A 34-year-old woman suffered hyperemia and blurred vision in the right eye half a year ago and visited a local clinic. Multifocal choroiditis in the right eye was suspected, and she received topical corticosteroid and subconjunctival injection of triamcinolone. However, she developed visual field deterioration in both eyes and was referred to our clinic. Best-corrected visual acuity (BCVA) was 20/200 (OD) and 20/16 (OS). We detected bilateral conjunctival hyperemia, mild iridocyclitis in the right eye, and multiple atrophic retinal lesions with some exudative changes widespread from the posterior pole to peripheral retina in both eyes (Fig. 1a). Fundus autofluorescence presented hypoautofluorescent regions corresponding to the outer retinal atrophy (Fig. 1b), and fluorescein angiography (FA) demonstrated late staining in the foveal region, especially from the margins of the region and vascular leakage in peripheral region (Fig. 1c). Late hyperfluorescence of the discs in both eyes was also observed. By optical coherence tomography (OCT) in the right eye, subretinal fluid in the subfoveal region and hyperreflective materials in ellipsoid zone were detected. Hyperplasia of retinal pigment epithelium (RPE) and ellipsoid zone were also observed (Fig. 1d). Complete blood count, erythrocyte sedimentation rate, C-reactive protein, kidney function tests, and liver function test were normal, and serology for syphilis and HIV were negative. Normal chest computed tomography, negative purified-protein derivative reaction, and negative T-SPOT.TB excluded the diagnosis of sarcoidosis and tuberculosis. Diagnosis of multifocal choroiditis and uveitis was made. We prescribed oral prednisolone at 30 mg/day and 0.1% betamethasone eyedrops for the right eye 4 times a day. After retinal exudative changes were alleviated, we began tapering both medications.
One month after the first visit (oral prednisolone: 10 mg/day), chorioretinitis near the disc and peripheral fundus relapsed in the left eye, and we increased oral prednisolone to 25 mg/day which improved the condition, and gradual tapering was restarted. Twelve months after the initial visit (oral prednisolone: 7 mg/day), the recurrence with multiple exudative changes in the periphery was observed in both eyes. In consideration of the clinical course and appearance, we made a diagnosis of RPC. We increased oral prednisolone (15 mg/day) and added oral cyclosporine (200 mg/day). Nevertheless, relapse occurred over the next 5 months. Thus, 17 months after the initial treatment, subcutaneous administration of adalimumab (40 mg/2 weeks) was introduced. Following the introduction, the oral immunosuppressants were drastically tapered without recurrence or any drug complications related to adalimumab. Three months after adalimumab therapy was started, oral cyclosporine was terminated. One year after introduction of adalimumab, oral prednisolone was successfully terminated without recurrence. BCVA had recovered up to 20/16 in both eyes. OCT image demonstrated alleviation of RPE hyperplasia, turned into rarefaction of outer retina and ellipsoid zone (Fig. 1e).