Optometry case study: Multifocal choroiditis with associated CNV

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By Ashleigh Wong, Specsavers Belconnen, ACT

History

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)
FOH: Unremarkable

Clinical Assessment

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
Vitreous: Clear
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)

Figure 1. OCT widefield report of the RE fundus showing multifocal round yellow lesions, disc swelling and a haemorrhage at the macula
Figure 2. RE OCT scan of the macula demonstrating CNV development
Figure 3. OCT widefield report of the LE fundus showing fewer yellow lesions and optic disc swelling

Diagnosis & Management

Differential diagnosis:

  • 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.

Discussion

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.

 
REFERENCES
Baumal, C R, de Carlo, T E, Waheed, N K, Salz, D A, Witkin, A J & Duker, J S 2015, ‘Sequential Optical Coherence Tomographic Angiography for Diagnosis and Treatment of Choroidal Neovascularization in Multifocal Choroiditis’, JAMA Ophthalmology, vol. 133, no. 9, doi:10.1001/jamaophthalmol.2015.1946

Bowling, B 2016, Kanski’s Clinical Ophthalmology: A Systematic Approach 8th Edition, Elsevier, Sydney.

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

Fine, H F, Zhitomirsky, I B, Freund K B, Barile G R, Shirkey B L, Samson C M & Yannuzzi L A 2009, ‘Bevacizumab (Avastin) and Ranibizumab (Lucentis) for Choroidal Neovascularization in Multifocal Choroiditis, Retina, vol. 29, no. 1, pp. 8-12, doi: 10.1097/IAE.0b013e318187aff9

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