Acute exudative polymorphous vitelliform maculopathy in a young man: a case report

Acute exudative polymorphous vitelliform maculopathy during pembrolizumab treatment for metastatic melanoma: a case report

Background

The use of immunomodulating therapy to treat various cancers has been on the rise and these immune checkpoint inhibitors are known to cause ocular side effects. In this article a case of acute exudative polymorphous vitelliform maculopathy (AEPVM) is reported which developed during a first line treatment with pembrolizumab.

Case presentation

A 54-year-old woman was referred because of blurry vision in both eyes with a yellow spot in the central visual field of the left eye. These symptoms started after four treatments with pembrolizumab (a monoclonal antibody against the programmed cell death receptor-1) for a metastatic recurrent vaginal mucosal melanoma. Her best corrected visual acuity was 10/10 in both eyes with a correction of + 2.00 bilaterally. There were no inflammatory findings in the anterior segment or the vitreous. Fundoscopy revealed an attenuation of the foveal reflex with subtle yellow-white subretinal macular deposits (vitelliform lesions) in both eyes. Fluorescein angiography did not show staining or leakage in the mid-phase, neither a late staining. Spectral-domain optical coherence tomography of the macula illustrated bilateral neurosensory retinal detachment with a thick, highly reflective band at the outer photoreceptor segment. En face structural OCT at the level of the photoreceptors showed focal areas of increased signal corresponding to hyperreflective vitelliform material. The treatment with pembrolizumab was ceased immediately. During the following visits we slowly saw an improvement of the neurosensory retinal detachment. After almost four months a total resolution of the subretinal fluid was visualized in both eyes without the use of additional treatment, though the vitelliform deposits persisted.

Conclusions

The development of AEPVM in melanoma patients could be triggered by treatment with Pembrolizumab. Pembrolizumab has the potential to disturb indirectly the retinal pigment epithelium homeostasis with accumulation of lipofuscin deposits and subretinal fluid, both signs of AEPVM.

Clinical Correlation between Acute Exudative Polymorphous Paraneoplastic Vitelliform Maculopathy and Metastatic Melanoma Disease Activity: A 48-month Longitudinal Case Report

PURPOSE

Longitudinal evaluation of acute exudative polymorphous paraneoplastic vitelliform maculopathy (AEPPVM) following diagnosis and treatment of metastatic melanoma.

METHODS

Case report of a 47-year-old male with unknown primary metastatic melanoma and AEPPVM monitored before and during melanoma treatment using clinical exam, retinal imaging, and electroretinograms (ERG). Genetic testing and autoantibody panels were performed.

RESULTS

He presented within a month of metastatic melanoma diagnosis with numerous bilateral vitelliform lesions in the posterior pole, consistent with AEPPVM. Metastatic disease was treated with immunotherapy, radiosurgery, and radiation over 48 months. Maculopathy and metastatic disease improved and worsened in parallel. Genetic testing was negative for bestrophin-1. An autoantibody panel was positive for anti-recoverin and transducin-α.

CONCLUSION

AEPPVM is an uncommon paraneoplastic retinopathy found in patients with metastatic malignancy. To our knowledge, this is the first report demonstrating a temporal association between metastatic disease activity and quantifiable changes in retinal imaging over a 4-year period.

Paraneoplastic acute exudative polymorphous vitelliform maculopathy improved with intravitreal methotrexate

Purpose

To describe a case of acute exudative polymorphous vitelliform maculopathy (AEPVM) treated with intravitreal methotrexate.

Observations

A 58-year-old man with a history of metastatic melanoma developed paraneoplastic acute exudative polymorphous vitelliform maculopathy, refractory to oral prednisone, intravitreal bevacizumab and intravitreal preservative-free triamcinolone. Improvement in vision and resolution of subfoveal fluid was later seen after intravitreal methotrexate therapy.

Conclusions and Importance

AEPVM is a rare and poorly understood retinal disorder that may be idiopathic or may manifest in patients with malignancies. The pathogenic process is thought to be an attack directed against the retinal pigment epithelium (RPE) and photoreceptors. Intravitreal methotrexate may provide benefit when treating AEPVM, especially when trials of steroids and anti-VEGF medications have failed.

Idiopathic Acute Exudative Polymorphous Vitelliform Maculopathy: Clinical Spectrum and Multimodal Imaging Characteristics

PURPOSE

To describe clinical findings in patients with acute exudative polymorphous vitelliform maculopathy (AEPVM).

DESIGN

Retrospective, observational, multicenter case series review.

PARTICIPANTS

Consecutive patients diagnosed with idiopathic AEPVM.

METHODS

Review of clinical charts, multimodal imaging, electrophysiologic findings, and genetic findings in previously unpublished patients and review of the literature.

MAIN OUTCOME MEASURES

Clinical features of idiopathic AEPVM and differential diagnosis.

RESULTS

Eighteen patients (age range, 21-74 years) with typical features of AEPVM, including initial localized, serous detachments followed by the development of characteristic yellow-white deposits in the vitelliform space. Over time, this hyperautofluorescent material gravitated within the larger lesions, resulting in typical curvilinear deposits characteristic of later stages. Symptoms and clinical findings lasted from weeks to several years. Some patients showed previously undescribed features such as fluorescein-negative intraretinal cystic changes, choroidal neovascularization, serous retinal elevations mimicking retinal folds, increased choroidal thickness, lack of rapid visual recovery, and recurrence years after complete resolution of initial manifestations.

CONCLUSIONS

Acute exudative polymorphous vitelliform maculopathy can present with a more variable natural course than previously described. Paraneoplastic retinopathy and autosomal recessive bestrophinopathy closely resemble AEPVM, necessitating medical and hereditary evaluation to exclude these clinical possibilities. This series of patients with AEPVM expands the clinical spectrum of the disorder, including demographics, clinical manifestations, imaging features, natural course, and visual prognosis.

Exudative Polymorphous Vitelliform Retinopathy: Importance of Early Recognition of the Condition in Patients with Metastatic Melanoma

Introduction

Because of the advent of monoclonal antibodies in the treatment of metastatic melanoma, patients with this disease are surviving longer. Early recognition of the disease has therefore become even more important.

Case report

We present a patient with vitelliform maculopathy, a paraneoplastic retinal maculopathy that is under-recognized. Clinically the retinal findings of serous detachments and pigmentary macular changes are remarkable, while at the same time these patients have surprisingly very few symptoms. This is in contrast to patients who develop melanoma associated retinopathy (MAR) who are very symptomatic early in the disease, but with more subtle retinal findings.

Conclusion

Monoclonal antibody treatment is changing the survival rates in metastatic disease making early diagnosis even more important. Exudative polymorphous vitelliform maculopathy (EPVM) needs to be recognized early to avoid delay in diagnosis of metastatic disease.

Nonantibestrophin Anti-RPE Antibodies in Paraneoplastic Exudative Polymorphous Vitelliform Maculopathy

PURPOSE

A previous report demonstrated antibodies to bestrophin in paraneoplastic exudative polymorphous vitelliform maculopathy (PEPVM). Other cases demonstrated antibodies to different proteins in the retinal pigment epithelium (RPE). In this report, serum was analyzed to determine whether a patient with PEPVM and a reduced Arden ratio had developed autoantibodies to human Bestrophin-1 (Best1).

METHODS

Human embryonic kidney 293 cells (HEK293) were transfected with Best1 and stained with an antibody specific to Best1 (E6-6), or patient serum. Staining patterns were compared with those of untransfected cells stained with E6-6, patient serum, control serum, or secondary antibody alone. Western blots were performed using lysed RPE and stained with E6-6, patient serum, control serum, or secondary antibody alone.

RESULTS

Immunofluorescence staining of HEK-293 cells or HEK-293 cells expressing Best1 did not differ between patient and control sera or show a staining pattern consistent with recognition of Best1. Immunoblotting of human RPE lysate with patient serum did not identify Best1 (68 kDa) but did recognize a band at approximately 48 kDa that was absent in blots using control serum.

CONCLUSIONS

To our knowledge, this is the first report of PEPVM with an autoantibody to an approximately 48-kDa RPE protein, but previous reports have demonstrated autoantibodies to other RPE proteins, suggesting that autoantibody formation is an important component of PEPVM.

TRANSLATIONAL RELEVANCE

This research emphasizes the role that autoantibodies play in PEPVM. The fact that different autoantibodies appear to cause similar patterns demonstrates the heterogeneity of causes of vitelliform lesions.