Case Presentation

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Case Presentation

• 1.3.2002
• SINGLETON HOSPITAL

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History

• GP 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
• PMH unremarkable

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16.11.01

• No medical Treatment
• Penicillin Allergy
• FH Mother had cataract

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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

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16.11.01

• DD
• Old /new CSCR
• central CNVM 2 to ?POHS
• FFA on 28.11.01

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Differential Diagnosis

• Myopic degeneration
• MIC (multifocal inner choroidopathy)
• PIC (punctate inner choroidopathy)
• POHS (Presumed ocular histoplasmosis syndrome)
• Idiopathic CNVM

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Differential Diagnosis

• Birdshot Chorioretinopathy
• APMPPE (acute posterior multiple placoid pigment
  epitheliopathy)

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MIC

• Age 20 - 50 yrs
• FM 31
• Young healthy moderately myope
• C/O
• Subacute blurred vision
• Floaters

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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

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PIC

• Young healthy myope
• Commoner in female
• Unknown etiology
• C/O
• acute decreased VA/ central Scotoma

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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

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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

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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

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Birdshot chorioretinopathy

• Uncommon
• FgtM past 4th decade
• HLA- A29 (50-80)
• C/O
• Reduced VA, nyctalopia
• Colour VA disturbed

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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

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APMPPE

• Young adults
• FM 11
• Assoc. HLA DR2 HLA B7
• C/O
• Unilateral visual loss
• prodromal flu-like symptomps 50
• few has CNS vasculitis

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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

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30.11.01

• Review
• Noticed improvement
• RVA 6/5 LVA 6/4
• Diag CSCR
• review 5/52

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11.1.02

• Sudden loss of VA 2/52
• RVA 6/18 LVA 6/5
• -4.0/-1.5x90 -3.75/-1.25x105
• FFA

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15.1.02

• PIC
• MIC
• Idiopathic CNVM
• Oral pred 40 mg od
• f/u 3/52

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5.2.02

• No change in VA
• Distortion gone
• Developed Diabetes

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A.Acute White spots Vanishing later on

• MEWDS
• Cat-scratch disease
• AIDS Microangiopathy
• CW spots
• Acute Vitelliform maculopathy

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B. Acute white spots with coalescence diffuse
scarring

• APMPPE
• Serpiginous choroiditis
• Herpes Retinitis

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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

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C. Acute white spots becoming white scars with
variable pigmentation

• Sarcoidosis
• Sympathetic Ophthalmia
• VKH
• Bacterial retinochoroiditis
• Fungal retinochoroiditis
• Pneumocystis carinii choroiditis

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D. Late white spots with or without initial
orange spots

• Birdshot choroidopathy