Optical coherence tomography angiography in unilateral multifocal choroiditis and panuveitis: A case report

RATIONALE

Optical coherence tomography angiography (OCT-A) has the advantage to visualize the microvascular structure of the retina in vivo and was utilized clinically in various neovascular retinal diseases. The OCT-A has also been used to examine the lesion in multifocal choroiditis and panuveitis (MCP). This study aimed to describe a case of MCP and present the disease process of a punched-out lesion in the chorioretina with neovascular activity using OCT-A.

PATIENTS CONCERNS

A 32-year-old female Caucasian patient presented with a 2-week history of progressive blurred vision in her right eye with photophobia and a diminished temporal visual field. On presentation, her best corrected visual acuity was 6/60 in the right eye with a prominent anterior uveitis seen under slit lamp examination.

DIAGNOSES

Dilated fundus examination of the right eye showed vitritis and multiple, punched-out yellowish-white lesions over the peripheral retina. Additional multimodal imaging (MMI) were done including fluorescein angiography (FA), indocyanine green angiography (ICGA) and fundus autofluorescence (FAF), which all revealed characteristic findings of MCP. In general, the diagnosis of unilateral MCP was made. Furthermore, one of the punched-out lesions in the right eye was particularly selected and examined under OCT and OCT-A, which revealed a subretinal elevated lesion with high flow signal under OCT-A.

INTERVENTIONS

Treatment with oral prednisolone at 30 mg daily with topical prednisolone acetate 1% every 2 hours were prescribed, which were gradually tapered down within a 2-month course.

OUTCOMES

The patient's best corrected visual acuity of the right eye returned to 6/6 at 2 months after the diagnosis. The flow signal in the OCT-A study of the punched-out lesion had also resolved after steroid treatment.

LESSONS

The MCP is an uncommon uveitis with multiple inflammatory chorioretinal lesions. Using multimodal imaging technique, physicians can better differentiate these lesions for diagnosis and for further monitoring. Our results demonstrated that these chorioretinal lesions in MCP may display neovascular activities that might not be seen easily using conventional FA or ICGA study. With OCT-A, ophthalmologists could identify and monitor subtle choroidal neovascularization (CNV) changes over these punched-out lesions.

Choroidal Imaging in uveitis: an update

An important goal of advancements in ocular imaging algorithms and devices has been to improve the image acquisition and resolution of deeper ocular tissues, namely the choroid and its vasculature that are otherwise inaccessible to direct clinical examination. These advancements have contributed to the understanding of the pathophysiology of a number of ocular inflammatory conditions. We focuse on the imaging characteristics of clinical conditions where imaging the choroid has improved or radically changed the understanding of the disease, has helped in differentiation of phenotypically similar but distinct lesions, and where imaging features have proven vital formonitoring disease activity. The last two decades have seen some major developments in ocular imaging relevant to uveitis. The current review addresses both the imaging characteristics and their interpretation on conventional modalities such as fundus photography, fluorescein angiography, indocyanine green angiography and fundus autofluorescence and the recent additions in the armamentarium including optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography.

Distinct Patterns of Choroidal Lesions in Punctate Inner Choroidopathy and Multifocal Choroiditis Determined by Heatmap Analysis

PURPOSE

A heatmap analysis of choroidal lesions in patients with punctate inner choroidopathy (PIC) or multifocal choroiditis (MFC) with or without uveitis was performed to determine if there were any distinguishing features among these uveitic entities.

METHODS

Retrospective review of medical records was conducted at the Byers Eye Institute, Stanford. Fundus photographs were masked and placed on a standardized template. Lesions were identified and heatmaps were generated in a standardized fashion.

RESULTS

30 eyes were identified with PIC or MFC. Heatmap analysis revealed three distinct patterns of fundus lesions: posterior, peripheral, and combined. All patients with PIC had the posterior pattern. Patients with MFC had the peripheral or combined pattern, and all patients with MFC with uveitis had the combined pattern.

CONCLUSION

Three patterns of fundus lesions were identified in patients with PIC and MFC. PIC and MFC may represent two separate disease entities with distinct phenotypes of choroidal lesions.

An update of multimodal imaging in white dot syndrome

The white dot syndromes are a group of phenotypically similar disorders characterized by multiple lesions at the level of the outer retina, retinal pigment epithelium, and choroid. Common white dot syndromes whose imaging modalities have been described in this article are multiple evanescent white dot syndrome, acute posterior multifocal placoid pigment epitheliopathy, acute zonal occult outer retinopathy, multifocal choroiditis and panuveitis, punctate inner choroidopathy, serpiginous choroiditis, and birdshot chorioretinopathy. The various imaging modalities help us to better understand the pathophysiology of the various entities and help in diagnosing, monitoring, and prognosticating them. Optical coherence tomography angiography (OCTA) is a comparatively newer tool that helps us to visualize lesions in the choroid that correlate with indocyanine green angiography (ICGA) findings. Even though it is of limited value and cannot replace ICGA, it had gained considerable interest among ophthalmologists. Similarly, the noninvasive nature of modalities such as fundus autofluorescence and OCT makes them appealing and preferable over invasive techniques such as fundus fluorescein angiography and ICGA.

Evidence and Consensus-Based Imaging Guidelines in Multifocal Choroiditis with Panuveitis and Punctate Inner Choroiditis - Multimodal Imaging in Uveitis (MUV) Taskforce Report 5

PURPOSE

To develop imaging and consensus-based guidelines on the application of multimodal imaging in noninfectious multifocal choroiditis and panuveitis (MFCPU) and punctate inner choroiditis (PIC).

DESIGN

Consensus agreement guided by the review of literature and an expert committee using nominal group technique (NGT).

METHODS

An expert committee applied a timed structured nominal group technique (NGT) to achieve consensus-based recommendations on specific disease characteristics, biomarkers of activity, and complications for MFCPU and PIC. Representative cases with non-infectious active and inactive MFCPU and PIC with color fundus photographs (CFP), optical coherence tomography (OCT), fundus fluorescein angiography (FFA), OCT angiography (OCTA), indocyanine angiography (ICGA), and fundus autofluorescence images (FAF) were reviewed. These recommendations were voted upon by the entire task force.

RESULTS

The experts agreed that lesions of MFCPU and PIC can be well characterized using CFP. OCT is the preferred modality for detecting active lesions. Both FAF and OCT are effective for monitoring disease recurrence. Late-phase ICGA is most valuable in recurrent disease when the lesions are not visible on FAF and CFP. While OCTA and ICGA can successfully identify lesions and complications such as choroidal neovascularization, no imaging biomarkers were found to reliably distinguish between active and inactive lesions on these two modalities.

CONCLUSIONS

Incorporating imaging findings, particularly OCT, into the Standardization of Uveitis Nomenclature (SUN) classification criteria for MFCPU and PIC enables more precise assessment of disease activity. These consensus-based guidelines provide a framework for selecting optimal imaging modalities for diagnosis, monitoring and identification of complications of MFCPU and PIC.