By Ashleigh Wong, Specsavers Belconnen, ACT
Px: 45-year-old female
Reason for visit: Central distortion in the RE for 3 days. LE unremarkable.
GH: Unremarkable, contraceptive implant only
POH: LASIK surgery OU 2013 (previous moderate myope)
Unaided vision: RE: 6/6-1 LE: 6/6-1
IOP: RE: 15mmHg LE: 12mmHg
Pupils: PERRLA, no RAPD
Amsler grid: RE central distortion and scotoma, LE unremarkable
Slit lamp examination
Anterior segment: LASIK scarring on the cornea RE and LE
Anterior chamber: Clear, no cells or flare RE and LE
Posterior segment (DFE): Slight optic disc swelling in RE and LE, yellow lesions at both maculae with a haemorrhage just inferonasal to the RE fovea, numerous yellow-white lesions throughout the mid- and peripheral retina RE and LE
OCT: Possible choroidal neovascular membrane at the RE macula (Figures 1-3)
Diagnosis & Management
- Multifocal choroiditis
- Acute posterior multifocal placoid pigment epitheliopathy
- Adult-onset vitelliform maculopathy
- Proliferative diabetic retinopathy
- Macular telangiectasia
Diagnosis: Previous bilateral multifocal choroiditis and resultant choroidal neovascularisation (CNV) at the RE macula
Management: An urgent referral was made to the local retinal specialist. The patient received Avastin anti–vascular endothelial growth factor (anti-VEGF) treatment within 24 hours of initial presentation and was scheduled for a review in 4 weeks’ time.
Multifocal choroiditis is idiopathic, bilateral inflammation of the choroid. It is characterised by multiple, round, yellow-grey lesions throughout the fundus, ranging from 10-1,000µm in diameter. It is fairly uncommon, and tends to occur in middle-aged, myopic, Caucasian females.
As severity is variable, not all patients are symptomatic, but the acute phase of multifocal choroiditis often presents with vitritis. Anterior uveitis presents in approximately 50% of cases and optic disc oedema may occur, resulting in an enlarged blind spot.
CNV has been found to develop in 24-35% of cases but has previously been difficult to diagnose with fluorescein angiography. The incorporation of OCT in practice has improved confidence in diagnosis of CNV development, allowing for earlier treatment and improved patient outcomes.
Multifocal choroiditis is typically treated with systemic and local steroids in the acute stage. However, anti-VEGF therapy has been found to improve visual acuity in multifocal choroiditis-associated CNV over a 6-month period. Anti-VEGF therapy has also been shown to decrease the CNV membrane at both clinical and angiographic levels.
This case highlights the clinical benefit of using OCT in conjunction with fundus examination in practice, as it provides optometrists with useful information to assist diagnosis and direct referrals and their urgency. It also demonstrates that although patients with multifocal choroiditis may not present initially with symptoms of ocular inflammation, there is a risk of neovascularisation developing, and so these patients should be closely monitored if possible.
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Essex, R W, Wong, J, Jampol, L M, Dowler, J & Bird, A 2013, ‘Idiopathic Multifocal Choroiditis: A Comment on Present and Past Nomenclature, Retina, vol. 33, no. 1, pp. 1-4, doi: 10.1097/IAE.0b013e3182641860
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