Case of the Month | October 2021

Case of the Month
October 20, 2021

The Case

The patient was a 29-year-old healthy woman with moderately high myopia who experienced a sudden loss of vision in the right eye nine months ago that has not changed subsequently. Her visual acuity was 20/80 OD and 20/20 OS. The anterior chamber examination was normal in each eye, and the vitreous was quiet bilaterally. The fundus findings were restricted to the posterior pole of the right eye, and the peripheral retinas were normal.

What is the most likely diagnosis? What treatment, if any, would you recommend?

The patient had multiple punched-out lesions and a fibrosed choroidal neovascular membrane (CNVM) in the right eye. The OCT of the right eye shows a deep central reflective lesion without edema or subretinal fluid. There was also loss of the ellipsoid and interdigitation zones nasal to the fovea, corresponding to a punched-out lesion. In terms of identifying the underlying condition, the patient’s myopia suggested multifocal choroiditis (MFC), but patients with multifocal choroiditis tend to have vitreous cells. Our patient lived in Cincinnati for several years, and therefore the underlying cause was most likely ocular histoplasmosis syndrome (OHS). With stable subjective vision and without hemorrhaging, subretinal fluid, or retinal edema, observation was recommended.

Patients with MFC and OHS often have healthy RPE except adjacent to the punched out lesions. The CNVMs in such patients tend to respond well to anti-VEGF treatment. Untreated lesions frequently spontaneously involute, as occurred in our patient, but there is often significant damage to central vision. Prior to the anti-VEGF era, some patients who were not candidates for laser photocoagulation or, later, photodynamic therapy with verteporfin responded favorably to surgical removal of the CNVM.

Case Photos

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The patient had multiple punched-out lesions and a fibrosed choroidal neovascular membrane (CNVM) in the right eye. The OCT of the right eye shows a deep central reflective lesion without edema or subretinal fluid. There was also loss of the ellipsoid and interdigitation zones nasal to the fovea, corresponding to a punched-out lesion. In terms of identifying the underlying condition, the patient’s myopia suggested multifocal choroiditis (MFC), but patients with multifocal choroiditis tend to have vitreous cells. Our patient lived in Cincinnati for several years, and therefore the underlying cause was most likely ocular histoplasmosis syndrome (OHS). With stable subjective vision and without hemorrhaging, subretinal fluid, or retinal edema, observation was recommended.

Patients with MFC and OHS often have healthy RPE except adjacent to the punched out lesions. The CNVMs in such patients tend to respond well to anti-VEGF treatment. Untreated lesions frequently spontaneously involute, as occurred in our patient, but there is often significant damage to central vision. Prior to the anti-VEGF era, some patients who were not candidates for laser photocoagulation or, later, photodynamic therapy with verteporfin responded favorably to surgical removal of the CNVM.

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