Case Presentation SINGLETON HOSPITAL

History GP referral RE visual loss R 9/6 L6/6 ?RP yr old myopic Caucasian male 2/7 distorted vision POHMyope since childhood PMHunremarkable

No medical Treatment Penicillin Allergy FHMother had cataract

VAR 6/6L 6/5 Near R N/10L N/5 (distorted) Normal Anterior Segment Posterior segment –lytic lesions, distributed in peripapillary –foveal fluid & marginal hg

DD –Old /new CSCR –central CNVM 2 to ?POHS FFA on

Differential Diagnosis Myopic degeneration MIC (multifocal inner choroidopathy) PIC (punctate inner choroidopathy) POHS (Presumed ocular histoplasmosis syndrome) Idiopathic CNVM

Differential Diagnosis Birdshot Chorioretinopathy APMPPE (acute posterior multiple placoid pigment epitheliopathy)

MIC Age: yrs F:M 3:1 Young healthy moderately myope C/O –Subacute blurred vision –Floaters

MIC Examination 50% - AAU Vitritis + multiple grey -white/ yellow lesions at RPE/ inner choroid New lesions & recurrences occur PrognosisFair –Visual loss: CMO/CNVM Treatment –Periocular steroid

PIC Young healthy myope Commoner in female Unknown etiology C/O –acute decreased VA/ central Scotoma

PIC Exam –Quiet Anterior segment –Multiple white/yellow lesion in peripapillary region/ fovea in RPE/IC level +/- serous elevation of NSR –No vitritis –1/3 rd develop CNVM Prognosis Good Treatment Controversial –Steroid –Submacular surgery

POHS Endemic area of Ohio-Missisipi river valley Exam –Histo spots atrophic punched out lesions around the disc maculopathy : pigment ring with overlying NSR det. Maculopathy develops in 2nd decade NO vitritis

POHS Treatment –early stages: steroids –CNVM:Photocoagulation/ Submacular sx PrognosisVariable –Without treatment59% with VA worse than 6/60 –Histo spots in macular area 25% chance of attack over next 3yrs –No spots in macular area2% chance of attack

Birdshot chorioretinopathy Uncommon F>M past 4th decade HLA- A29 (50-80%) C/O –Reduced VA, nyctalopia –Colour VA disturbed

Birdshot chorioretinopathy Exam –Minimal/No Anterior segment inflamm –Cream coloured depigmented spots throughout fundus (birdshot from a shotgun) –attenuated & sheathed vessel, disc oedema, OA –CMO –Reduced ERG Treatment –Periocular / systemic steroids

APMPPE Young adults F:M 1:1 Assoc. HLA DR2 & HLA B7 C/O –Unilateral visual loss –prodromal flu-like symptomps 50% –few has CNS vasculitis

APMPPE Exam –Deep placoid cream-coloured lesions Post- equatorally –Vascular sheathing / Disc oedema –Tends to affect One eye few days before the other eye is affected Prognosis Generally Good TreatmentNone effective

Review Noticed improvement RVA6/5LVA6/4 Diag: CSCR review 5/52

Sudden loss of VA2/52 RVA6/18LVA6/5 -4.0/-1.5x /-1.25x105 FFA

PIC MIC Idiopathic CNVM Oral pred 40 mg od f/u 3/52

No change in VA Distortion gone Developed Diabetes

A.Acute White spots Vanishing later on MEWDS Cat-scratch disease AIDS Microangiopathy CW spots Acute Vitelliform maculopathy

B. Acute white spots with coalescence & diffuse scarring APMPPE Serpiginous choroiditis Herpes Retinitis

C. Acute white spots becoming white scars with variable pigmentation Multifocal choroiditis - classical form –a) PIC –b) Difuse subretinal fibrosis Toxoplasma retinochoroiditis Tuberculous chorioretinitis Syphilitic chorioretinitis Lyme disease

C. Acute white spots becoming white scars with variable pigmentation Sarcoidosis Sympathetic Ophthalmia VKH Bacterial retinochoroiditis Fungalretinochoroiditis Pneumocystis carinii choroiditis

D. Late white spots with or without initial orange spots Birdshot choroidopathy