Simultaneous Appearance of Multiple Evanescent White Dot Syndrome and Multifocal Choroiditis Indicate a Common Causal Relationship

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.

Presumed Recurrent MEWDS following Covid-19 Vaccination

PURPOSE

To present an unusual case of recurrent multiple evanescent white dot syndrome (MEWDS) following the coronavirus 2019 (Covid-19) vaccination.

METHODS

Review of the clinical, laboratory, photographic, and angiographic records of a patient with MEWDS.

RESULTS

A 49-year-old female who had MEWDS nine years ago presented to our clinic with blurred vision in her left eye. These symptoms occurred 2 days following Covid-19 vaccination. Fundus examinations and diagnostic testing were consistent with recurrent MEWDS.

CONCLUSION

While rare, MEWDS can reoccur following Covid-19 vaccination.

Review of the Current Literature and Our Experience on the Value of OCT-angiography in White Dot Syndromes

PURPOSE

To describe the application of OCT-A in various posterior uveitis disorders in our experience and to compare it with the available literature.

METHODS

Eighteen eyes with the diagnoses of multifocal choroiditis (MFC), multifocal placoid pigment epitheliopathy (APMPPE), multiple evanescent white dot syndrome (MEWDS), tuberculous serpiginous-like choroiditis (SLC), serpiginous choroiditis (SC), and birdshot chorioretinopathy (BSCR) were studied.

RESULTS

We found flow void of the choriocapillaris in patients with APMPPE, SC, MFC, BSCR, and in SLC. In contrast, perfusion of the choriocapillaris seemed normal in patients with MEWDS.

CONCLUSIONS

We confirmed that OCT-A contributes new information on the physiopathology of white dot syndromes and inflammatory chorioretinopathies, notably on whether or not the choriocapillaris is involved. Comparing the OCT-A features allowed us to suggest that both APMPPE and SLC might be part of the same spectrum of inflammatory disease with primary involvement at the level of the choriocapillaris and secondary RPE damage.

Use of Short-wave Blue Fundus Autofluorescence to Detect and Monitor Acute Regional Outer Retinopathy in Punctate Inner Choroidopathy

Purpose: To describe the utility of fundus autofluorescence (FAF) for detection and monitoring of acute regional outer retinopathy in punctate inner choroidopathy (PIC).Design: Multimodal imaging case series.Methods: Patients with PIC and acute regional hyperautofluorescence were identified. Multimodal imaging, treatment, and clinical course were reviewed.Results: Six eyes of five patients were included (5 women, mean age 39 years, range 28-69). All endorsed new symptoms. Short-wave blue FAF revealed regional hyperautofluorescence in the symptomatic eye, corresponding to ellipsoid zone (EZ) loss on optical coherence tomography (OCT). All patients were treated with local or systemic corticosteroids or immunosuppression, with resolution of symptoms and acute imaging abnormalities.Conclusions: Symptomatic acute regional outer retinopathy in PIC, manifesting as hyperautofluorescence and EZ loss, is easily identifiable using widefield FAF imaging. Treatment resulted in resolution of symptoms and imaging findings in our cohort, and should be considered in this patient population.

Multiple Evanescent White Dot Syndrome: Findings from a Large Northern California Cohort

PURPOSE

To report the clinical and imaging characteristics of multiple evanescent white dot syndrome (MEWDS) from a large single-center cohort.

DESIGN

Single-center, retrospective cohort study.

PARTICIPANTS

A total of 111 patients previously diagnosed with MEWDS in the Kaiser Permanente Northern California system from 2012 to 2019.

METHODS

Two retina specialists reviewed the medical records and all available retinal imaging, including Humphrey visual field testing, fundus photography (FP), OCT, fluorescein angiogram (FA), and fundus autofluorescence (FAF). Patients were excluded from analysis if confirmatory imaging was unavailable.

MAIN OUTCOME MEASURES

Patient characteristics, visual acuity, clinical examination and imaging findings, and final diagnosis.

RESULTS

Seventy-three patients (65.8%) were confirmed to have the diagnosis of MEWDS. Fifty-eight (79.5%) were female, with a mean (standard deviation [SD]) age at presentation of 35.2 (14.2) years, and mean refractive error of -1.6 diopters. Initial mean (SD) visual acuity was logarithm of the minimum angle of resolution (logMAR) 0.39 (0.31) and improved to mean (SD) logMAR 0.07 (0.15) at final follow-up. Presenting symptoms included blurred vision (82%), scotomas (56%), photopsias (43%), and floaters (23%). Nine patients (12%) had a previously diagnosed autoimmune condition, and 2 patients (3%) had documentation of a recent vaccination. Antecedent upper respiratory infection was documented in 15 of 66 patients (23%). Noted clinical and imaging features include ellipsoid zone disruption (100%), white fundus lesions (92%), FA hyperfluorescence (92%), foveal granularity (74%), vitreous cell (53%), and optic disc edema (52%). Twenty-nine of the 111 patients (26%) were initially misdiagnosed with MEWDS and subsequently given an alternative diagnosis, including other white dot syndromes, syphilis, primary vitreoretinal lymphoma, myopic degeneration, and central serous chorioretinopathy.

CONCLUSIONS

Multiple evanescent white dot syndrome is a rare self-limiting condition of the outer retina. Although a distinct set of clinical exam and imaging findings permit recognition of this disease, misdiagnosis is not uncommon.

Early Progressive Circumpapillary Lesion as Atypical Presentation of Multiple Evanescent White Dot Syndrome: A Case Report

Classical clinical findings of multiple evanescent white dot syndrome (MEWDS) include multiple, small white dots scattered throughout the posterior pole, foveal granularity, posterior vitreous cells, and mild optic disc swelling. We describe the case of a 35-year-old man who was admitted to our department with an unusual presentation of MEWDS at the early onset of the disease. A unilateral circumpapillary retinal white spot was observed. Spectral domain optical coherence tomography demonstrated irregularities of the retinal pigment epithelium and disruptions of the outer retinal layers around the optic nerve without other abnormalities. A few days later, the lesion spread centrifugally from the peripapillary region and along the vascular arcades. This distinctive appearance in an early stage of the disease may suggest a disorder other than MEWDS, which can lead to a misdiagnosis and unnecessary treatment.

MULTIPLE EVANESCENT WHITE DOT SYNDROME WITH CENTRAL VISUAL LOSS

PURPOSE

To report the clinical case of a 64-year-old man who developed several features of multiple evanescent white dot syndrome (MEWDS) but with central visual loss that persisted because of significant structural macular disease.

METHODS

A case report was generated by a review of the clinical course and imaging investigations of one patient, along with review of the literature.

RESULTS

A 64-year-old man noted decreased vision in the right eye for 2 weeks, associated with a central scotoma with shimmering, gauze effect of the vision. He had a good vision with normal ophthalmic examinations in the past. Ophthalmic examination revealed acuity of 20/400 with central scotoma and trace pupillary defect in the right eye, normal anterior segment, no evidence of intraocular inflammation, and fundus findings of unilateral MEWDS associated with a central zone of macular pigmentary atrophy. Autofluorescence imaging revealed reflectance changes of MEWDS as well as prominent central hypofluorescence and a zone of hyperfluorescence in inferior macula. Spectral-domain optical coherence tomography identified mild disruptions of outer retina in the regions of the MEWDS lesions and disorganization of the outer retina in the macular region overlying a shallow irregular retinal pigment epithelial detachment. The choroid demonstrated increased thickness compared with the fellow eye with suggestions of dilated outer vessels/pachyvessels. Fluorescein angiography and indocyanine green angiography revealed window defects and staining and hypocyanescence, respectively, of the central macular lesion. The MEWDS lesions resolved without evolution to chorioretinal scars, and the central vision and lesions did not benefit from a systemic steroid course or intravitreal anti-vascular endothelial growth factor therapy.

CONCLUSION

This case illustrates an unusual presentation of MEWDS characterized by unilateral retinal disease presenting with symptoms and signs of profound central macular dysfunction. The clinical course did not evolve into other inflammatory retinal phenotypes, such as multifocal choroiditis or AZOOR (acute zonal occult outer retinopathy) that can sometimes develop MEWDS-like features or central disease. The central structural disease resembles some features of the pachychoroid clinical spectrum, which may have represented a superimposed diagnosis unrelated to the inflammatory phenotype.

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.

Diagnostic dilemmas in retinitis and endophthalmitis

Visual loss in infectious posterior uveitis or panuveitis can occur if proper therapy is delayed because of diagnostic uncertainty. Some disorders, such as acute retinal necrosis and bacterial endophthalmitis, can be rapidly progressive, and therefore require prompt and accurate diagnosis to guide initial therapy. Other more slowly evolving infections, such as toxoplasmic chorioretinitis or fungal endophthalmitis, can be worsened by empiric use of corticosteroids without specific antimicrobial coverage. Key ocular diagnostic features are helpful but highly variable with overlap with both non-infectious uveitis and neoplastic masquerades, even for key signs such as hypopyon. Close examination of the fundus with attention to color, location, size, border, and opacity of lesions and associated arteriolitis or frosted branch angiitis is helpful in the diagnosis of chorioretinitis. Ultrasonography is an important tool in the evaluation of eyes with suspected endophthalmitis, especially those with intracapsular infection or focal infected deposits. Testing of intraocular fluid can be extremely useful but suffers from inaccessibility, poor sensitivity, and test selections dependent on a presumptive diagnosis, which may be wrong. The dilemma for clinician is to make the correct diagnosis of a rare, blinding, variegated disease quickly enough to intercede with specific therapy or to apply empiric therapy in a sufficiently skilled manner to avert disaster and confirm the diagnosis by response to treatment. When non-infectious uveitis is in the differential, empiric corticosteroids must sometimes be used, at great risk, if clinical examination, ancillary testing, and any available intraocular diagnostic tests have failed to confirm a diagnosis.

Subfoveal choroidal thickness in multiple evanescent white dot syndrome

BACKGROUND

Multiple evanescent white dot syndrome (MEWDS) is an inflammation of the choriocapillaris, which typically presents with unilateral vision loss and is characterised by the presence of multiple yellow-white spots in the posterior pole to the midperipheral fundus. This study was conduced to evaluate subfoveal choroidal thickness between the acute and convalescent phases in two patients with MEWDS.

METHODS

Two young female Japanese patients underwent a comprehensive ophthalmic examination, including slitlamp biomicroscopy, funduscopy and both fluorescein and indocyanine green angiographies. The subfoveal choroidal and central retinal thicknesses were measured using Cirrus high-definition spectral-domain optical coherence tomography.

RESULTS

The two patients were diagnosed with unilateral MEWDS based on characteristic funduscopic and angiographic findings. The disrupted foveal inner segment-outer segment boundary line in the acute phase was restored in the convalescent phase in both patients. In the affected eye of Patient 1, the subfoveal choroidal thickness (337 µm) noted in the acute phase decreased to 249 µm at 133 days after the initial visit (convalescent phase). Similarly, the acute phase thickness (440 µm) in Patient 2 decreased to 358 µm at 133 days after the initial visit. The thickness in the asymptomatic opposite eye also decreased during the convalescent phase in both patients. In the acute phase, thickness in the affected eyes was greater than that in the opposite eyes in both patients. In contrast, central retinal thickness remained unchanged in both eyes during follow up in both patients.

CONCLUSION

  This is the first report to describe the relationship between subfoveal choroidal thickness and MEWDS. We found that the choroid was thicker in the acute phase than the convalescent phase in both the affected and opposite eyes of both patients, suggesting that an inflammatory reaction might occur in the choroidal stroma in addition to the choriocapillaris and might be bilateral rather than unilateral.

Ocular parasitic diseases: a review on toxocariasis and diffuse unilateral subacute neuroretinitis

Parasitic infections may damage various ocular tissues, thereby causing visual dysfunction. In 1950, Wilder described the first case in which larval forms of nematodal intestinal roundworms (Ascaridoidea: Ascaris, Toxocara, Ancylostoma, Necator, and Strongyloides) were implicated as a cause of intraocular disease. This review focuses on two disorders associated with parasitic infections: ocular toxocariasis and diffuse unilateral subacute neuroretinitis.