punctate inner choroidopathy ( pic ) , an idiopathic primary choriocapillaritis , affects especially young myopic women .
multiple yellowish white dots ( 100 - 300 m ) can aggregate in the inner choroid or retinal pigment epithelial layer , resulting in exudative retinal detachment .
choroidal neovascularization ( cnv ) secondary to pic is the most vision - impairing complication next to subretinal fibrosis . due to cnv maculopathy ,
clinical diagnosis is based on funduscopy , angiography with fluorescein ( fa ) or indocyanine green ( icga ) and spectral - domain optical coherence tomography ( sd - oct ) .
additionally autofluorescence images can provide further information due to autofluorescent spots in active and hypofluorescent spots in scar regions .
a 29-year - old woman was referred to our department of ophthalmology with impaired visual acuity , photopsia and a central scotoma at her right eye ( re ) for 2 weeks .
neither operation nor laser surgery was done before , and no additional ocular or systemic diseases were known .
best corrected visual acuity ( bcva ) was 0.3 ( re , 8.50 sph ) and 1.0 at the left eye ( le , 6.50 sph ) .
vitreoretinal glitter ( glitzerbeete ) at the inferior part of the retina and multiple yellowish dots at the posterior pole without other signs of inflammation ( fig .
1a ) , being hyperfluorescent ( early phase ) with a diffuse leak ( late phase ) in fa ( fig .
blood chemistry and count ( except decreased basophil granulocytes ) as well as immunoglobulins ( igm and igg ) for borrelia burgdorferi , treponema pallidum ( tpha ) were normal .
starting with an anti - inflammatory therapy ( prednisolone acetate eye drops ) in our policlinic resulted in a discrete improvement of bcva ( 0.5 re ) after already 4 days until 0.8 bcva after 2 months .
as paracentral scotoma occurred at that point of follow - up , further fa revealed a classic cnv .
because of this cnv , an intravitreal injection of anti - vascular endothelial growth factor ( vegf , bevacizumab , 1 mg/0.05 ml ) was administered , stabilizing bcva at 0.8 - 1.0 in the following months .
three months after the first anti - vegf injection , the patient was referred again because of spreading of central scotoma ( re : bcva 0.8 ) .
now a systemic anti - inflammatory therapy with prednisone ( 120 mg ) and azathioprine ( 2 mg / kg body weight / day ) was started .
two more intravitreal injections of bevacizumab ( 1 mg/0.05 ml , bcva at injection 2 : 0.5 ; bcva at injection 3 : 0.8 ; re ) were administered . under this therapy ,
afterwards bcva decreased again ( 0.2 ) with recurrence of cnv and increased spreading in the central part of the fovea .
on the patient 's demand , no further intravitreal injection of anti - vegf was done , but local and systemic therapy were continued .
bcva stabilized at 0.5 under azathioprine and tapered prednisone medication without cnv activity in sd - oct .
rates of 69 - 75% were reported in the literature , yet treatment is still a challenge .
only few cases have been published reporting the use of local or systemic anti - inflammatory medications ( e.g. corticosteroids , immunomodulators ) , argon laser photocoagulation , photodynamic therapy ( pdt ) , retinal surgery of cnv or intravitreal anti - vegf injections .
systemic corticosteroids were applied successfully in the treatment of juxtafoveal ( bcva increase 1/10 - 6.7/10 ) and subfoveal cnv ( average bcva increase 6/18 - 6/12 ) .
laser photocoagulation is discussed controversially because of an increased risk of generating cnv , scare growth and the potential of reaching foveal structures .
an increase in bcva was also observed for the combination of pdt with systemic corticosteroids ( mean : 8.6 letters , follow - up 12 months , number of pdt : 2 ) or with intravitreal triamcinolone ( bcva 0.52 - 0.20 , follow - up 12 months ) .
submacular surgery can be considered for subfoveal cnv , yet a 66.7% recurrence of cnv was reported .
no studies are available for surgical treatment of extrafoveal cnv at this moment . a further option in medical treatment
either bevacizumab ( 1.25 mg/0.05 ml ) or ranibizumab ( 0.5 mg/0.1 ml ) resulted in an improved bcva ( mean : 6485 etdrs letters , follow - up 87.2 weeks ) . in our patient , after resolution of the acute pic inflammation , resulting in a rapid increase of bcva from 0.3 to 0.8 , a classic cnv decreased bcva due to macula involvement .
an intravitreal anti - vegf injection ( bevacizumab ) was given , and bcva increased up to 1.0 .
after 3 months , a recurrence of cnv occurred , systemic immunosuppression was intensified ( prednisone and azathioprine ) , and two additionally bevacizumab injections were applied .
a further recurrence of cnv after 5 months ( bcva 0.2 ) was treated without anti - vegf injection ( considering the patient 's desire ) , but with continuation of local and systemic immunosuppression , resulting in a lasting improvement of bcva ( 0.5 ) and stabilizing cnv in sd - oct .
it is not a matter of course that a combined therapy , as in the presented case , does always lead to this good visual outcome . whether a combination of distinct therapeutic options , a single medical treatment or a simple  wait and see regime is the best therapy for pic remains open , as pic can also show a spontaneous resolution
combined therapy of immunosuppression with intravitreal anti - vegf injections should be considered as therapeutic strategy in the management of recurrent cnv associated with pic .
the patient has consented to the submission of the case report for submission to this journal .
all authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest ( such as honoraria , educational grants , participation in speakers ' bureaus , membership , employment , consultancies , stock ownership , or other equity interest , and expert testimony or patent - licensing arrangements ) , or non - financial interest ( such as personal or professional relationships , affiliations , knowledge or beliefs ) in the subject matter or materials discussed in this paper .
 purposechoroidal neovascularization ( cnv ) associated with punctate inner choroidopathy ( pic ) is a rare clinical entity , yet still a challenge for medical treatment . 
 a case of a young myopic woman developing cnv secondary to unilateral pic is presented . 
 clinical morphology , diagnostic procedure and follow - up are reported.case reporta 29-year - old woman presented with multiple yellowish dots at the posterior pole . 
 no other signs of inflammation could be seen . 
 angiography with fluorescein yielded hyperfluorescent signals in the affected areas with a diffuse leak , and sd - oct showed a slightly elevated retinal pigment epithelial layer , consistent with the diagnosis of pic . 
 additionally a classic cnv was observed.resultsanti-inflammatory therapy with local prednisolone acetate eye drops in combination with intravitreal injection of anti - vascular endothelial growth factor ( vegf , bevacizumab ) yielded an increased best - corrected visual acuity . 
 as cnv reappeared , systemic medication with prednisone and azathioprine in combination with two further intravitreal injections of anti - vegf stabilized cnv and increased visual acuity again.conclusioncombined therapy of immunosuppression with intravitreal anti - vegf injections can be considered as therapeutic strategy in the management of recurrent cnv associated with pic . 
Introduction
Case Report
Discussion
Conclusion
Statement of Ethics
Disclosure Statement