A 32-year-old Caucasian woman presented to our department for progressive blurry vision in her right eye with photophobia and a diminished area in the temporal visual field for 2 weeks. There was no known history of systemic disease, major surgery or recent medication use also there was no noticeable flu-like symptoms during the previous 3 months. Her initial best corrected visual acuity was 6/60 in the right eye and 6/6 in the left eye with myopia. The intraocular pressure was normal. The anterior segment examination of the right eye revealed prominent cells and flares in the anterior chamber with mild congestion of the conjunctiva. Indirect ophthalmoscopy revealed multiple white-dot lesions in the mid-periphery retina, especially focused in the nasal quadrant with some scattered pigmented lesion (Fig. 1A). The macula was uninvolved, but the optic disc was hyperemic and swollen. Mild vitritis was also observed. The fundus examination of the left eye was unremarkable. The patient was then admitted to our ward with a tentative clinical diagnosis of MCP for further survey and management.
A systemic survey was conducted to exclude infectious entities and possible specific inflammatory etiologies. Chest and sacroiliac X-ray imaging, to exclude pulmonary tuberculosis, sacrodosis, and ankylosing spondylosis, revealed normal results. Routine blood analysis, including a full blood count, C-reactive protein, electrolytes, liver, and renal profile were normal. Specific autoimmune markers for rheumatology screening were negative. Serologic tests for infectious entities were negative, exclude all possible systemic infections.
Fluorescein angiography (FA) revealed an early blockage with late staining in the area of the white and pigmented dot lesions shown in the fundus examination (Fig. 1B). The optic disc also showed late staining compatible with the swelling hyperemic fundus appearance. The ICGA showed numerous hypocyanescent lesions larger in area and number compared to the fundus examination and FA (Fig. 1C). The FAF image, captured using ultra-widefield retinal imaging, showed speckled hyper-autofluorescent pattern in the macula area, and a clustered, hypo-autofluorescent lesion at the mid-periphery retina with hyper-autofluorescence surrounding few of these clustered lesions (Fig. 1D). One of these white-dot lesions with a hyper-autofluorescent ring (yellow circle in all figures) at the nasal retina was singled-out and examined using spectral domain optical coherence tomography (SD-OCT) and OCT-A for follow up purpose.
The OCT image, acquired at presentation of the singled-out white dot lesion, revealed vitreous cell aggregation above the lesion and disruption of the inner segment/outer segment (IS/OS) junction and retinal pigment epithelium (RPE) band with subretinal hyperreflectivity deposits (Fig. 2A). The OCT-A image showed a focal area of clustered circular flow in the outer retinal level, suggesting a possible CNV formation, (Fig. 2C) and a corresponding projection shadowing at the choriocapillary layer (Fig. 2D).
Under the impression of MCP, oral prednisolone at 30 mg daily with topical prednisolone acetate 1% every 2 hours were prescribed and gradually tapered down within a 2-month course. The patient was regularly followed up weekly in the outpatient clinic and had a smooth recovery. She reported significant vision improvements and recovery in the diminished temporal visual field. The singled out nasal lesion was examined again with OCT and OCT-A at week 3. The OCT showed a recovery of the retinal structure and reduced thickness, with resolved disrupted IS/OS and RPE band with fewer subretinal deposits compared to the previous examination (Fig. 3A). The focal area of suspicious neovascular flow previously seen on OCT-A (Fig. 2C) were not able to identify after treatment at week 3 (Fig. 3C and D). The best corrected visual acuity of her right eye has returned to 6/6 with total cessation of the anterior chamber and vitreous inflammation 2 months after treatment.
This case report was approved by the ethic committee (Institutional Review Board) of the Tri-service General Hospital in Taiwan (TSGH IRB No. 2-107-05-125). Informed written consent was obtained from the patient for publication of this case report and accompanying images.