The initial fundus photograph of the right eye reveals a deep yellowish, placoid lesion, and the fundus photograph three weeks later shows significant enlargement. The area of involvement shows hyperautofluorescence, indicating stress on the retinal pigment epithelium with tiny spots of more intense hyperautofluorescence. Fluorescein angiography at initial presentation shows early hyperfluorescence indicating loss of RPE pigmentation as well as tiny spots of hyper- and hypofluorescence. The late-phase picture shows well-defined enhanced hyperfluorescence at the edge of the lesion, indicating uptake of fluorescein dye by inflamed RPE at the border of the lesion.
The different diagnosis includes the following:
Acute posterior multifocal placoid pigment epitheliopathy. APMPPE typically presents as an acute loss of vision with multifocal placoid lesions following a flu-like illness. It is usually bilateral, and it typically has an age of onset between 16-40. Our patient had a single, large, oval lesion, which is atypical of APMPPE. In contrast to our patient, APMPPE patients have early hypofluorescence on fluorescein angiography followed by late hyperfluorescence. Patients with APMPPE often recover vision, but there can be vision loss due to RPE atrophy or choroidal neovascular membrane formation.
Serpiginous choroiditis. This is a progressive, much more destructive chorioretinitis in which there are creamy deep deposits followed by atrophy and, if the central macula is involved, significant visual loss.
Acute zonal occult outer retinopathy. AZOOR is a rare condition that typically occurs in young or middle-aged women and presents with photopsias and progressive visual field loss in one or both eyes. Though gradual improvement sometimes occurs, patients are left with pigmentary atrophy and persistent visual field defects.
Syphilitic outer retinopathy. Syphilis, which has a range of chorioretinal manifestations, can present as a placoid outer retinopathy, as in our patient. Our patient had a history of sex with women and men. He did not have a rash on his palms, but there was a recent history of significant peeling of skin on his feet. He had a positive RPR and FTA-Abs. Following a spinal tap, the details of which we do not have, he was treated for neurosyphilis, and the placoid lesion resolved with restoration of vision.
Amaral C, Joy L, Jimenez H, et al. Syphilitic outer retinopathy: A case report and review of the literature. J VitreoRetinal Dis 2022;6:63-70.
Soares RR, Pandit RR, Dunn JP. Acute syphilitic placoid posterior chorioretinopathy. Ophthalmol Retina 2019;3:1090.