A 31-year-old woman was referred to the retina ward of Farabi eye hospital with a history of sudden decreased vision and metamorphopsia in OD for 3 days. On clinical examination, the best-corrected visual acuity was 20/40 and 20/20 in OD and OS, respectively; with +3.00 diopters of hyperopic refraction in OD and Plano refraction in OS. Funduscopy of the OS was normal and the OD was remarkable for a serous retinal detachment (SRD) and a 4 to 5-disc diameter submacular elevated mass with extension beyond the inferior arcade (Figure 1(a)). Anterior segment examination was normal in both eyes without inflammatory findings. No cells or flare in the vitreous cavity, signs of retinitis, or vasculitis were observed.
Spectral-domain optical coherence tomography (SD-OCT) confirmed a dome-shaped elevated choroidal mass with associated SRD (Figure 1(b)) OD. Enhanced depth OCT (EDI-OCT) of the OD demonstrated a homogenous hyporeflective elevated choroidal lesion, with compression of the choroidal vascular structures (Figure 1(c)). Ultrasonography confirmed a hyperechoic choroidal mass (Figure 1(d)). Early-phase fluorescein angiography (FA) showed pooling consistent with SRD and multiple hyperfluorescent dots over the mass with the persistence of these dots through late phases without disc leakage (Figure 1(e)). Indocyanine green angiography (ICGA) revealed diffuse and multiple foci of small, round, hypocyanescent dots in both early and late phases (Figure 1(f)).
A complete metastatic workup for detecting malignancy including genitourinary system evaluation (Pap smear, ultrasonography, and urine analysis), gastrointestinal system analysis (upper and lower endoscopy, liver function tests, and abdominopelvic computed tomography with contrast), breast examination, and consult with an internist was done, and all were negative for any malignancy. Other evaluations including sarcoidosis (serum angiotensin-converting enzyme and calcium), tuberculosis (chest X-ray, QuantiFERON Gold, and purified protein derivative (PPD) skin test), syphilis (The Venereal Disease Research Laboratory test (VDRL) and rapid plasma reagin (RPR)), and lupus (Anti-nuclear antibodies (ANA), anti-double-stranded DNA antibody (anti-dsDNA)) were negative. Inflammatory markers (erythrocyte sedimentation rate and C-reactive protein) were within normal limits, and the chest X-ray showed no abnormalities. Two weeks after initial evaluation the patient showed spontaneous resolution with improvement in central vision (BCVA: 20/25) and metamorphopsia. Reevaluation was consistent with decreased SRD and choroidal mass volume. Interestingly, there was disruption of the ellipsoid zone (EZ) and multifocal accumulation of hyperreflective material not previously seen on initial OCT (Figures 2(a) and 2(b)). Ultrasonography confirmed the decrease in the size of choroidal mass (Figure 2(c)).
One month after initial presentation visual acuity returned to 20/20 without any refractive error or symptoms. OCT and ultrasonography showed nearly complete resolution choroidal mass effect, SRD, and EZ disruption (Figure 2(d)).