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Niederer RL, Samalia PD, Chen YH, Goh JK, Cornish EE, Guest S, McCluskey PJ, Lim LL, Sims JL, Lightman S, Tomkins-Netzer O. Acute posterior multifocal placoid pigment epitheliopathy: clinical presentation and risk of stroke and transient ischaemic attack. Br J Ophthalmol 2024; 108:398-404. [PMID: 36657959 DOI: 10.1136/bjo-2022-321517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 01/02/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND/AIMS Acute posterior multifocal placoid pigment epitheliopathy is a rare but important disease that can be associated with life-threatening complications due to cerebral vasculitis. The primary objective was to determine the incidence of neurological complications and risk factors for stroke and transient ischaemic attack (TIA) associated with acute posterior multifocal placoid pigment epitheliopathy. Secondary objectives included the clinical presentation, visual outcomes and recurrence rates. METHODS This was a multicentre retrospective case series including 111 eyes from 60 subjects presenting from January 2009 to June 2020. RESULTS Median age at presentation was 29 years (IQR 24.7-35.1) and 36 subjects (60.0%) were male. 20 subjects (33.3%) reported a viral prodrome. Stroke and TIA were observed in seven subjects (11.7%). Older age was the only significant risk factor for stroke/TIA (p=0.042). Vision loss occurred in seven eyes, with four eyes (3.6%) having final visual acuity 6/15-6/60 and three eyes (2.7%) having visual acuity of 6/60 or worse. Recurrence occurred in 10 subjects (16.7%). CONCLUSIONS The presence of headache cannot reliably predict those at risk of stroke/TIA. Individuals presenting with acute posterior multifocal pigment epitheliopathy should therefore undergo a clinical neurological review and work-up for cerebral vasculitis as deemed appropriate by the treating ophthalmologist and collaborating neurologist.
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Affiliation(s)
- Rachael L Niederer
- Ophthalmology, Auckland District Health Board, Auckland, New Zealand
- Department of Ophthalmology, The University of Auckland, Auckland, New Zealand
| | - Priya D Samalia
- Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Yi-Hsing Chen
- Institute of Ophthalmology, University College London, London, UK
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jonathan Ks Goh
- Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Elisa Eleanor Cornish
- Save Sight Institute, Faculty of Medicine & Health, University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Guest
- Ophthalmology, Waikato District Health Board, Hamilton, New Zealand
| | - Peter J McCluskey
- Save Sight Institute, Faculty of Medicine & Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lyndell L Lim
- Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
- Centre for Eye Research Australia, Melbourne, Victoria, Australia
| | - Joanne L Sims
- Ophthalmology, Auckland District Health Board, Auckland, New Zealand
| | - Susan Lightman
- Institute of Ophthalmology, University College London, London, UK
- Moorfields Eye Hospital, London, England
| | - Oren Tomkins-Netzer
- Institute of Ophthalmology, University College London, London, UK
- Department of Ophthalmology, Lady David Carmel Medical Center, Ruth and Bruch Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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El Mahdaoui S, Isenberg AL, Hansen K, Langkilde AR, Hamann S, Romme Christensen J. Acute posterior multifocal placoid pigment epitheliopathy resembling multiple sclerosis. Pract Neurol 2022; 22:practneurol-2022-003463. [PMID: 35863880 DOI: 10.1136/pn-2022-003463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/03/2022]
Abstract
A 23-year-old man presented with right eye blurred vision; he was diagnosed with acute posterior multifocal placoid pigment epitheliopathy (APMPPE), and his symptoms resolved with prednisolone. Two months later, he developed a right arm weakness that resolved after 3 weeks. MR scan of brain identified changes suggesting multiple sclerosis, with four hyperintense FLAIR lesions; there was contrast enhancement of two lesions and no diffusion restriction. Cerebrospinal fluid showed mononuclear pleocytosis. We eventually diagnosed these as APMPPE-associated CNS lesions. APMPPE is a rare inflammatory chorioretinopathy that rarely can resemble multiple sclerosis clinically and radiologically.
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Affiliation(s)
- Sahla El Mahdaoui
- Danish Multiple Sclerosis Center, Copenhagen University Hospital Department of Neurology, Glostrup, Denmark
| | - Asher Lou Isenberg
- Danish Multiple Sclerosis Center, Copenhagen University Hospital Department of Neurology, Glostrup, Denmark
| | - Klaus Hansen
- Copenhagen University Hospital Department of Neurology, Copenhagen, Denmark
| | | | - Steffen Hamann
- Copenhagen University Hospital Department of Ophthalmology, Glostrup, Denmark
| | - Jeppe Romme Christensen
- Danish Multiple Sclerosis Center, Copenhagen University Hospital Department of Neurology, Glostrup, Denmark
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Testi I, Vermeirsch S, Pavesio C. Acute posterior multifocal placoid pigment epitheliopathy (APMPPE). J Ophthalmic Inflamm Infect 2021; 11:31. [PMID: 34524577 PMCID: PMC8443720 DOI: 10.1186/s12348-021-00263-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare inflammatory eye disease, affecting the inner choroid and the outer retina. Recent advances in multimodal imaging have been important in the understanding of the pathophysiology of the disease, allowing a better characterization of the morphology of this condition. Methods Narrative review. Results In this review, a comprehensive overview of clinical features, imaging findings, treatment management, and long-term outcomes of patients with APMPPE will be provided. Conclusions Although APMPPE was originally believed to be a self-limited condition with a good prognosis, the disease can be recurrent and result in significant loss of vision function. Fundus imaging plays an important role in the diagnosis and management of the disease, allowing to evaluate response to treatment and onset of complications.
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Affiliation(s)
- Ilaria Testi
- Department of Uveitis, Moorfields Eye Hospital, National Health Service Foundation Trust, 162 City Rd, Old Street, London, EC1V 2PD, UK
| | - Sandra Vermeirsch
- Department of Uveitis, Moorfields Eye Hospital, National Health Service Foundation Trust, 162 City Rd, Old Street, London, EC1V 2PD, UK
| | - Carlos Pavesio
- Department of Uveitis, Moorfields Eye Hospital, National Health Service Foundation Trust, 162 City Rd, Old Street, London, EC1V 2PD, UK.
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Pillar S, Gepstein R, Gal-Or O, Kramer M. Acute posterior multifocal placoid pigment epitheliopathy associated with CN III palsy. Am J Ophthalmol Case Rep 2021; 22:101102. [PMID: 33981916 PMCID: PMC8082550 DOI: 10.1016/j.ajoc.2021.101102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 02/23/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose To report a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) associated with cranial nerve (CN) III palsy. Observations A 20-year-old woman developed bilateral anterior uveitis, which resolved with topical steroids. Three weeks later she exhibited posterior pole lesions in both eyes, corresponding with a diagnosis of APMPPE, as confirmed by multimodal imaging. Two days later the patient presented with right CN III palsy. The patient was started on oral prednisone, which was gradually tapered off. Signs and symptoms improved rapidly, with complete resolution within two months. Conclusion and importance Though rare, APMPPE may present with neurological involvement, as in this previously unreported association with CN III palsy. Unlike uncomplicated APMPPE cases, in patients with neurological manifestations systemic therapy is advocated.
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Affiliation(s)
- Shani Pillar
- Department of Ophthalmology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raz Gepstein
- Department of Ophthalmology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Gal-Or
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Kramer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel
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Recurrent Vertebrobasilar Strokes Associated With Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE). Neurologist 2020; 25:131-136. [PMID: 32925484 DOI: 10.1097/nrl.0000000000000273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is an ophthalmologic condition of likely immune origin. Typically, it presents as a chorioretinitis with bilateral visual disturbance and characteristic funduscopic lesions of the retinal pigment epithelium. APMPPE has been associated with several systemic and neurological complications, including cerebrovascular diseases. CASE REPORT A 58-year-old woman presented with sudden right hemiparesis and dysarthria, with magnetic resonance imaging evidence of an acute ischemic lesion in the left pons. Five days later, she developed contralateral hemiparesis and evolved into a locked-in syndrome. A new lesion located at the right pontomedullary junction was detected by magnetic resonance imaging. The patient developed a visual deterioration that had started 1 week before admission. An ophthalmologic evaluation showed visual acuity loss (20/200 in both eyes) and characteristic yellow-white lesions in the posterior pole of both eyes. Laboratory analyses were remarkable for positive antinuclear antibodies, an elevated erythrocyte sedimentation rate, and C-reactive protein. The cerebrospinal fluid showed elevated protein levels, lymphocytic pleocytosis, and normal glucose levels. The fundoscopy findings together with recurrent strokes led to the diagnosis of APMPPE and appropriate immunomodulatory treatment with corticosteroids and azathioprine was started. CONCLUSIONS This case illustrates the importance of careful evaluation and high clinical suspicion for this entity when dealing with patients with new-onset headache or stroke associated with visual impairment. Proper ophthalmologic evaluation is important so that adequate therapy is established.
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Shields RA, Oska SR, Farley ND, Randhawa S. Influenza-Induced Acute Macular Neuroretinopathy With Cerebral Involvement in a Ten-Year-Old Boy. Ophthalmic Surg Lasers Imaging Retina 2020; 51:293-297. [PMID: 32511734 DOI: 10.3928/23258160-20200501-08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/30/2020] [Indexed: 11/20/2022]
Abstract
A 10-year-old male presented with 1-week duration of painless bilateral central vision loss after having been diagnosed with influenza A. Optical coherence tomography revealed superficial retinal nerve fiber layer infarcts, hyperreflectivity of the inner nuclear layer consistent with paracentral acute middle maculopathy (PAMM), and outer nuclear layer hyperreflectivity and disruption of the ellipsoid zone suggesting acute macular neuroretinopathy (AMN). Brain MRI revealed enhancement of the right basal ganglia consistent with focal encephalitis. He was diagnosed with presumed influenza-induced leukocytoclastic vasculitis (LCV) and treated with intravenous steroids. Influenza-induced LCV is a rare phenomenon and can present with AMN, PAMM, and encephalitis. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:293-297.].
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Bigaut K, Kremer L, Hacquard A, Wolff B, Collongues N, De Seze J. A case of acute posterior multifocal placoid pigment epitheliopathy with aseptic meningitis and cerebral infarction. Rev Neurol (Paris) 2019; 175:329-331. [DOI: 10.1016/j.neurol.2018.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
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