Multiple evanescent white dot syndrome: a review and case report

Application of Ophthalmic Electrophysiology in Inflammatory Disorders of Retina and Optic Nerve

This review covers the utility of electrophysiological studies relevant to inflammatory diseases of the retina in conditions such as acute posterior multifocal placoid pigment epitheliopathy, acute zonal occult outer retinopathy, Adamantiades-Behçet disease, autoimmune retinopathy and neuro-retinopathy, birdshot chorioretinopathy, multiple evanescent white dot syndrome, and Vogt-Koyanagi-Harada disease. Electrophysiological studies can help with the diagnosis, prognostication, evaluation of treatment effects, and follow-up for these conditions.

Quantitative analysis of retinal and choriocapillary vascular density of multiple evanescent white dot syndrome by optical coherence tomography angiography

PURPOSE

To describe optical coherence tomography angiography (OCTA) and other multimodal imaging features of multiple evanescent white dot syndrome (MEWDS).

METHODS

The retinal and choriocapillary vascular density of MEWDS patients were measured by OCTA (OptoVue Inc.) in the acute and recovery phases. And other multimodal imaging data were also retrospectively reviewed.

RESULTS

Sixteen patients with a mean age of 26.5 ± 6.99 years were included. Three patients were complicated with choroidal neovascularization (CNV). The mean baseline logMAR BCVA of the affected eyes was 0.52 ± 0.36 (Snellen equivalent 20/50). OCTA revealed significant reductions in vascular densities of deep capillary plexus (45.72 ± 3.70%, P = 0.0007), and choriocapillaris (46.08 ± 3.22%, P < 0.0001) of the affected eyes compared with the contralateral eyes (50.23 ± 4.06% and 52.28 ± 4.19%, respectively) in the acute phase. During the recovery phases, vascular densities of deep capillary plexus (49.50 ± 3.15%, P < 0.0001) and choriocapillaris (53.67 ± 2.58%, P < 0.0001) increased significantly in the affected eyes while those of the superficial capillary plexus remained stable. SD-OCT revealed an increase of the subfoveal choroidal thickness and disruption of the outer retinal layer, including ellipsoid zone discontinuities and the accumulation of hyperreflective material, corresponding to the hypofluorescent spots and dots on ICGA, respectively. BCVA increased to normal values after recovery, together with restoration of the structural morphology and choroidal thickness on SD-OCT, except in eyes with CNV.

CONCLUSION

The inner retinal layer and choroid can be secondarily transiently compromised in MEWDS. MEWDS complicated with CNV is associated with worse visual outcomes.

A CARE-compliant article: a case report of possible association between recurrence of multiple evanescent white dot syndrome and the Herpesviridae family

RATIONALE

Multiple evanescent white dot syndrome (MEWDS) is a self-limited multifocal chorioretinopathy that typically affects otherwise healthy young females in the second to fourth decades of life. Current understanding of the pathophysiology of MEWDS is still limited. One of the possible underlying causes is an infectious etiology.

PATIENT CONCERNS

A 24-year-old female with recurrent episodes of typical MEWDS ocular manifestation was observed over 2 years. Viral-specific antibody serologic tests showed evidence of exposure to the Herpesviridae family during the acute stage of MEWDS in the first and recurrent episodes.

DIAGNOSES

MEWDS was diagnosed by the clinical findings and ancillary testing results of fundus photography, optical coherence tomography, fluorescein angiography, indocyanine green angiography and electroretinogram. The laboratory serology data was positive for varicella-zoster virus (VZV) immunoglobulin M (IgM) in the first episode and exhibited high Epstein-Barr virus (EBV) elevated immunoglobulin G (IgG) titer in the recurrent episode.

INTERVENTIONS

Due to the self-limited nature of MEWDS, we observed the clinical course without intervention.

OUTCOMES

During acute onset of MEWDS, serologic data for VZV IgM antibody was positive in the first episode. Two years later, the patient had recurrent episodes of MEWDS in the contralateral eye. Serologic study showed highly elevated IgG titer (1:160) of Epstein-Barr virus capsid antigen (EB-VCA) in the acute stage. The follow-up paired serum virus serology test showed that the prior EB-VCA IgG titer decreased fourfold to 1:40 in the recovery stage.

LESSONS

Recurrence of MEWDS may be associated with acute systemic infection of the Herpesviridae family or virus-induced autoimmune inflammatory reaction.

Choroidal juxtapapillary neovascularization regression in multiple evanescent white dot syndrome by optical coherence tomography angiography: a case report

BACKGROUND

Multiple evanescent white dot syndrome most often resolves spontaneously without complications; however, choroidal neovascularization can sometimes occur.

CASE PRESENTATION

Here, we describe a case of a 22-year-old white Caucasian man with blurred vision in his left eye who exhibited juxtapapillary choroidal neovascularization on optical coherence tomography angiography. Although multiple evanescent white dot syndrome is often self-limiting, to reduce the possibility of an inflammatory reaction, we preferred to administer prednisolone orally. After 3 months, significant regression of juxtapapillary neovascularization was observed by B-scan and optical coherence tomography angiography. Symptoms resolved in 3 months. A steady situation was observed at 4 years of follow-up.

CONCLUSION

This case report highlights the helpful use of optical coherence tomography angiography in daily clinical practice, even in inflammatory diseases, such as atypical juxtapapillary neovascularization in multiple evanescent white dot syndrome. Choroidal neovascularization associated with multiple evanescent white dot syndrome by means of optical coherence tomography angiography showed neovascular activity regression, thus avoiding invasive therapy.

Multimodal Imaging in an Unusual Cluster of Multiple Evanescent White Dot Syndrome

Objective

To describe an unusual cluster of multiple evanescent white dot syndrome (MEWDS) encountered within a 3-month period.

Methods

This retrospective observation study is comprised of seven patients who presented with MEWDS in a 3-month period in central Israel. Data were collected from patients' medical records on clinical, multimodal imaging, and viral serology findings.

Results

Six women and one man of mean age 31.5 ± 7.2 years. Three reported a precedent viral infection. All had unilateral decreased vision. Funduscopy revealed foveal granularity.

Main Imaging Findings

Hyperfluorescent spots on blue autofluorescence (BAF), hypofluorescent spots on indocyanine green angiography, dark lesions on infrared photos, and ellipsoid zone irregularities on spectral domain optical coherence tomography (SD-OCT). Resolution of the spots on BAF correlated with anatomic (SD-OCT) and visual recovery. OCT angiography performed following the convalescence stage demonstrated intact retinal and choroidal flow. Serologic findings were inconclusive.

Conclusion

We report a unique cluster of MEWDS patients presented in a short period of time. SD-OCT findings of ellipsoid zone disruption in combination with other multimodal imaging modalities are outlined meticulously. Recognizing these imaging features along with high index of clinical suspicion is important for the diagnosis of MEWDS. Serologic testing might be considered in future patients.

Multi-modal imaging and anatomic classification of the white dot syndromes

The white dot syndromes (WDS) are a diverse group of posterior uveitidies that share similar clinical findings but are unique from one another. Multimodal imaging has allowed us to better understand the morphology, the activity and age of lesions, and whether there is CNV associated with these different ocular pathologies. The “white dot syndromes” and their uveitic masqueraders can now be anatomically categorized based on lesion localization. The categories include local uveitic syndromes with choroidal pathology, systemic uveitic syndromes with choroidal pathology, and multifocal choroiditis with outer retinal/choriocapillaris pathology with uveitis and without uveitis. Neoplastic and infectious etiologies are also discussed given their ability to masquerade as WDS.

Clinical findings and management of multiple evanescent white dot syndrome

PURPOSE

This case report presents the diagnosis and management of a patient who was ultimately diagnosed as having multiple evanescent white dot syndrome (MEWDS), a rare retinal inflammatory disorder classified under the white dot syndromes.

CASE REPORT

A 34-year-old Hispanic woman presented with chief complaints of flickering lights and spots in her right eye that started 2 weeks earlier. Retinal examination revealed multiple white dots scattered across the retina, with an accompanying foveal granularity. Spectral domain optical coherence tomography and fundus autofluorescence were performed, which confirmed the diagnosis of MEWDS. The patient was monitored without treatment until resolution.

CONCLUSIONS

The etiology and pathogenesis of MEWDS remain unknown; fortunately, the natural course of the disease is favorable because almost all patients retain a good outcome without the need for treatment. This case highlights the importance of considering MEWDS and other white dot syndromes in the differential diagnosis of patients who present with a history of photopsia. Because many clinical findings are absent or very subtle when patients present, the clinician should consider supplemental testing such as spectral domain optical coherence tomography and fundus autofluorescence in aiding in the diagnosis.

Masquerades of acquired demyelination in children: experiences of a national demyelinating disease program

The diagnosis of acquired demyelinating syndromes of the central nervous system in children requires exclusion of other acute central nervous system disorders. In a 23-site national demyelinating disease study, standardized clinical, laboratory, and magnetic resonance imaging (MRI) data were obtained prospectively from onset, and serially at 3, 6, and 12 months and annually. Twenty of 332 (6%) participants (mean [SD] age, 10.21 [4.32] years; 12 (60%) female) were ultimately diagnosed with vascular disorders (primary or secondary central nervous system vasculitis, vasculopathy, stroke, or migraine, n = 11 children), central nervous system malignancy (n = 3), mitochondrial disease (n = 2), or central nervous system symptoms in the accompaniment of confirmed infection (n = 4). Red flags that may serve to distinguish disorders in the differential of acquired demyelination are described.

White dot syndromes: a 20-year study of incidence, clinical features, and outcomes

PURPOSE

To measure the incidence of white dot syndromes (WDS) in a community-based population and to report clinical features and outcomes.

METHODS

Multicenter retrospective study using the Rochester Epidemiology Project medical records linkage system of Olmsted County, Minnesota. Databases were searched to identify all patients with WDS from January 1, 1988 through December 31, 2008.

RESULTS

Mean ophthalmic follow-up was 4.5 years and mean general medical follow-up was 9.1 years. The incidence of WDS was 0.45 per 100,000 per year (95% CI 0.19-0.71). Incidence rates for specific disease entities were also calculated. The authors report some associated autoimmune diseases in this series. Multiple evanescent white dot syndrome (MEWDS) was more common in females, and acute posterior multifocal placoid pigment epitheliopathy (APMPPE) was more common in males. Both MEWDS and APMPPE generally carried a good visual prognosis. Fifty percent of cases with APMPPE had a positive history of psoriasis. The only punctuate inner choroidopathy (PIC) case carried that diagnosis as well.

CONCLUSIONS

WDS are rare diseases and may be associated with other autoimmune diseases. Further studies with more patients and longer follow-up periods are needed to draw conclusions about visual prognosis, development of other ocular conditions, and associated medical diseases.