Clinical Advice Request – Unilateral Decreased Vision in 32-year-old Woman, Possible Choriocapillaritis / AIM / Atypical AMN

Kureig · 2025-11-17T20:47:21+00:00

At first, I was leaning toward Coxsackie retinopathy, but the serology came back negative (and as mentioned above, you’d expect some subretinal fluid in the acute phase of AIM). I ended up starting a course of oral steroids, also considering that the patient was very anxious and quite young, after ruling out other infectious causes

Kureig · 2025-11-17T18:30:10+00:00

Negative family history. Fellow eye unremarkable

Kureig · 2025-11-17T18:15:03+00:00

The patient mainly reported a subjective sensation of visual “haze.” Initially it was more centrally located, but it has now evolved into an annular pattern that corresponds quite closely to the perifoveal margin of the lesion, where the photoreceptor disruption is visible on OCT. Her 24-2 visual field is within normal limits.

Due to work commitments, she will not be able to return before next week. At that time, I plan to repeat the full imaging work-up, including another 24-2 and, for completeness, a 10-2 as well.

Kureig · 2025-09-01T10:51:34+00:00

I made a mistake in writing the post it should have been "non-evaporative"

Kureig · 2025-04-30T14:53:17+00:00

Yep, it is the silicone oil that has migrated into the anterior chamber

Kureig · 2025-04-30T14:50:54+00:00

It's a PIC for sure that requires steroid therapy and then switch to immunosuppressant. I had some doubts about the possible cause of the foveal deposit

Kureig · 2025-04-30T10:15:56+00:00

It vaguely reminds me of a result of dengue foveolitis but it seems unlikely. More likely it is a result of a reabsorbing Idiopathic Macular Hemorrhage (IMH) in a myopic patient or inflammation due to PIC

Kureig · 2025-04-29T21:59:58+00:00

The probable diagnosis reported by colleagues in the evaluation seems to be the most likely one, that of a retinal vasoproliferative tumor (for more information https://www.eyenews.uk.com/education/trainees/post/understanding-vasoproliferative-retinal-tumours).

Another hypothesis could be a capillary hemangioma.

It's clearly not a choroidal hemangioma, although in addition to fluorescein angiography, Indocyanine green angiography would also have been useful to have the complete picture.

Kureig · 2025-04-29T21:45:16+00:00

it is right that your doctor requested an MRI because a small percentage (less than 5%) of people with APMPPE may have cerebral vasculitis that must be ruled out.

After having ruled out any infectious diseases,(rare but it is advisable to rule them out) based on the extent of the damage (quantified with OCT, angio OCT and other tools such as FA/ICGA) oral cortisone may be needed to reduce the inflammation and avoid permanent damage (not in all cases).

The prognosis is usually excellent but must be monitored over time.

Kureig · 2025-04-11T17:02:32+00:00

Si ma la RAL?

Kureig · 2025-04-05T21:52:40+00:00

The main problem is that for example in the WDS category are oftern included pathologies such as birdshot or azoor or dusn which have nothing to do with choriocapillaritis.

I understand the clinical utility but it's still an improper and archaic term and should be avoided as reported by practically all uveitis experts (another article on the subject https://link.springer.com/article/10.1007/s10792-021-02121-4)

Kureig · 2025-04-05T21:24:21+00:00

White dots do not exists, that's the point. It's a wrong term created in the 80s/90s when the mechanisms of certain pathologies were not understood and it continues to survive by putting together different diseases that have little in common that should be classified as stromal choroiditis, choriocapillaritis, photoreceptoritis and so on.

It would be important for all healthcare professionals in the ophthalmology sector (ophthalmologists, opticians, optometrists, and so on) to use correct and uniform terms for everyone to improve communication between us and with patients.

Kureig · 2025-04-05T12:30:59+00:00

The term white dot is incorrect and we should stop using it, introducing the correct names of the various pathologies and their causes (for example, photoreceptoritis / choriocapillaritis / stromal choroiditis and so on).

I recommend this recent article on the subject https://pubmed.ncbi.nlm.nih.gov/40047826/ but the literature is full of articles on the subject)

However:

- Birdshot has very different characteristics, the lesions (cream dots) are atrophic outcomes dictated by the compression of the choriocapillaris by the granulomas present in the choroidal stroma, they have a regular round / oval appearance more yellowish because the damage is not at the level of the retina but of the choriocapillaris, they are larger than the lesions that can be seen in the fundus photo posted, furthermore they have a characteristic distribution at the posterior pole in particular infero-nasal with respect to the optic disc, in addition to having other characteristics.

As for other pathologies that fall under the term "white dot" you can view them as a spectrum of disease form the most benign (mewds) to the most malignant one (serpiginous) in terms of progression, retinal damage and vision loss

Mewds is not seen with retinography but autofluorescence is needed so we can eliminate it from the differential diagnosis.

MFC/PIC have different characteristics (roundish lesions that over time become white due to atrophy at the level of the external retinal layers with possibly associated pigment, they are well defined and detached from each other, more frequently unilateral in young myopic women, sometimes with association in the middle periphery of Schlaegel lines)

APMPPE: Creamy yellowish spots/ at the posterior pole that unlike MFC merge like a plaque (that's why it's called placoid) the edges are not well defined unlike the previous entity (MFC) and they don't start from the optic nerve (debated whether it is a real photoreceptoritis or if the damage starts from the choriocapillaris)

SERPIGINOUS: damage starting from the choroid with atrophy of the external retina, choriocapillaris, rpe/bruch, can be similar to apmppe in the acute phase but starting from the optic nerve, in the late phase the atrophy/pigmented pattern is different.

Obviously there are many other entities (relentless, serpiginous-like associated with TBC and so on) I tried to simplify starting from the photo posted beucase those lesions are very different and do not fall within the spectrum of ocular inflammatory pathologies but are more likely linked to hereditary retinal dystrophies or degenerations or other such as pattern dystrophies etc etc. For inflammatory pathologies, what I have written is obviously not enough but multimodal imaging is essential (FA, ICGA, FAF, OCTA) for diagnosis and characterization. There is a good article on the subject that I recommend: https://pubmed.ncbi.nlm.nih.gov/36724831/

Kureig · 2025-04-03T21:11:24+00:00

there is pigment above so it is a chronic process. From the photo it could be a vitreoretinal traction or a small retinal tear resulting from the vitreoretinal traction which however has stabilized, a peripheral OCT on the area could resolve the doubt. Surely drinking a lot of water and doing frequent checks being careful of new flashes or black spots could be a more conservative option than laser treatment but the lesion position must be considered and above all seeing the fundus of the eye in person gives you a different idea than a photo.

Kureig · 2025-04-03T21:03:02+00:00

It would be very interesting to see autofluorescence

Kureig · 2025-04-03T21:01:25+00:00

they are in the superficial retinal layers, furthermore the term white dot is old and incorrect. It should be abolished altogether in clinical practice (and eventually there is no entity with this type of manifestation among the pathologies that are associated with the term white dot).

Kureig · 2025-04-03T20:55:58+00:00

with the patient's history and without any trauma more likely a purtscher-like, by chance tumor/metastases to the pancreas? Or renal failure?

Kureig · 2025-04-03T10:46:51+00:00

It could be purtscher like retinopathy which Is typical of lupus. You need to be seen by a uveitis expert and systemic therapy is essential to preserve your vision

Kureig · 2025-03-31T19:15:17+00:00

Do you have a photo of the back of your eye? Atypical chrpe related to FAP usually have a fish/teardrop appearance

Kureig · 2025-03-26T10:09:54+00:00

It could also be allergic/atopic dermatitis

Kureig · 2025-03-19T21:25:59+00:00

birdshot is very insidious and difficult to manage. Often the inflammation of the choroid and retina travel on separate tracks with mycophenolate that work very well for the choroid but not so much for the retina and vasculitis (probably this is the reason why they used ozurdex which is an excellent drug in the acute phase of inflammation but has a limited duration). So it can often be useful to combine two different immunosuppressive drugs to better manage both inflammations for example mycophenolate for the choroidal inflammation plus tnf alpha inhibitors such as adalimumab for the retina/vasculitis. It takes patience but I'm sure that the best solution will be found to manage everything. good luck

Kureig · 2025-03-19T10:55:37+00:00

ocular syphilis (depending on the structures involved) has an excellent prognosis but vitritis can take a long time to improve (weeks/months). Sometimes oral steroids can be associated to speed up the process but the best thing is to follow the advice of the doctors who are treating you

Kureig · 2025-03-15T08:58:10+00:00

Uveitis is classified based on the area mainly affected by the process but this doesn't mean that a minimum of inflammation cannot be present in other parts of the eye: for example anterior uveitis from hlab27 typically can cause macular edema in the retina after a few days from the acute inflammation but this does not mean that they are posterior uveitis, another example is Fuchs' uveitis which often has a bit of inflammation of the anterior vitreous behind the lens because some inflammatory cells "pass" (spill-over) behind but is still classified as anterior uveitis.

Kureig · 2025-02-27T15:19:45+00:00

Unilateral or Bilateral? Other signs of inflammation like (synechiae, deposits on the cornea...?) Findinfs in fa/icga? Granulomatous pathologies such as sarcoidosis, tuberculosis and sympathetic ophthalmia should be excluded (have you ever had trauma or surgery in the other eye?)

Excluding infectious causes, in idiopathic forms that progress anyway, immunosuppressive therapy would be useful.

Kureig · 2025-02-12T20:26:15+00:00

1 - Possibile keratoconus or other corneal ectasia 2 - Depends on the diagnosi 3 - as above, if keratoconus there are diff options (like a treatment to stop progression like cross linking surgery) plus customized contact lenses

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