggravated episcleral inflammation and caused an anterior chamber reaction in a patient with positive serum titers for Lyme.7
Scleritis is a deeper inflammation of the scleral vessels that typically does not blanch with application of topical phenylephrine. It is often associated with a systemic autoimmune disease in contrast to episcleritis. Scleritis tends to have dramatic focal tenderness and in its more severe form can lead to scleral thinning and perforation.
Treatment for scleritis commonly involves systemic anti-inflammatory and immunosuppressive agents, while episcleritis often resolves on its own or can be treated with a short course of topical steroids versus oral NSAIDs.2
- Jabs DA, Mudun A, Dunn JP, Marsh MJ. “Episcleritis and scleritis: clinical features and treatment results.” American journal of ophthalmology. 2000;130(4):469-76.
- Kirkwood BJ, Kirkwood RA. “Episcleritis and scleritis.” Insight. 2010;35(4):5.
- Akpek EK, Uy HS, Christen W, Gurdal C, Foster CS. “Severity of episcleritis and systemic disease association.” Ophthalmology. 1999;106(4):729-31.
- Flach AJ, Lavoie PE. “Episcleritis, conjunctivitis, and keratitis as ocular manifestations of Lyme disease.” Ophthalmology. 1990;97(8):973-5.
- de la Maza MS, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. “Clinical characteristics of a large cohort of patients with scleritis and episcleritis.” Ophthalmology. 2012;119(1):43-50.
- Zaidman GW. “Episcleritis and symblepharon associated with Lyme keratitis. American journal of ophthalmology. 1990;109(4):487-8.
- Mikkilä HO, Seppälä IJ, Viljanen MK, Peltomaa MP, Karma A. “The expanding clinical spectrum of ocular lyme” Ophthalmology. 2000;107(3):581-7.
Faculty Approval By: Dr. Amy Lin, Dr. Severin Pouly and Dr. Griffin Jardine
Title: Ocular Candidiasis
Authors: Christopher D. Conrady, MD, PhD, Rachel Jacoby, MD, Akbar Shakoor, MD, and Paul Bernstein MD, PhD
Keywords/Main Subjects: candidiasis, endophthalmitis, fungal endophthalmitis
Diagnosis/Differential Diagnosis: Presumed Candida endophthalmitis
Brief Description of Case: In the following cases, we present a 13-year-old boy that was being treated for B cell ALL. He developed a fever of unknown origin and was subsequently found to have GI imaging findings consistent with systemic candida. Blood cultures remained negative. Due to concern for candida, ophthalmology was asked to evaluate the patient and he was subsequently found to have two chorioretinal lesions of the left eye. He was initially closely monitored on IV antifungal therapy but then required intraocular injections, and finally, a pars plana vitrectomy due to re-activation of the lesions. Unfortunately, no microbiology could help direct therapy in this case and the full case is seen in detail in the presentation.
Slides 4, 5, 9, 10, 11, 14, and 17 are dilated fundus photographs. Slide 14 specifically shows the re-activation of the lesion once the patient was transitioned to oral antifungals as seen with the hazy borders and enlarged size compared to prior images.
Slide 21: Denotes a second case of presumed candida fungal endophthalmitis in a 10-year-old boy being treated for ALL. He has two notable peripheral lesions in the left eye. Due to their non-central nature, the spots were monitored closely and remained unchanged while on anti-fungal therapy. His other eye (not shown) had a foveal-involving lesion that required intravitreal antifungal therapy in addition to systemic antifungals.
Summary of Cases:
These two cases highlight the medical and surgical management of fungal endophthalmitis.
References for further reading:
- Brod RD, Flynn HW Jr., Clarkson JG, Pflugfelder SC, Culbertson WW, Miller D. Endogenous Candida endophthalmitis: management without intravenous amphotericin B. Ophthalmology 1990;97:666-72.
- Essman TF, Flynn HW Jr, Smiddy WE, Brod RD, Murray TG, Davis JL. Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis. Ophthalmic Surg Lasers. 1997 Mar. 28(3):185-94.
- Hariprasad SM, Mieler WF, Holz ER, et al. Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans. Arch Ophthalmol 2004;122:42-7.
- O’Day DM, Head WS, Robinson RD, Stern WH, Freeman JM. Intraocular penetration of systemically administered antifungal agents. Curr Eye Res 1985;4:131-4.
- Paulus YM, Cheng S, Karth PA, Leng T. PROSPECTIVE TRIAL OF ENDOGENOUS FUNGAL ENDOPHTHALMITIS AND CHORIORETINITIS RATES, CLINICAL COURSE, AND OUTCOMES IN PATIENTS WITH FUNGEMIA. Retina. 2015 Dec 11.
- Riddell et al., Treatment of Endogenous Fungal Endophthalmitis: Focus on New Antifungal Agents. Clinc Inf Dis.
- Schmid S, Martenet AC, Oelz O. Candida endophthalmitis: clinical presentation, treatment and outcome in 23 patients. Infection 1991;19:21-4.
- Sridhar J, Flynn HW Jr, Kuriyan AE, Miller D, Albini T. Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections. J Ophthalmic Inflamm Infect. 2013 Sep 20. 3 (1):60.
- Tod M, Lortholary O, Padoin, Chaine G. Intravitreous penetration of fluconazole during endophthalmitis. Clin Microbiol Infect 1997;3:379A.
- Walsh TJ, Foulds G, Pizzo PA. Pharmacokinetics and tissue penetration of fluconazole in rabbits. Antimicrob Agents Chemother 1989;33:467-9.
Copyright statement: Christopher D. Conrady, ©2016. For further information regarding the rights to this collection, please visit: URL to copyright information page on Moran CORE
Title: A Case Report of Hypertensive Retinopathy
Author: Tyler Scott Quist, BS
Photographer: James Gilman
Keywords/Main Subjects: Hypertensive retinopathy, hypertensive emergency
Hypertensive retinopathy refers to the microvascular changes of the retina that occur in the setting of hypertension and is a common cause of ocular disease. Hypertensive emergency refers to a systolic blood pressure (SBP) ≥ 180 and/or diastolic blood pressure (DBP) ≥ 120 with evidence of end organ damage, such as retinopathy.
A 40-year-old male with a history of newly diagnosed systolic blood pressure over 200 presents with a three-week history of bilateral blurry vision and halos worse in the left eye. The patient reported new-onset migraines and denied any other ocular symptoms. On exam, his visual acuity was 20/25 and 20/150 in the right and left eye, respectively. Tonometry, pupils, visual fields, extraocular movements, and slit lamp exam were unremarkable. The fundus exam was remarkable for bilateral optic disc edema and hemorrhage, macular hemorrhages and exudates, and arteriolar narrowing as shown in Figure 1. The patient was sent to the emergency department, where magnetic resonance imaging (MRI) revealed a small stroke in the corpus collosum. The patient was treated for hypertensive emergency with antihypertensives and his vision slowly improved over the course of several months.
Hypertension results in retinal microvascular changes called hypertensive retinopathy, which may be categorized as mild, moderate, or severe. The mild form is characterized by retinal arteriolar narrowing, the moderate form is characterized by hemorrhages and exudates, and the severe form is characterized by optic disc edema1. Hypertensive retinopathy is more common with increased age and among black persons and has a prevalence rate from two to fifteen percent1. Patients with malignant hypertensive retinopathy may present with blurry vision, decreased visual acuity, eye pain, and headaches. The dilated fundoscopic exam and coexisting hypertension is paramount in establishing the correct diagnosis and classification of the disease. Previously published literature has shown that reducing systemic blood pressure below 140/90 mmHg improves hypertensive retinopathy2,3. However, it is uncertain whether antihypertensive agents with a direct effect on microvasculature have any benefit over other antihypertensive medications.
- Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310.
- Bock KD. Regression of retinal vascular changes by antihypertensive therapy. Hypertension 1984;6:III-158.
- Dahlof B, Stenkula S, Hansson L. Hypertensive retinal vascular changes: relationship to left ventricular hypertrophy and arteriolar changes before and after treatment. Blood Press 1992;1:35-44.
Faculty Approval By: Dr. Amy Lin
Footer: Copyright 2016, Tyler Scott Quist. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/
Disclosure (Financial or other): No authors have any financial or proprietary interest in any material or methods mentioned.
Home / Pediatric Ophthalmology and Strabismus / Special Forms of Strabismus
Title: Opthalmoplegic Migraine / Recurrent Painful Ophthalmoplegic neuropathy
Keywords: Opthalmoplegic Migraine, Recurrent Painful Ophthalmoplegic neuropathy
Chief Complaint: Lid drooping and drifting eye
History of Present Illness: 3 year 3month old girl with past medical history of oculomotor nerve palsy (episode 2 years prior, resolved) presents with recurrent symptoms of oculomotor palsy. Four days prior, she experienced a GI illness with vomiting and decreased energy. Her parents deny fever, upper respiratory infection, cough, eye pain, rash or HA. The GI illness resolved two days later and around the same time her right upper eyelid began to droop. Over the next two days the drooping progressed and the patient developed deviated eye and asymmetric pupils. Her previous episode of oculomotor nerve palsy developed much like the present one. The parents report a sub-acute onset over a few days that progressed from ptosis, to anisocoria and strabismus. The episode resolved without treatment over about one week. An MRI was performed at an outside hospital and the read was as follows: “Enhancement of the right third cranial nerve which is most prominent immediately adjacent to the origin of the nerve at the brain stem. The enhancement extends anteriorly along the nerve to the cavernous sinus.” Her clinical presentation and imaging were felt to be consistent with inflammatory neuritis, most likely post viral.
Past Medical History: Otherwise non-contributory
Past Surgical History: None
Allergies: No known drug allergies
Immunizations: Up to date
Development: Age appropriate
Family History: No family history of eye disease, migraine, MS, neurologic disease, childhood cancers. Maternal cousins with celiac disease and DM1
Social History: Lives with parents; 2 cats and a dog. Attends daycare
Review of Symptoms: All negative except as above
Ocular Physical Exam:
- General: Alert and oriented, NAD
- isual Acuity: Fix and Follow OU
- OD: 5mm > 4mm
- OS: 4mm > 2mm
- Primary gaze: right eye deviated inferiorly and temporally
- -3 adduction
- -2 elevation
- -1 depression
- -0 abduction
- Full EOM
- Orbits: No deformities, ecchymosis or edema
- Lids/Lashes: Right ptosis, MRD1 0.5mm, normal eyelid position OS
- Conjunctiva/Sclera: white and quiet OU
- Cornea: clear OU
- Anterior Chamber: formed without hyphema or hypopyon OU
- Iris: flat and round OU
- Lens: WNL OU
- Dilated Fundus exam:
- Optic Nerve: sharp margins, no disc edema
- Macula: Healthy OU
- Vessels: Normal caliber OU
- Periphery: WNL OU
Vital signs and labs:
- T: 36.8
- HR: 104
- RR: 24
- BP: 112/60
- Sat: 99% RA
- CRP, BMP CBC: within normal limits
Image 1: Axial MRI T1 with contrast showing enhancement of the right 3rd nerve in the cisternal segment.
Image 2: Coronal MRI T1 with contrast showing enhancement and thickening of the cisternal portion of the right oculomotor nerve.
- Post-Viral Neuritis
- Ophthalmoplegic migraine/Recurrent painful ophthalmoplegic neuropathy
- Miller-Fisher Syndrome
- TB, Lyme, Sarcoid, Lymphoma
Based on clinical presentation, the list of differential diagnoses for our patient’s third nerve palsy would be quite extensive. ADEM and Miller-Fischer syndrome can present as third nerve palsies but they would also tend to be accompanied by other neurologic deficits such as ataxia or areflexia. When the recurrent and resolving history is taken into account aneurysm, schwannoma, TB, Lyme, sarcoid, and lymphoma become less likely as these would tend to be slowly progressive and unlikely to resolve without treatment. Imaging confirms the absence of schwannoma and also rules out Tolosa-hunt which would show inflammation in the cavernous sinus and meningeal enhancement. Aneurysm, Tolosa-Hunt, and Miller-Fisher syndrome would also be quite rare in this age group.
With all of these factors taken together the most likely diagnosis is either post-viral neuritis or Ophthalmoplegic migraine/Recurrent painful ophthalmoplegic neuropathy (OM/RPON). It is possible that these two conditions are related.
OM/RPON is a rare condition with a prevalence of 0.7 per million6; it usually begins in childhood.2,3 A systematic review authored by Gelfand found a median age of onset at 8 years old (interquartile range 3, 16). They also found that approximately 2/3 of patients affected by OM/RPON were female. 4
Signs and Symptoms
OM/RPON typically presents as a headache followed ophthalmoplegia. If headache is present, it is typically unilateral and ipsilateral to the affected eye. The headache may or may not have migrainous features; accompanied by photophobia, phonophobia, or nausea/vomiting. The ophthalmoplegia can occur immediately or up to 14 days after the headache. One or multiple nerves may be affected. The frequency of nerves affected in Gelfand’s paper was CNIII 83%, CNVI 20%, and CNIV 2%. If multiple nerves were affected, CNIII was always included.4 When CNIII is affected it may be a partial or complete palsy. Both ptosis and mydriasis are common, especially among children.
According to the International Classification of Headache Disorder 3-beta1:
A. At least Two attacks fulfilling criterion B.
B. Unilateral headache accompanied by ipsilateral paresis of one, two or all three ocular motor nerves.
C. Orbital, parasellar, or posterior fossa lesion has been excluded by appropriate investigation.
D. Not better accounted for by another ICHD-3 dx
As stated above, before the diagnosis of OM/RPON is made it is very important to rule out other possible etiologies such as aneurysm, schwannoma, granulomatous disease, and inflammatory neuropathy.2
The pathophysiology of OM/RPON is a topic of ongoing debate. The diagnostic criteria in ICHD have been updated over the years to mirror the trends in the etiologic discussion by classifying it first as a migraine, then as a neuralgia, and most recently as a neuropathy.5 In fact, with the newest release of ICHD-3beta, the International Headache Society recommended the term ‘ophthalmoplegic migraine’ be abandoned.1 The driving force for this progression has been the need to explain the reversible contrast enhancement at the root entry zone of the affected cranial nerve.
Some who support the viewpoint of a neuropathy will point to the possibility of a benign neurotropic viral infection and highlight the similarities of the imaging in OM/RPON to those found in Bell’s Palsy.2 Others advocate for an immune-mediated neuropathy similar to chronic inflammatory demyelinating polyneuropathy (CIDP).5 In both of these explanations, the headache of OM/RPON is a result of inflammation of the nerve. The inflammation causes vasoconstriction of the nearby vasculature subsequently triggering the headache. However, these hypotheses are not without their weaknesses, CSF analysis and viral studies typically return unremarkable in OM/RPON.
Even with the current trend towards viewing OM/RPON as a neuropathy, there are still some who continue to advocate for a migrainous etiology. A paper published in 2014 proposed that a migraine induced vasospasm of the arteries supplying CNIII, IV, or VI could lead to ischemia of the nerves causing reversible breakdown of the nerve-blood barrier allowing for contrast extravasation and subsequent nerve enhancement on MRI.3 The authors make a great case, yet still leave questions unanswered. If migraine is the causal process then why does treatment with acute and prophylactic migraine medication offer little to no benefit or protection to patients?
In summary, there is still much work to be done towards reaching an understanding of how and why OM/RPON occurs. It is valuable to consider that OM/RPON may in fact have a multifactorial etiology resulting from processes and predispositions related to both neuropathy and migraine.
Treatment: With such ambiguity clouding the pathophysiology of OM/RPON it follows that there is also uncertainty regarding effective treatment for the condition. Migraine medications both acute and prophylactic have been tried with unconvincing efficacy while the results of steroids have been positive yet mixed. Gelfand found steroids to be beneficial in 54% of cases reviewed. Yet the effects were either unclear, not beneficial or even harmful in 35%, 8%, and 4% respectively.4
Prognosis: Prognosis in OM/RPON is generally excellent and most patients can experience a full recovery in days to weeks. However small minority of patients may be left with
persistent neurological deficits, especially those who suffer from repeated attacks.2,3,4,5
1. The International Classification of Headache Disorders, 3rd edition (beta version).
2. Alexander, et. Al. Ophthalmoplegic Migraine: Reversible Enhancement and Thickening of the Cisternal Segment of the Oculomotor Nerve on Contrast-Enhanced MR Images. AJNR Am J Neuroradiol 19:1887–1891, November 1998
3. Ambrosetto, et. Al. Ophthalmoplegic migraine: From questions to answers. Cephalalgia 2014, Vol. 34(11) 914–919
4. Gelfand, et. Al. Ophthalmoplegic ‘‘Migraine’’ or Recurrent Ophthalmoplegic Cranial Neuropathy: New Cases and a Systematic Review.
Financial Disclosure: None
Title: Vitreitis Secondary to CNS Lymphoma
Authors: Michael Simmons, BS
Photographer: Melissa Chandler
Keywords / Main Subjects: CNS lymphoma; Disc edema; vitreitis
Diagnosis: Central nervous system extranodal natural killer cell/t-cell lymphoma (ENKTL) with optic nerve involvement and left vitreitis
Brief Description of Image: Extranodal natural killer/T-cell lymphoma (ENKTL) is a type of non-Hodgkin lymphoma . It makes up approximately 1% of all lymphomas in the US, but may occur more frequently in Hispanics and Native Americans. It has a close association with Epstein-Barr virus infection and typically manifests in the nasal cavity . ENKTL is an aggressive disease with a poor prognosis . There is a tendency to metastasize to the central nervous system . Although rare, ocular involvement has been noted. Ocular symptoms are nonspecific, and include such entities as eyelid edema and ptosis, blurred vision, optic nerve swelling, and steroid refractory anterior uveitis and vitreitis [2,5,7].
The patient is a 38-year-old man with a 26-year history of extranodal natural killer cell/T-cell lymphoma with multiple recurrences including central nervous system recurrences despite allogeneic bone marrow transplant. He presented for evaluation of six weeks of floaters and a new blind spot in his left eye. On exam, he was found to have diminished visual acuity with a 0.6 log left afferent pupillary defect, but color vision testing with Ishihara plates and a flicker fusion test were normal. He was found to have an intraocular pressure in his left eye. On slit lamp exam, there were 2+ cells in the left anterior chamber and 3+ vitreous cells with a pre-papillary and pre-macular vitreous infiltrate. There was also grade II disc edema. Fluorescein angiography showed no evidence of retinitis, but there was bilateral disc leakage, more prominent on the left than the right.
Flow cytometry performed on the patient’s cerebrospinal fluid revealed 20% abnormal natural killer cells lacking CD16 with prominent expression of CD57. Labs investigating alternate etiologies, including tuberculosis, syphilis, toxoplasmosis, bartonellosis, Lyme disease and sarcoidosis were negative. Previous therapies included chemotherapy, radiation therapy, infusions of EBV-specific T-cells, and allogeneic bone marrow transplant. With his current relapse, the patient received palliative external radiation therapy of the head and intrathecal cytarabine. The team also renewed discussions regarding hospice and end-of-life care.
- Harris NL, Jaffe ES, Diebold J, Flandrin G, Muller-Hermelink HK, Vardiman J, et al. World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues: report of the Clinical Advisory Committee meeting-Airlie House, Virginia, November 1997. J Clin Oncol. 1999;17: 3835–3849.
- Cimino L, Chan C-C, Shen D, Masini L, Ilariucci F, Masetti M, et al. Ocular involvement in nasal natural killer T-cell lymphoma. Int Ophthalmol. 2009;29: 275–279.
- Li S, Feng X, Li T, Zhang S, Zuo Z, Lin P, et al. Extranodal NK/T-cell lymphoma, nasal type: a report of 73 cases at MD Anderson Cancer Center. Am J Surg Pathol. 2013;37: 14–23.
- Hatta C, Ogasawara H, Okita J, Kubota A, Ishida M. Non-Hodgkin’s malignant lymphoma of the sinonasal tract—treatment outcome for 53 patients according to REAL classification. Auris Nasus Larynx. Elsevier; 2001; Available: http://www.sciencedirect.com/science/article/pii/S0385814600000948
- Abe RY, Pinto RDP, Bonfitto JFL, Lira RPC, Arieta CEL. Ocular masquerade syndrome associated with extranodal nasal natural killer/T-cell lymphoma: case report. Arq Bras Oftalmol. 2012;75: 430–432.
- Maruyama K, Kunikata H, Sugita S, Mochizuki M, Ichinohasama R, Nakazawa T. First case of primary intraocular natural killer t-cell lymphoma. BMC Ophthalmol. 2015;15: 169.
- Yoo JH, Kim SY, Jung KB, Lee JJ, Lee SJ. Intraocular involvement of a nasal natural killer T-cell lymphoma: a case report. Korean J Ophthalmol. 2012;26: 54–57.
Disclosure (Financial or other): None
Title: Sickle Cell Retinopathy
Author: Elizabeth Ann Urias, MSIV
Image or video:
Diagnosis: Sickle Cell Retinopathy: Salmon Patch Hemorrhage
Description of Image: In sickle cell hemaglobinopathy, RBC sickling causes peripheral retinal arteriolar occlusion, leading to ischemic necrosis and weakening of the vessel walls. Fragile vessels result in hemorrhages in one or more layers of the retina. An intra-retinal hemorrhage is round or oval shaped, bright red, and measures ¼-1 disc diameter. In days or weeks, this bright red color becomes a salmon color, which is known as a “salmon patch.” After time, hemoglobin degradation occurs and the defect appears as bright yellow dots at several layers of the sensory retina, also known as “iridescent bodies.” (Bonanomi & Lavezzo, 2013)
- Bonanomi, M. T. B. C., & Lavezzo, M. M. (2013). Sickle cell retinopathy: diagnosis and treatment. Arquivos Brasileiros de Oftalmologia, 76(5), 320–327.
Faculty Approval by: Griffin Jardine, MD
Financial Disclosures: None
Title: Corneal Allograft Rejection Three Years Status Post Penetrating Keratoplasty
Author: Charlotte L. Marous, B.S., M.S.G.H.; Brian E. Zaugg M.D. July 2016
Photographer: James Gilman
Image or Video:
Keywords/Main Subject: Keratoconus, Penetrating Keratoplasty, Transplant Rejection, Corneal Graft Rejection, Allograft Rejection, Corneal Vascularization, Immunosuppressives
Diagnosis: Corneal Transplant Rejection, Keratoconus
Chief Complaint: blurry vision of left eye for two weeks
History of Present Illness: A 35-year-old Caucasian female with bilateral keratoconus status post bilateral penetrating keratoplasty three years prior was referred for progressive blurry vision of the left eye for the past two weeks. Exam one year ago showed a healthy graft and clear cornea OU with visual acuity of 20/20 OD uncorrected and 20/20 OS corrected with a contact lens. The patient denied pain, discomfort, or discharge, stating only that the blurriness is “annoying.” No vision complaints OD. Using 1 drop of prednisolone acetate 1% once daily OU.
Past Ocular History: Keratoconus OU status post penetrating keratoplasty OU. Phacoemulsification with toric IOL for posterior subcapsular cataract OD, levator resection for ptosis OU, and a nuclear cataract OS currently stable under observation.
Medical history: FAP Gardner’s Syndrome
Family History: None
Social History: denies smoking, alcohol, illicit drugs
Medications: 1 drop prednisolone acetate 1% daily OU
- Visual Acuity – best corrected with contact lens:
- OD – 20/25 +/-2
- OS – 20/200, 20/70 with pinhole
- Intraocular pressure (IOP by applanation):
- OD – 12 mmHg
- OS – 18 mmHg
- Pupils: No APD OU
- Slit lamp examinations:
- OD – cornea clear, penetrating keratoplasty, posterior chamber intraocular lens
- OS – cornea 3+ edema, superior rejection line, neovascularization 360 degrees, broken suture inferior
Corneal transplant rejection OS
Prednisolone 1% every hour OS
Preservative free tears hourly OS
Follow-up in 2 weeks
CORNEAL ALLOGRAFT REJECTION DISCUSSION
Corneal graft transplant is the most widely practiced and successful type of solid organ transplantation in humans.1 Approximately 60,000 procedures are performed annually worldwide for diseases such as keratoconus, psuedophakic or phakic bullous keratopathy, trauma, infections, and corneal dystrophies or ectasias.1 It is associated with a high survival rate of 86% at 1-year post initial graft, largely attributed to the immune privilege of the eye.2 However, the 15-year graft acceptance rate declines to 55%, similar to survival rates in other forms of organ transplant.3 Graft rejection is one of the leading causes of corneal graft failure in the immediate and late postoperative period.1 Immune rejection and graft-related problems constitute the most important emergent presentations in graft patients. Long-term prophylactic use of topical steroids and immunosuppressive drugs can improve graft survival rate, but do not eliminate the risk, especially in “high-risk” recipients, and can be accompanied by side effects and potential toxicity.1 Novel biologic agents are showing promise in these patients unable to tolerate steroids.
Corneal graft rejection is a reversible immune response against donor antigens. If signs of immunologic graft rejection do not clear within 2 months, the diagnosis of graft failure is made. Graft failure is the irreversible loss of graft clarity. It is important to rule out other common causes of loss of graft clarity before declaring failure. These include, but are not limited to infection, surgical trauma, glaucoma, and aging. Graft rejection is the most common cause of ultimate graft failure, accounting for >30% of cases.2
The immune privilege of the cornea is maintained by the absence of blood vessels and lymphatics that deliver antigens to T cells in lymph nodes, scarcity of mature antigen presenting cells (APCs) in the central cornea, unusually low expression of major histocompatibility complex (MHC) antigens, and expression of the FAS ligand that induces apoptosis of stimulated Fas+ T cells.1 This privilege can be revoked by inflammation, infection, or trauma that induce neovascularization and lymphatic growth into the cornea; thus permitting APCs to enter the corneal stroma.1 Infection also induces pro-inflammatory cytokines that upregulate MHC antigen expression on corneal cells. Once the host immune system recognizes these foreign histocompatibility antigens on the cells of the corneal allograft, an immune cascade and response is initiated against these antigen, leading to eventual decompensation of the graft tissue.1 This rejection represents a form of delayed-type hypersensitivity response mediated by CD4+ T cells.2
Allograft rejection can affect one or more layers of the cornea (epithelium, stroma, and endothelium). The endothelium possesses minor regenerative properties and is a key player to maintaining corneal deturgescence.2 Thus, when >50% of the corneal endothelium is lost, graft rejection is likely to progress to graft failure.
Donor, host, and intraoperative factors influence graft rejection in corneal transplant recipients (Table 1). “High Risk” is defined as deep stromal vascularization of the host cornea of two or more quadrants, or a previous graft rejection in the affected eye.1
Table 1: Risk factors predisposing to graft rejection
|· High antigenic load (depends on HLA/ABO compatibility between donor/host)
· Longer duration of storage of donor cornea (may reduce rejection)
· Pretreatment of donor tissue with UV radiation (may reduce rejection by preventing activation of cytotoxic T cells)
|· Vascularization of host cornea
· History of previously rejected graft (pre-sensitizes the host)
· Ocular surface diseases (severe dry eye, chemical burns, radiation burns, ocular pemphigoid, Stevens-Johnson Syndrome, neuroparalytic disease)
· Active keratitis
· Pediatric patients (immune systemic of children is more active than adults)
|Intraoperative Factors||· Large/eccentric graft
· Synechiae at graft host junction
· Penetrating grafts
· Previous anterior segment surgical reconstruction
· Bilateral graft
· Suture removal (may trigger immune rejection)
Clinical Signs and Symptoms:
Patients may be asymptomatic or may complain of increased blurry vision, redness, pain, irritation, or photophobia. Signs of graft rejection include:
- Stromal and/or epithelial edema
- Keratic precipitates (KPs) localized to the donor graft
- Corneal vascularization
- Stromal infiltrates
- Khodadoust line (separating immunologically damaged endothelium from unaffected endothelium)
- Elevated epithelial rejection line
- Krachmer spots (subepithelial infiltrates)
- Conjunctival injection
- Anterior chamber inflammation
Rejection can be classified based on corneal layer involvement (Table 2).1 Chronic focal endothelial rejection is the most common cause of graft rejection constituting 50% of cases. Epithelial rejection and stromal rejection represent roughly 2% and 1% of graft rejections, respectively.4
Table 2: Differentiating Features in Corneal Graft Rejection
|Epithelial||· Epithelial rejection line at the host graft junction
· No edema, keratic precipitates, or infiltrate
|Stromal||· Circumferential limbal injection
· Patches of stromal infiltrate and haze
· Stromal edema
· Lymphocytes and plasma cells outside endothelial capillary wall
|Endothelial||· Endothelial line
· Stromal and epithelial edema
· Keratic precipitates on graft endothelium
· Cell and flare possible, but difficult to visualize due to edematous cornea
Adapted from Panda A, Vanathi M, Kumar A, et al. Corneal graft rejection. Survey of Ophthalmology. 2007; 52: 375-95.
Differential Diagnosis of Corneal Graft Rejection:
- Suture abscess or corneal infection
- Epithelial downgrowth
- Recurrent herpetic keratitis
- Sterile or infectious endophthalmitis
- Increased IOP
Diagnosis is based on history and slit lamp examination. Important questions to be considered include: time since corneal transplantation, current eye medications, compliance with eye medications and postoperative follow-up, recent changes in topical steroid regimen, and inquiry into the initial indication for the corneal transplant. On slit lamp exam, inspect for endothelial rejection line, keratic precipitates, subepithelial infiltrates, edema, and cells in anterior chamber.
Prevention Practices and Immunosuppressive Agents:
Prevention can be subdivided into preoperative, intraoperative, and postoperative measures. Preoperatively, minimizing the antigenic difference between the host and donor tissue (tissue matching) and reducing the antigenic load of the donor tissue (UV light exposure) can help diminish the risk of rejection. Intraoperative measures of preventing immune-mediated allograft rejection are achieved by meticulous surgical techniques including good graft-host apposition and sterile suturing. Close follow-up monitoring for IOP, intact sutures, and compliance to immunosuppressive medications contribute to post-operative risk reduction.
Immunosuppressive medications play a fundamental role in the reduction of graft rejection. Current practice guidelines suggest “low risk” patients be put on long-term once daily prophylactic topical steroids (1% prednisolone drops), while “high risk” recipients adhere to a more stringent prophylactic regimen of long-term daily topical steroid plus a systemic immunosuppressive.1 Topical and oral steroids control the host immune system by preventing invasion by IL-1 and IL-6 producing macrophages and initiation of T-cell responses. Given the side effect profile of prolonged steroid use including cataract formation, glaucoma, and impaired wound healing, newer preventative therapeutics are becoming more widely available. Calcineurin inhibitors including cyclosporine (CsA), tacrolimus (FF-506), and mycophenolate mofetil (MMF) have been shown to be effectively substituted for steroids.5 Intraocular delivery of immunosuppressants in “high risk” rabbits was associated with reduced rate of graft rejection compared to those treated with topical or oral agents alone; supporting another potential route of prophylaxis.2 Novel biologic agents blocking receptors of TNF-a, VEGF, and CCL2 are also showing promise as prophylactic treatment in patients affected by high immune risk and corneal neovascularization.6 These agents work by reducing corneal inflammation, vascularization, angiogenesis, lymphangiogenesis; all factors common to graft rejection.2
Despite prophylactic efforts, graft rejection may transpire. Management is aimed at reducing the active immune response. The likelihood of reversibility is largely dependent on the corneal layer affected. For epithelial and subepithelial acute rejections, which have a higher rate of reversibility, primary treatment involves topical steroids (1% prednisolone) six times per day along with preservative-free artificial tears that hydrate the ocular surface.7 Severe endothelial rejection requires hourly topical steroids in combination with systemic therapy (40 to 80 milligrams of oral prednisone daily, or 1-2 intravenous doses of 400 milligrams of methylprednisolone with or without subconjunctival betamethasone 3 milligrams in 0.5 milliliters).7 Careful monitoring for IOP and resolution of the inflammation should be assessed every 3-7 days until improvement is noted, at which point steroids may be slowly tapered and maintained at a long-term low dose.
Alternatives to Normal Corneal Tissue Grafts in “High Risk” Patients:
One alternative for patients with multiple failed corneal grafts is a Boston keratoprosthesis, an artificial cornea. This is a synthetically generated cornea FDA-approved for use in patients with severe corneal opacification and high risk of transplant failure. Donor corneal tissue is secured between a rigid polymethyl methacrylate optic front plate and back plate lined with holes to allow for communication with the aqueous for nutrition and hydration of the cornea. The plates are snapped together and sutured into the recipient eye, similar to a typical corneal transplant.8-9 A prospective case series of 141 cases across 17 centers reported visual acuity of 20/40 in 23% of patients and 20/200 in 57% of patients after keratoprosthesis placement.10 Failure for visual acuity improvement and post-operative complications included epithelial defects, stromal thinning, dellen formation, retroprosthetic membrane formation, retinal detachment, and development of glaucoma.2,11
Bioengineered corneal equivalents represent another possible option. These biosynthetic implants are equivalent to corneal stromal extracellular matrix and are based on chemically crosslinked collagen designed to function as regeneration templates. The idea is that regeneration of endogenous corneal layers and functional corneal nerves occur in the collagen matrix, thus hydrogel implants that mirror this natural cornea structurally may promote active regeneration of endogenous corneal epithelial and stromal cells.2 A recent 4-year follow-up clinical study provided strong evidence supporting high acceptance and adaptation of the hydrogel with improved visual acuity and central nerve ingrowth.12 The major limitation of this method resides in the fact that positive outcomes are limited to lamellar keratoplasty, in which host endothelium is still intact. This would not be helpful in patients requiring penetrating keratoplasty.
- Panda A, Vanathi M, Kumar A, et al. Corneal graft rejection. Surv Ophthalmol. 2007;52:375-95.
- Yu T, Rajendran V, Griffith M, Forrester JV, Kuffova L. High-risk corneal allografts: a therapeutic challenge. World J Transplant. 2016;6:10-27.
- Williams KA, Esterman AJ, Bartlett C, Holland H, Hornsby NB, Coster DJ. How effective is penetrating corneal transplant? Factors influencing long-term outcome in multivariate analysis. Transplantation. 2006;81:896-901.
- Guilbert E, Bullet J, Sandali O, Basli E, Laroche L, Borderie VM. Long-term rejection incidence and reversibility after penetrating and lamellar keratoplasty. Am J Ophthalmol. 2013;155:560-69.
- Hill JC. Systemic cyclosporine in high-risk keratoplasty: long-term results. Eye (Lond). 1996;9:422-28.
- Fasciani R, Mosca L, Giannico MI, Ambrogio SA, Balestrazzi E. Subconjunctival and/or intrastromal bevacizumab injections as preconditioning therapy to promote corneal graft survival. Int Ophthalmol. 2015;35:221-7.
- Bagheri N, Wajda BN. The Wills Eye Manual: office and emergency room diagnosis and treatment of eye disease, 7th edition. Philadelphia: Lippincott Williams and Wilkin, 2017:98-99.Print.
- Ilhan-Sarac O, Akpek EK. Current concepts and techniques in keratoprosthesis. Curr Opin Ophthalmol. 2005;16:246-50.
- Birkholz ES, Goins KM. Bostom keratoprosthesis: an option for patients with multiple failed corneal graft. March 9, 2009; Available from: http://www.EyeRounds.org/cases/94-Boston-Keratoprosthesis-Failed-Corneal-Graft.htm
- Zerbe BL, Belin MW, Ciolino JB. Boston type 1 keratoprosthesis study group, results from the multicenter Boston Type 1 Keratoprosthesis study. Ophthalmol. 2006;113:1779.
- Ray S, Khan BF, Dohlman CH, D’Amico DJ. Management of vitreoretinal complications in eyes with permanent keratoprosthesis. Arch Ophthalmol. 2002; 120: 559–566.
- Fagerholm P, Lagali NS, Ong JA, Merrett K, Jackson WB, Polarek JW, Suuronen EJ, Liu Y, Brunette I, Griffith M. Stable corneal regeneration four years after implantation of a cell-free recombinant human collagen scaffold. Biomaterials. 2014; 35: 2420-27.
Faculty Approval by: Brian E. Zaugg, M.D.
Copyright: Charlotte L Marous © 2016. For further information regarding rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/
Disclosure (Financial or other): The authors have no financial conflicts of interest.
Title: Familial Exudative Vitreoretinopathy
Author (s): Jeffrey Z. Kartchner, BS; Mary E. Hartnett, MD
Keywords/Main Subjects: Familial exudative vitreoretinopathy, exudative retinal detachment, persistent fetal vasculature, retinopathy, leukocoria
Secondary CORE Category: Retina and Vitreous / Diseases of the Vitreous and Vitreoretinal Interface
Diagnosis: Familial Exudative Vitreoretinopathy
Format: Case presentation
History of Present Illness: A 4-month old boy born at full term after an uncomplicated pregnancy presented with exophoria and microphthalmia of the left eye, and also with right eye preference. He was seen by an outside pediatric ophthalmologist and diagnosed with leukocoria and probable persistent fetal vasculature (PFV) and referred to our retina service for surgery.
Past medical history was unremarkable. Family history was positive for mother with strabismus and maternal uncle with congenital cataract of unknown etiology.
Initial Examination: The patient’s visual acuity was “fix & follow” in both eyes. He had a mild afferent pupillary defect in the left eye, but none present in the right eye. His corneal diameter on the left side was 10mm, compared to 11mm on the right. External exam was otherwise normal bilaterally. Fundus exam of the right eye was normal, but no view was achieved on the left eye because of a dense retrolental membrane. A B-Scan ultrasound was performed, which showed a total retinal detachment with an open funnel. The decision was made to proceed with examination under anesthesia (EUA) with plans to perform a lensectomy and vitrectomy in the left eye for presumed PFV.
Clinical Course: The patient underwent EUA and was found to have an area of peripheral avascular retina in the right eye. Fluorescein angiography of this eye later showed peripheral avascular retina and leakage of the vessels at the junction of vascular and avascular retina consistent with stage 2A FEVR (Figure 1). The patient underwent lensectomy and vitrectomy in the left eye which revealed a retrolental membrane and a complete retinal detachment with a nasal exudative retinal fold, consistent with Stage 5 FEVR (Figure 2).
The patient underwent scatter photocoagulation of the avascular retina in the right eye (Figure 3). The patient subsequently underwent several additional EUAs and surgeries to drain subretinal fluid or release traction. Genetic studies revealed a heterozygous mutation of the FZD4 gene via the EyeGene research study.
Current Exam: At age 21-months the patient’s visual acuity in the right eye is 20/32 by Allen acuity cards and light reactive in the left eye. There is a 3+ afferent pupillary defect in the left eye. Disease in the right eye has been stable after scatter photocoagulation. The left eye shows reattachment of the retinal detachment with resolving subretinal exudates and the persistent subretinal band and nasal fold (Figure 4). Current management includes regular monitoring and maximizing his visual outcome with consideration of the aphakic correction of the left eye.
FEVR is a genetically inherited disease with multiple modes of inheritance, including autosomal dominant, autosomal recessive, and X-linked. Expressivity is variable, such that it is common for patients to present with widely different phenotypes, even between eyes in the same individual. Up to 58% of relatives of patients diagnosed with FEVR have asymptomatic clinical findings1. Mutations in FZD4, LRP5, NDP and TSPAN12, members of the Wnt signaling pathway, are implicated in about 50% of cases. Newly discovered mutations in ZNF408 have also been shown to lead to disease2.
Genetic mutations lead to incomplete vascularization of the peripheral retina in full-term infants that may progress to neovascularization. The disease appears similar to acute retinopathy of prematurity (ROP). Exudative retinal detachment, retinal folds, macula ectopia, fibrous bands, and tractional retinal detachments also occur with FEVR progression. Studies have been performed evaluating the location of retinal folds in children with FEVR3,4. It was shown that patients with retinal folds extending from the posterior pole to the lens present in such a way that the diagnosis of FEVR can be difficult to distinguish from PFV, as was the case in the current patient presentation. It is, therefore, imperative to perform EUA with careful examination of the contralateral eye for any signs of FEVR.
Management of FEVR includes early screening in suspected cases, with prompt laser photocoagulation therapy or cryotherapy to any avascular retina and neovascularization. Retinal detachments are managed surgically, with frequent follow-up for monitoring of repeat detachments. Recent studies have been performed evaluating the efficacy of anti-VEGF agents in the treatment of FEVR. While initial results can be promising, the long-term therapy in these patients did not provide sustained positive outcomes5. Limitations to research regarding FEVR include the small patient population and wide variability of expressivity between patients.
1. Trese MD et al. High prevalence of peripheral retinal vascular anomalies in family members of patients with familial exudative vitreoretinopathy. Ophthalmology. 2014;121(1):262-8.
2. Collin RW, Nikopoulos K, Dona M, Gilissen C, Hoischen A, Boonstra FN et al. ZNF408 is mutated in familial exudative vitreoretinopathy and is crucial for the development of zebrafish retinal vasculature. Proc Natl Acad Sci USA. 2013; 110: 9856–9861.
3. Robitaille JM et al. Phenotypic Overlap of Familial Exudative Vitreoretinopathy (FEVR) with Persistent Fetal Vasculature (PFV) Caused by FZD4 Mutations in two Distinct Pedigrees. Ophthalmic Genet. 2009;30(1):23-30
4. Trese MD et al. Clinical Presentation of Familial Exudative Vitreoretinopathy. Ophthalmology. 2011;118(4):2070–2075.
5. Henry CR. Long-term follow-up of intravitreal bevacizumab for the treatment of pediatric retinal and choroidal diseases. J AAPOS. 2015 Dec;19(6):541-8.
Faculty Approval by: Mary E. Hartnett, MD
Disclosure (Financial or other): None
Authors: Judd Cahoon, PhD; Dr. Jeff Pettey, MD
Photographer: James Gillman, CRA, FOPS, Project Administrator Ophthalmic Imaging Date: 7/21/2015
Diagnosis/Differential Diagnosis: Aniridia, salzmann’s nodules, non-proliferative diabetic retinopathy
Description of Case:
42-year-old male with congenital aniridia presents for annual diabetic screen. He has multiple medical comorbidities including type-1 diabetes since the age of 12 and congenital partial agenesis of the corpus callosum. His diabetes is poorly controlled (A1C of 8). The patient states his vision (both near and far) is worsening over the past few years. He states he bumps into things often because he doesn’t see them and this has led to some falls.
Past Ocular History: Cataract surgery in both eyes in 2011
Past Medical and Surgical History: T1DM since age of 12, no other surgeries Medications: Novolin subq daily.
Family History: Mother and father with history of diabetes mellitus, no history of aniridia in family.
Social History: Lives in a house with others who help him make his food. He smokes 8-10 cigarettes a day. No alcohol use or drug use.
• External exam: Normal both eyes (OU)
• Distance visual acuity (Snellen)
o Right eye (OD) 20/200, no improvement with pinhole
o Left eye (OS) 20/250, no improvement with pinhole
o OD: Dark 7mm, light 7 mm, no reaction
o OS: Dark 7mm, light 7mm, no reaction
• Motility: Full OU, nystagmus present in all directions
• Visual Fields
o OD: all peripheral fields decreased
o OS: decreased in inferior nasal and temporal fields
• Tonometry (Applanation)
o OD: 16 mmHg
o OS: 16 mmHg
• Anterior Segment exam (Figure 1)
o Lids and lashes: Normal OU
o Conjunctiva and Sclera: white and quiet OU
o Cornea: Inferior circular subepithelial opacity – likely Salzmann’s nodules, OU
o Anterior Chamber: Deep and quiet OU
o Iris: Aniridia OU
o Lens: Posterior chamber intraocular lens, open posterior capsule (OD), PCIOL with 1+ poster capsular opacification (OS)
o Vitreous: normal OU
• Fundus Exam:
o Disc: atrophic area inferior to nerve (OD), normal (OS)
o C/D ratio: 0.6 (OD), 0.65 (OS)
o Macula: normal OU
o Vessels: normal OU
o Periphery: inferonasal circular retinal scar next to optic nerve (OD), normal (OS)
Aniridia, or absence of the iris, is estimated to have a prevalence of about 1.8 per 100,000 in the population. It is inherited commonly in an autosomal dominant fashion with complete penetrance but variable expressivity (Familial congenital aniridia), but can also be acquired in both sporadic form (Miller syndrome) or, rarely, in an autosomal recessive fashion (Gillespie Syndrome). Additionally, aniridia can be acquired after trauma. Caused by mutations a gene on chromosome 11p13, PAX6 is involved in regulating transcription in the cornea, lens, ciliary body, and retina, genetic testing can be acquired in patients presenting with aniridia.
Patients with aniridia often present with bilateral absence of the iris, which can be either complete or partial. Caregivers can often notice severe light sensitivity, or photophobia, in the child. Multiple ocular comorbidities are also noted including dry eye, meibomian gland dysfunction, and (as seen in our patient) nystagmus, decreased visual acuity, corneal opacification, aniridia-associated keratopathy, cataracts, and optic nerve hypoplasia. Glaucoma is also of major concern and often develops due to inhibition of aqueous flow by the iris stump blocking the trabecular meshwork. Tonometry, pachymetry, and optic nerve exams, and visual field testing are all useful in the diagnosis of an individual with suspected aniridia. However, aniridia remains a clinical diagnosis that can be supported by genetic testing (for PAX6 mutations). A careful family history is also required to rule out other syndromes.
Clinicians should be suspicious of syndromic sequelae in individuals with sporadic aniridia. WAGR syndrome (Wilms tumor, aniridia, genitourinary abnormalities, and mental retardation) is caused by deletion of the short arm of chromosome 11, which, in addition to PAX6, houses the WT1 gene. Presentation of WAGR syndrome includes characteristic facies (long face, stubby nose, long philtrum) in addition to renal and genital abnormalities. Bardet-Biedl Syndrome is an autosomal recessive disease which, like WAGR syndrome, causes kidney and genitourinary abnormalities, but also includes retinal pigment atrophy, zonular cataracts, and polydactyly.
Treatment for aniridia can include colored contact lenses with dark periphery or filter/tinted lenses of photophobia. Importantly, treatment of ocular co-morbidities is paramount.
Preservative free tears may be used to for associated keratopathy and dry eye syndrome. Limbal stem cell transplants with amniotic membranes can prevent corneal pannus and scarring. Regular dilated eye exams are useful to follow optic nerve changes along with pressure checks and visual fields. If genetic testing was not obtained, regular abdominal ultrasounds are useful to screen patients for Wilms tumor.
Summary of Case:
Vision usually remains poor in patients with aniridia, around 20/200, thus preserving the vision patients have is of utmost importance. In our patient, the nystagmus and corneal disease were not uncommon findings for someone with aniridia. Neither were his visual field deficits, though his pressure was normal. He had his cataracts removed previously and will be referred to a corneal specialist to follow his Salzmann’s nodules. The patient previously underwent YAG laser for PCO and has some remnant opacifications that could benefit from further treatment. Fortunately, his diabetes has not affected his eyes clinically, yet.
- Goetz K, Vislisel JM, Raecker ME, Goins KM. Congenital Aniridia. March 10, 2015; Available from: http://EyeRounds.org/cases/211-Aniridia.htm
- Hingorani, M., Hanson, I., Van Heyningen, V. Aniridia. European Journal of Human Genetics 2013; 20:1011-1017.
- Kokotas, H. et al: Clinical and molecular aspects of aniridia. Clin Genet. 2010, 77(5):409-20.
- Lee, H., Khan, R. and O’Keefe, M. Aniridia: current pathology and management. Acta Ophthalmologica 2008; 86:708–715.
Title: Punctate Inner Choroidopathy (PIC)
Author: Sai Bhuvanagiri (MS IV); Akbar Shakoor, MD
Photographer: Photo courtesy of Dr. Shakoor
Financial Disclosure: None
Image: SD-OCT of images of Active Punctate Inner Choroidopathy (above) with Choroid Neovascular Membrane complication and Inactive Punctate Inner Choroidopathy lesion (below)
Keyword/ Main Subject: SD-OCT images of Active Punctate Inner Choroidopathy (PIC) with complication of Choroidal Neovascular Membrane (CNV) (above) and bottom image of lnactive Punctate Inner Choroidapthy of the same patient after appropriate anti-VEGF treatment
Diagnosis/ Differential Diagnosis: Punctate Inner Choroidopathy, Multiple Evanescent White Dot Syndrome, Multiple Choroiditis, Presumed Ocular Histoplasmosis Syndrome, Birdshot’s Retinopathy
Brief Description: Punctate Inner Choroidopathy (PIC) is a very rare ocular inflammatory disease considered to be part of the White Dot syndromes that fall under the umbrella of uveitis. PIC frequently affects young Caucasian myopic women with mostly bilateral involvement 2.
Patients present with symptoms of loss of central visual acuity (VA), photopsia and central scotoma. PIC is usually a benign disease; however, visual loss can occur secondary to complications of CNV or subretinal fibrosis. The current etiology is unknown but is thought to have familiar predisposition to autoimmune/ inflammatory diseases with response against antigens in the outer retina and inner choroid and increase in choroidal thickness during acute phases of PIC and reduction during regression of PIC 4 • The mainstay of treatment for PIC is anti-VEGF intravitreal injections with mean visual acuity (VA) that returned from baseline of
3.2 /10 to 6/10 in 12 months with no disease recurrence 6. Other treatment option includes oral steroids with VA return from baseline of 1/10 to 6.7/10 in a week 5. However, they are not the primary form of treatment due to systemic side effects. Other treatment options include mycophenolate mofetil, laser photocoagulation, and submacular surgery 1.
When this patient was diagnosed with PIC, she initially presented with central vision loss in the right due to CNVM. On further investigation of patient’s history and ruling out infectious causes, the patient was found to have PIC. The main factors that lead to the diagnosis of PIC are patient’s acute symptoms, patient’s demographic correlation to similar patients with PIC, lack of anterior chamber inflammation and SD-OCT image (above) finding of RPE elevation with a loss of photoreceptor (PR) layer 3. The patient was treated with Avastin (anti-VEGF) intravitreal injections with week duration to treat both CNVM and PIC. The patient is followed every three months and had no recurrences so far for the past nine months. The latest SD-OCT image confirms the resolution of the patient’s active PIC phase with re-appearance of her PR layer and reduced RPE layer elevation 2.
Identifier: Moran_CORE_ 21453
- Campos J, et al. “Punctate Inner Choroiditis” Innovations in Ophthalmology. October, 2014.
- Channa R, et al. “Characterization of macular lesions in punctate inner choroidopathy with spectral domain optical coherence tomography “Journal of Ophthalmic Inflammations and Infections. July, 2012.
- Goldstein D, et al. “Multifocal Choroiditis vs. PIC: Variations on a Theme”.
Ophthalmology Review, July, 2004.
- Hiraoka K, et al. “Increased macular choroidal blood flow velocity and decreased choroidal thickness with regression of punctate inner choroidopathy “BMC Ophthalmology. May, 2014.
- Olsen TW, Capone A, Sternberg P, et al. Subfoveal choroidal neovascularization in punctate inner choroidopathy. Surgical management and pathologic findings. Ophthalmology. 1996.
- Zhang X, Wen F, Zuo C, Li M, Chen H, Huang S, Luo G. Clinical features of punctate inner choroidopathy in Chinese patients. Retina.