Choroidal neovascularisation triggered multiple evanescent white dot syndrome (MEWDS) in predisposed eyes

Choroidal neovascularization and MEWDS like reaction in a child: A rare case

PURPOSE

To report a case of choroidal neovascularization (CNV) associated with Multiple Evanescent White Dot Syndrome (MEWDS) in a child.

STUDY DESIGN

Case report.

RESULTS

A 13-year-old child visited us with a month-long history of blurred vision in his right eye. His right fundus showed several subretinal white dots and an atrophic macular lesion corresponding to a CNV. Angiography and optical coherence tomography (OCT) were consistent with the diagnosis of MEWDS. The patient's condition poorly improved after an intravitreal injection of anti-vascular endothelial growth factor (anti VEGF) in his right eye.

CONCLUSIONS

We reported the case of CNV associated with MEWDS like reaction. The hypothesis of a triggered-MEWDS was highly suspected but no cause was found, which is often the case in paediatric inflammatory eye disorders. Long-term follow-up is needed to judge the evolution.

The multimodal imaging features and outcomes of multifocal choroiditis/punctate inner choroidopathy lesion with multiple evanescent white dot syndrome-like features: a retrospective study

BACKGROUND

Multiple evanescent white dot syndrome (MEWDS)-like features is a rare condition triggered by a macular disease or iatrogenic injury, exhibiting MEWDS changes in the fundus. This study aims to describe the multimodal imaging features and outcomes of multifocal choroiditis/punctate inner choroidopathy (MFC/PIC) lesions with MEWDS-like features.

METHODS

Six cases were studied retrospectively. All cases were given regional and oral corticosteroids.

RESULTS

All cases showed an isolated juxtafoveal yellowish-white MFC/PIC lesion with disruption of RPE-Bruch's membrane-choriocapillaris complex (RPE-BM-CC), subretinal hyperreflective materials and choroidal thickening on optical coherence tomography. Two weeks after presentation, the grayish-white dots disappeared spontaneously and the corticosteroids were given. After four weeks, the ellipsoid zone (EZ) around the lesion and hyper-autofluorescence resolved. After 13 weeks, five cases showed shrinkage of the juxtafoveal lesion and restoration of foveal EZ. After six months, the juxtafoveal lesion became pigmented. Only one case developed type 2 choroidal neovascularization.

CONCLUSIONS

The clinical course of MEWDS-like manifestations is still evanescent in our cases. The yellowish-white juxtafoveal MFC/PIC lesions with disruption of RPE-BM-CC and choroidal thickening showed a well-controlled prognosis after corticosteroid treatment.

Latest advances in white spot syndromes: New findings and interpretations

White spot syndromes (WSS) pose challenges in the field of ophthalmology, particularly in terms of accurate diagnosis and effective management. However, recent advancements in multimodal imaging (MMI) have significantly contributed to our understanding of WSS, allowing for improved characterization of these inflammatory chorioretinopathies. By employing various imaging modalities, including fundus fluorescein angiography, indocyanine green angiography, fundus autofluorescence, optical coherence tomography (OCT), ultra-widefield imaging, and OCT angiography, researchers and clinicians have gained valuable insights into the underlying pathophysiological changes and clinical progression of WSS. Furthermore, MMI has unveiled novel and atypical variants within the spectrum of WSS, expanding our knowledge in this field. Notably, the identification of secondary forms of WSS occurring concurrently with unrelated chorioretinal disorders has suggested a potential autoimmune mechanism underlying these conditions. The introduction of MMI has also facilitated a more comprehensive evaluation of previously ill-defined entities, such as acute zonal occult outer retinopathy, leading to improved diagnostic criteria and enhanced recognition of distinct features. This review paper provides a comprehensive overview of the latest advances and interpretations in WSS. By integrating MMI into the diagnosis and management of these conditions, this review aims to enhance patient outcomes and provide valuable insights into the complexities surrounding WSS.

Topographic patterns of retinal lesions in multiple evanescent white dot syndrome

PURPOSE

To demonstrate different topographic distributions of multiple-evanescent white dot syndrome (MEWDS) and secondary MEWDS disease and to describe possible associations.

METHODS

Clinical evaluation and multimodal retinal imaging in 27 subjects with MEWDS (29 discrete episodes of MEWDS). Ophthalmic assessment included best-corrected visual acuity testing and multimodal retinal imaging with OCT, blue-light autofluorescence, fluorescein and indocyanine green angiography, fundus photography, and widefield pseudocolor and autofluorescence fundus imaging.

RESULTS

The topographic distribution of MEWDS lesions was centered on or around the optic disc (n = 17, 59%), centered on the macula (n = 7, 24%), sectoral (n = 2, 7%), or was indeterminate (n = 3, 10%). The MEWDS episodes either occurred in the absence ('primary MEWDS'; n = 14, 48%) or presence of concurrent chorioretinal pathology ('secondary MEWDS'; n = 15, 52%). In patients with the latter, MEWDS lesions were often centered around a coexisting chorioretinal lesion. The majority of patients in both groups experienced resolution of their symptoms and retinal changes on multimodal imaging by 3 months.

CONCLUSIONS

Distinct distributions of MEWDS lesions were identified. MEWDS may occur in tandem with other chorioretinal pathology, which may impact the topography of MEWDS lesions.

PRIMARY MULTIPLE EVANESCENT WHITE DOT SYNDROME AND MULTIPLE EVANESCENT WHITE DOT SYNDROME SECONDARY TO MULTIFOCAL CHOROIDITIS/PUNCTATE INNER CHOROIDOPATHY: A Comparative Study

PURPOSE

To present and compare the clinical features and multimodal imaging (MMI) findings of the primary form of multiple evanescent white dot syndrome (MEWDS) and MEWDS secondary to multifocal choroiditis/punctate inner choroidopathy (MFC/PIC).

METHODS

A prospective case series. Thirty eyes of 30 MEWDS patients were included and divided into the primary MEWDS group and MEWDS secondary to MFC/PIC group. Demographic, epidemiologic, and clinical characteristics and MEWDS-related MMI findings of the two groups were compared.

RESULTS

Seventeen eyes from 17 patients with primary MEWDS and 13 eyes from 13 patients with MEWDS secondary to MFC/PIC were evaluated. Patients with MEWDS secondary to MFC/PIC tended to have a higher degree of myopia than those with primary MEWDS. No other significant differences in demographic, epidemiologic, and clinical characteristics and MMI findings were found between the two groups.

CONCLUSION

"MEWDS-like reaction" hypothesis seems to be correct for MEWDS secondary to MFC/PIC, and the authors highlight the importance of MMI examinations in MEWDS. Further research is needed to confirm whether the hypothesis is applicable to other forms of secondary MEWDS.

PUNCTATE INNER CHOROIDOPATHY-LIKE REACTIONS IN UNRELATED RETINAL DISEASES

PURPOSE

To report a cohort of patients with a punctate inner choroidopathy (PIC)-like reaction in concurrent, unrelated, chorioretinal disorders.

METHODS

This was a retrospective observational study of patients seen at two referral centers with lesions consistent with PIC on multimodal imaging; patients with lesions resembling idiopathic multifocal choroiditis were also included. Active PIC-like lesions appeared as focal hyperreflective lesions splitting the retinal pigment epithelium/Bruch membrane (RPE/BrM) complex on optical coherence tomography. Chronic PIC-like lesions included subretinal fibrosis, multifocal punched-out chorioretinal atrophy, and curvilinear streaks. Patients' demographics, additional imaging features, and treatment responses were collected and summarized.

RESULTS

Twenty-two eyes of 16 patients with a PIC-like reaction were included (75% females; median age 40 years). Underlying diagnoses included hereditary retinal conditions (10 patients, 63%) and acquired etiologies, all characterized by the RPE/BrM or outer retinal disruption. Fifteen eyes (68%) had active PIC-like lesions; seven eyes (32%) had chronic PIC-like lesions. Active PIC-like lesions regressed with time and responded to systemic steroids. Subretinal fibrosis (3 eyes, 20%), macular atrophy (3 eyes, 20%), and concomitant subretinal fibrosis and macular atrophy (5 eyes, 33%) developed on follow-up. Recurrences occurred in five eyes (23%).

CONCLUSION

RPE/BrM or outer retina disruption may trigger a PIC-like reaction in susceptible patients, presumably because of the loss of immune privilege. A PIC-like reaction may influence the clinical progression and the visual prognosis of the primary chorioretinal disease.

Multifocal Evanescent White Dot Syndrome-like Phenotypes Associated with Inflammatory and Myopic Choroidal Neovascularization

PURPOSE

To present the observation of multifocal evanescent white dot syndrome (MEWDS)-like phenotypes developing in association with the onset of choroidal neovascularization (CNV) in a series of patients.

METHODS

Patients presenting to tertiary-care centers with MEWDS-like phenotypes and CNV were identified.

RESULTS

Five patients presented for the management of CNV in the context of previous diagnoses of punctate inner choroidopathy (PIC) and/or myopia. In time-periods ranging from 0 days to 12 weeks from the diagnosis of active CNV, MEWDS-like changes were observed. Treatment with anti-VEGF agents were instituted in four cases, in an as-required protocol. 1 patient received systemic steroid.

CONCLUSIONS

The development of MEWDS-like phenotypes in association with CNVM can occur in eyes with either inflammatory or non-inflammatory CNVM, and in those who were or were not treated with anti-VEGF therapy. The association suggests an inflammatory event, which causes RPE changes and probably induces the development of the CNV.

Multiple Evanescent White Dot Syndrome and Choroidal Neovascularization following SARS-COV-2 Infection in a Patient on Dabrafenib and Trametinib

PURPOSE

to describe multimodal imaging and electrophysiology of multiple evanescent white dot syndrome (MEWDS) concomitant with COVID-19 infection in a patient on BRAF (B Rapidly Accelerated Fibrosarcoma) and MEK (Mitogen-activated Protein Kinase) inhibitors.

METHODS

observational case report and literature review.

RESULTS

a 37-year-old woman affected by cutaneous melanoma on BRAF and MEK inhibitors developed visual symptoms in the right eye simultaneously with a SARS-COV-2 infection. The right eye visual acuity was hand movement, and clinical examination disclosed vitreous cells, yellow-white retinal spots, and macular yellowish material. Fundus autofluorescence and angiograms were consistent with MEWDS. Angiograms, optical coherence tomography, and optical coherence tomography angiography revealed a macular choroidal neovascular membrane. The infectious and inflammatory work-up was negative. Electrodiagnostic tests revealed cone dysfunction. MEWDS resolved and anti-VEGF treatment allowed partial vision recovery.

CONCLUSION

the case illustrates the association of MEWDS and choroidal neovascularization developing after COVID-19 infection in the setting of immunotherapy.

ARE THERE TWO FORMS OF MULTIPLE EVANESCENT WHITE DOT SYNDROME?

PURPOSE

To analyze the nature of multiple evanescent white dot syndrome (MEWDS) and differentiate an idiopathic or primary form of MEWDS from a secondary form that is seen in association with other clinical conditions affecting the posterior segment of the eye.

METHODS

Clinical and multimodal imaging findings including color fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral-domain optical coherence tomography, and optical coherence tomography angiography of patients with secondary MEWDS are presented.

RESULTS

Twenty consecutive patients with secondary MEWDS were evaluated. Fifteen patients were female. Most were young adults aged between 20 to 40 years with myopia (less than -6 diopters). Pathologic conditions associated with the secondary MEWDS reaction were high myopia (greater than -6 diopters) in two eyes, previous vitreoretinal surgery for rhegmatogenous retinal detachment in 2 eyes, and manifestations of multifocal choroiditis in 18 eyes. In all eyes, the MEWDS lesions followed a course of progression and resolution independent from the underlying condition.

CONCLUSION

Secondary MEWDS seems to be an epiphenomenon ("EpiMEWDS") that may be seen in association with clinical manifestations disruptive to the choriocapillaris-Bruch membrane-retinal pigment epithelium complex.

Multiple evanescent white dot syndrome (MEWDS): update on practical appraisal, diagnosis and clinicopathology; a review and an alternative comprehensive perspective

BACKGROUND

Multiple evanescent white dot syndrome (MEWDS) is a rare inflammatory eye condition affecting the outer retina as a consequence of choriocapillaris non perfusion. The pathophysiology of MEWDS will be discussed based clinical appraisal and on multimodal imaging appraisal.

METHODS

Narrative review and perspective opinion.

RESULTS

Literature review results helped us to put forward (1) the specific symptomatology (decreased/blurred vision, photopsia, subjective scotomas), (2) the ill-asserted character of clinical findings (foveal granularity, white dots in fundoscopy), (3) and the crucial importance of multimodal imaging with the diagnostic triad of ICGA hypofluorescent areas, BL-FAF hyperautofluorescent areas and loss/damage of IS/OS-ellipsoid zone on SD-OCT that characterise the disease and can practically help the clinician to diagnose MEWDS. A comprehensive alternative perspective of the disease was formulated.

CONCLUSIONS

The bulk of evidence that we are presenting in this review, thanks to new performing non-invasive and invasive imaging modalities, is sufficiently compelling to consider MEWDS as a primary choriocapillaritis/inflammatory choriocapillaropathy. Multimodal imaging allows the clinician to diagnose MEWDS with a high level of certainty and ensures a precise follow-up.

HYPERAUTOFLUORESCENT SPOTS IN ACUTE OCULAR TOXOPLASMOSIS: A New Indicator of Outer Retinal Inflammation

PURPOSE

The aim of this study was to describe the fundus autofluorescence patterns in acute ocular toxoplasmosis (OT) and to correlate these findings with other imaging.

METHODS

A retrospective multicenter case series of 27 eyes from 27 patients with acute onset of posterior OT was conducted. Multimodal imaging including fundus autofluorescence was performed at diagnosis and during follow-up.

RESULTS

All OT lesions were hypoautofluorescent on fundus autofluorescence imaging. Fourteen patients (51.8%) also had hyperautofluorescent spots around the active foci that disappeared after retinal photobleaching. Although these spots were not seen on early phase of indocyanine green angiography, they become hypofluorescent in the late phase without choriocapillaris flow impairment on optical coherence tomography angiography. On B-scan spectral domain optical coherence tomography, spots corresponded to outer retinal alterations in all cases. All hyperautofluorescent spots disappeared during follow-up as acute OT resolved. Younger patients and those with more posterior inflammatory symptoms (vasculitis and/or papillitis) were more frequent with the presence of hyperautofluorescent spots.

CONCLUSION

Ocular toxoplasmosis may trigger a transient outer retinal disruption in eyes with marked inflammatory symptoms of the younger patients.

Multiple Evanescent White Dot Syndrome (MEWDS) Associated with Progression of Lacquer Cracks in High Myopia

PURPOSE

To report a case of multiple evanescent white dot syndrome (MEWDS) associated with acute progression of lacquer cracks in high myopia.

CASE REPORT

A 41-year-old female patient with high myopia developed typical signs, symptoms, and disease course of MEWDS in her right eye. At the same time, the same eye showed progression of lacquer cracks when compared to images taken 2 months prior. Retinal imaging findings characteristic of MEWDS were most obvious on fundus autofluorescence, whereas alterations on color fundus photography, optical coherence tomography, fluorescein, and indocyanine green angiography were very mild, probably because of the myopia-related fundus pathology.

CONCLUSION

We present a case of MEWDS co-occurring with acute progression of lacquer cracks. This adds to the increasing evidence that impaired integrity of the retinal pigment epithelium-Bruch's membrane complex may be a factor in causing MEWDS, possibly by exposing otherwise isolated antigens. The anatomy in a highly myopic eye may make it challenging to diagnose MEWDS-associated fundus changes.

Expanding the Clinical Spectrum of Multiple Evanescent White Dot Syndrome with Overlapping Multifocal Choroiditis

PURPOSE

To evaluate multifocal evanescent white dot syndrome (MEWDS) patients with and without overlapping multifocal choroiditis (MFC).

METHODS

Thirty-four patients diagnosed between November 2008 and August 2018 at 2 hospitals were retrospectively reviewed. Multimodal imaging including optical coherence tomography angiography (OCTA) was assessed.

RESULTS

Twenty-seven (79%) patients were women (overall mean age, 30 years). Five developed MFC lesions in the affected eyes, and one developed MFC in the unaffected fellow eye. Another developed combined MEWDS and MFC in the fellow eye during follow-up. Eyes with MFC had thicker choroids (316.5 and 197.3 µm, respectively; P = .001) at presentation, which became thinner after resolution (P = .043). Those with subfoveal MFC had poor visual prognosis (P = .019). Areas of suspected choriocapillaris flow deficit were identified on OCTA.

CONCLUSION

Some MEWDS patients may develop overlapping MFC in the same or fellow eyes, presenting with increased choroidal thickness which decreased after resolution.

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.