Acute zonal occult outer retinopathy (AZOOR) associated with multifocal choroidopathy

Diagnosis, Mechanisms, and Differentiation of Inflammatory Diseases of the Outer Retina: Photoreceptoritis versus Choriocapillaritis; A Multimodal Imaging Perspective

Background and aim: Inflammatory diseases that affect the outer retina do so by different mechanisms. Some of them result from the direct, primary involvement of the outer retina (primary photoreceptoritis) such as acute zonal outer occult retinopathy (AZOOR). Others affect the photoreceptors secondarily due to the inflammatory involvement of the choriocapillaris. This results in choriocapillaris non-perfusion that damages the photoreceptors due to the ensuing ischaemia, a mechanism characterising primary inflammatory choriocapillaropathies (PICCPs) such as multiple evanescent white dot syndrome (MEWDS), idiopathic multifocal choroiditis (MFC), and others. Thanks to multimodal imaging (MMI), it is now possible to differentiate between these two mechanisms of outer retinal damage. The aim of this study is to determine the MMI characteristics that allow us to differentiate primary photoreceptoritis, including AZOOR, from PICCPs such as MEWDS and MFC. Methods: A series of eight PICCPs cases (five typical MEWDS and three typical active MFC cases) and four typical primary photoreceptoritis/AZOOR cases (five eyes) that had undergone complete MMI investigation, including fundus photography (FP), blue light fundus autofluorescence (BL-FAF), spectral domain optical coherence tomography (SD-OCT), OCT angiography (OCT-A, when available), fluorescein angiography (FA), and indocyanine green angiography (ICGA) were analysed, pointing out the differences that allow us to distinguish primary photoreceptoritis from PICCPs. Results: All primary photoreceptoritis/AZOOR cases showed (1) faint fundus pallor around the fovea, (2) BL-FAF hyperautofluorescence, (3) loss of photoreceptor outer segments (PROS) on SD-OCT, (4) absence of choriocapillary drop-out on OCT-A, (5) normal FA or faint FA hyperfluorescence, and (6) conserved ICGA fluorescence/no hypofluorescent areas; (1), (2), (3), and (5) indicated loss of photoreceptor outer segments, and (4) and (6) indicated conserved choriocapillaris circulation. For PICCPs, (a) fundus showed discreet white dots or none (in MEWDS) and punched-out scars in MFC, (b) BL-FAF hyperautofluorescence, (c) loss of PROS on SD-OCT, (d) FA faint hyperfluorescence in MEWDS, also minimal in active MFC lesions (e) in all cases ICGA hypofluorescent areas; (b) and (c) indicating loss of PROS, and (e) indicating choriocapillaris non-perfusion in all cases. The OCT-A did not show consistent findings with faint or no capillary drop-out in MEWDS and MFC. Conclusions: MMI combining the SD-OCT and BL-FAF clearly showed loss of PROS in both groups, while the ICGA determined whether this was due to choriocapillaris non-perfusion in PICCPs or whether the choriocapillaris was intact in case of primary photoreceptoritis. The FA and OCT-A were found to be less useful and/or less sensitive for the appraisal of both these entities.

Acute Zonal Occult Outer Retinopathy (AZOOR) Results from a Clinicopathological Mechanism Different from Choriocapillaritis Diseases: A Multimodal Imaging Analysis

Background and aim: AZOOR is a rare disease characterized by loss of zones of outer retinal function, first described by J Donald Gass in 1993. Symptoms include acute onset photopsias and subjective visual field losses. The syndrome is characterized by a normal fundus appearance, scotomas and electroretinographic changes pointing towards outer retinal dysfunction. Evolution, response to immunosuppressive treatment and outcome are difficult to predict. The aim of this small case series was to identify the morphological changes and sequence of events in AZOOR thanks to multimodal imaging. Methods: Charts of AZOOR patients seen in the Centre for Ophthalmic Specialized care (COS, Lausanne, Switzerland) were analyzed by multimodal imaging including fundus photography, fluorescein angiography (FA), indocyanine green angiography (ICGA), blue light fundus autofluorescence (BL-FAF) and spectral domain optical coherence tomography (SD-OCT) in addition to a complete ophthalmological examination including visual field testing and microperimetry, as well as OCT angiography (OCT-A) and ganglion-cell complex analysis when available. Cases and Results: Three AZOOR patients with a mean follow-up of 47 ± 25.5 months were included following the clinical definitions laid down by J Donald Gass. The primary damage was identified at the level of the photoreceptor outer segments with an intact choriocapillaris and retinal pigment epithelium (RPE) layer, these structures being only secondarily involved with progression of the disease. Conclusion: Although AZOOR has often been included within white dot syndromes, some of which are now known to be choriocapillaris diseases (choriocapillaritis entities), our findings clearly commend to differentiate AZOOR from entities such as MEWDS (Multiple evanescent white dot syndrome), APMPPE (Acute Posterior Multifocal Placoid Pigment Epitheliopathy), MFC (Multifocal Choroiditis) and others, as the damage to photoreceptors is primary in AZOOR (a retinopathy) and secondary in choriocapillaritis (a choriocapillaropathy).

Classification of Non-Infectious and/or Immune Mediated Choroiditis: A Brief Overview of the Essentials

The choroid was poorly accessible to imaging investigation until the last decade of the last century. With the availability of more precise imaging methods such as indocyanine green angiography (ICGA) and, later, optical coherence tomography (OCT), enhanced depth OCT (EDI-OCT), and OCT angiography (OCTA), appraisal of choroidal inflammation has substantially gained in accuracy. This allowed to precisely determine which structures were touched in the different non-infectious choroiditis entities and made it possible to classify this group of diseases, ICGA signs, mainly hypofluorescent lesions, were identified and described. Previous publications have divided angiographic findings into two main sets of signs: (1) irregular “geographic” hypofluorescent areas corresponding to choriocapillaris non-perfusion and (2) round more regular, hypofluorescent dark dots more evenly distributed in the fundus corresponding to more deep choroidal stromal foci. These distinct findings allowed to subdivide and classify choroiditis into choriocapillaritis and stromal choroiditis. Additional signs were identified from EDI-OCT and OCTA examination supporting the classification of choroiditis into choriocapillaritis and stromal choroiditis. Results: Diseases involving principally the choriocapillaris included Multiple Evanescent White Dot Syndrome (MEWDS), Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE), Idiopathic Multifocal Choroiditis (MFC), and Serpiginous Choroiditis (SC) as well as mixed forms. Diseases primarily involving the choroidal stroma included HLA-A29 Birdshot Retinochoroiditis (BRC), Vogt-Koyanagi-Harada disease (VKH), Sympathetic Ophthalmia (SO), and Sarcoidosis chorioretinitis (SARC). Thanks to new imaging investigations of the choroid, it is now possible to classify and understand the diverse clinicopathological mechanisms in the group of non-infectious choroiditis entities.

Acute idiopathic blind spot enlargement syndrome following influenza vaccination

Purpose

To report a case of acute idiopathic blind spot enlargement syndrome (AIBSES) following influenza vaccination.

Observations

A 57-year old woman presented with a one-month history of photopsia, temporal visual field disturbance on the right eye, 11 days following the administration of the influenza virus vaccine. Visual acuity was 20/30, and color vision remained normal. Examination revealed mild venular dilation at the edge of the right optic disk and was otherwise unremarkable. Visual field testing revealed enlargement of the right physiological blind spot. Medical workup, including brain CT scan, brain MRI, RPR, Treponema pallidum antibodies, Chest X-Ray, ANA, and PPD testing, was found within normal limits. Ancillary testing was compatible with an assessment of AIBSES secondary to influenza virus vaccination.

Conclusions and Importance

Although direct causation may not be absolutely established by a single report, our case suggests that the influenza virus vaccine may serve as an immunological trigger for some cases of AIBSES. Thoughtful vaccination history is of the utmost importance when evaluating patients with AIBSES, as it may help elucidate the underlying precipitating factor. To our knowledge, this is the first reported case of AIBSES following influenza virus vaccination.

Acute Idiopathic Blind Spot Enlargement and Acute Zonal Occult Outer Retinopathy: Potential Mimics of Neuro-Ophthalmic Disease

In 1988, William Hoyt, MD, et al described "acute idiopathic blind spot enlargement" (AIBSE) in 7 symptomatic patients who had no apparent abnormalities of the optic disc or surrounding retina. With the use of multifocal electroretinography, they showed that the scotoma was caused by occult retinal dysfunction. In 1992, J. Donald Gass, MD, described "acute zonal occult outer retinopathy" (AZOOR) in 13 patients who had sudden loss of often large zones of visual field without fundus abnormalities. Most patients developed zonal atrophy of retinal pigment epithelium and had no improvement in vision. Gass believed that AZOOR, multiple evanescent white dot syndrome, multifocal choroiditis, and AIBSE were all variants of the same disorder. Despite over 3 decades of numerous reports, the classification of these entities, their pathogenesis, and treatment remain controversial. AIBSE and AZOOR may be mistaken for an acute optic neuropathy, so it behooves the neuro-ophthalmologist to be familiar with these disorders. This review describes the initial recognition of AIBSE and its relationship to AZOOR.

Expanding the Clinical Spectrum of Multiple Evanescent White Dot Syndrome with Overlapping Multifocal Choroiditis

PURPOSE

To evaluate multifocal evanescent white dot syndrome (MEWDS) patients with and without overlapping multifocal choroiditis (MFC).

METHODS

Thirty-four patients diagnosed between November 2008 and August 2018 at 2 hospitals were retrospectively reviewed. Multimodal imaging including optical coherence tomography angiography (OCTA) was assessed.

RESULTS

Twenty-seven (79%) patients were women (overall mean age, 30 years). Five developed MFC lesions in the affected eyes, and one developed MFC in the unaffected fellow eye. Another developed combined MEWDS and MFC in the fellow eye during follow-up. Eyes with MFC had thicker choroids (316.5 and 197.3 µm, respectively; P = .001) at presentation, which became thinner after resolution (P = .043). Those with subfoveal MFC had poor visual prognosis (P = .019). Areas of suspected choriocapillaris flow deficit were identified on OCTA.

CONCLUSION

Some MEWDS patients may develop overlapping MFC in the same or fellow eyes, presenting with increased choroidal thickness which decreased after resolution.

Quantitative Autofluorescence Intensities in Acute Zonal Occult Outer Retinopathy vs Healthy Eyes

Importance

Acute zonal occult outer retinopathy (AZOOR) remains a challenging diagnosis. Early recognition of the disease depends on advances in imaging modalities that can improve phenotyping and contribute to the understanding of the underlying pathogenesis.

Objectives

To expand the range of approaches available to assist in the identification of AZOOR by multimodal imaging and to analyze the fundus lesions by quantifying short-wavelength fundus autofluorescence (quantitative fundus autofluorescence [qAF]) and spectral-domain optical coherence tomography.

Design, Setting, and Participants

In this observational study, patients underwent imaging at Columbia University Medical Center between November 2010 and March 2016 and were analyzed between September 2015 and August 2016. Six patients diagnosed as having AZOOR were studied by qAF and spectral-domain optical coherence tomography and were compared with 30 age and race/ethnicity–matched controls from a database of 277 healthy control eyes.

Main Outcomes and Measures

In unaffected regions of the macula, qAF was calculated within predetermined circularly arranged segments (qAF8). In addition, qAF was measured within specified regions of interest positioned at the autofluorescent lesion border (AZOOR line). Electroretinograms and electro-oculograms were recorded in 5 of 6 patients.

Results

Among 6 patients (age range, 26-61 years; 4 female; 4 of white race/ethnicity, 1 Asian, and 1 Hispanic), 5 exhibited an autofluorescent AZOOR line in short-wavelength fundus autofluorescence images, delineating the peripapillary lesion. The mean (SD) region-of-interest qAF measured on the AZOOR line was 60 (26) times higher than in healthy control eyes (P = .03) at equivalent fundus locations. The qAF8 within nondiseased macular regions were within the normal range. At the lesion border, spectral-domain optical coherence tomography revealed a loss of outer retinal integrity in all patients. Single-flash cone b-wave latency and 30-Hz flicker latency responses were significantly delayed bilaterally. Lesions with smooth, homogeneous borders exhibited only minimal expansion in size over time, while the lesion in a patient with a heterogeneous border progressed more rapidly.

Conclusions and Relevance

The finding that qAF is elevated at the border between diseased and nondiseased retina in patients with AZOOR contributes to the understanding of the natural history of the disease.

Observation and Clinical Pattern in Patients with White Dot Syndromes: The Role of Color Photography in Monitoring Ocular Changes in Long-Term Observation

Background

The aim of this study was to assess the clinical course and distinctive features of different white dot syndromes (WDS) in patients attending the Ophthalmology Department, Medical University of Warsaw in the years 1995–2015.

Material/Methods

Sixty-two (62) patients (43 females and 19 males), aged 18 to 77 years, referred with a WDS were included in this prospective study, with observation period ranging from 5 months to 16 years. All patients underwent a complete ophthalmological examination and multimodal imaging studies.

Results

In this cohort of 62 patients, the following WDS entities were identified: multifocal choroiditis with panuveitis (MFCPU), multifocal choroiditis (MFC), punctate inner choroidopathy (PIC), birdshot, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), subretinal fibrosis and uveitis, multiple evanescent white dot syndrome (MEWDS), serpiginous choroiditis, and single cases of acute annular outer retinopathy (AAOR).

Conclusions

The study was performed at a Polish referral center and may to some extent reflect the varied geographical distribution of white dot syndromes, as none of the subjects was found to suffer from acute zonal occult outer retinopathy (AZOOR), acute macular neuroretinopathy (AMN), or diffuse unilateral subacute neuroretinitis (DUSN). Long-term follow-up is warranted by the evolution of lesions in the eye fundus, while management depends on correct diagnosis of WDS. When the posterior pole is involved in some cases of the WDS an immunosuppressive treatment, the use of the PDT or anti-VEGF injections were necessary.

The Fundus Autofluorescence Spectrum of Punctate Inner Choroidopathy

Purpose. To investigate the fundus autofluorescence (FAF) spectrum of punctate inner choroidopathy (PIC). Methods. This is a retrospective observational case series of 27 consecutive patients with PIC admitted from October 2013 to March 2015, who underwent short-wavelength- (SW-) and near-infrared- (NIR-) FAF imaging, spectral domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), and indocyanine green angiography (ICGA). Results. There were three primary findings on the FAF imaging of patients with PIC. First, active PIC lesions revealed hypoautofluorescent spots with hyperautofluorescent margin. After the lesions regressed, the hyperautoflurescent margin faded. Second, subclinical and most of the atrophic PIC lesions appeared to be hypoautofluorescent spots. But subclinical PIC lesions were more distinctive on NIR-FAF imaging than on SW-FAF imaging. Third, hypoautofluorescent spots of PIC lesions coexisted with hyperautofluorescent patches on SW-FAF imaging. These hyperautofluorescent patches were demonstrated to be multiple evanescent white dot syndrome (MEWDS) or acute zonal occult outer retinopathy (AZOOR) lesions by subsequent multimodal imaging and faded during follow-up examinations. Conclusion. FAF imaging helps in noninvasively tracking the evolution of PIC lesions and identifying the combined MEWDS or AZOOR lesions, complementary to SD-OCT and angiographic studies.

Idiopathic multifocal choroiditis/punctate inner choroidopathy with acute photoreceptor loss or dysfunction out of proportion to clinically visible lesions

PURPOSE

To report acute/subacute vision loss and paracentral scotomata in patients with idiopathic multifocal choroiditis/punctate inner choroidopathy due to large zones of acute photoreceptor attenuation surrounding the chorioretinal lesions.

METHODS

Multimodal imaging case series.

RESULTS

Six women and 2 men were included (mean age, 31.5 ± 5.8 years). Vision ranged from 20/20-1 to hand motion (mean, 20/364). Spectral domain optical coherence tomography demonstrated extensive attenuation of the external limiting membrane, ellipsoid and interdigitation zones, adjacent to the visible multifocal choroiditis/punctate inner choroidopathy lesions. The corresponding areas were hyperautofluorescent on fundus autofluorescence and were associated with corresponding visual field defects. Full-field electroretinogram (available in three cases) showed markedly decreased cone/rod response, and multifocal electroretinogram revealed reduced amplitudes and increased implicit times in two cases. Three patients received no treatment, the remaining were treated with oral corticosteroids (n = 4), oral acyclovir/valacyclovir (n = 2), intravitreal/posterior subtenon triamcinolone acetate (n = 3), and anti-vascular endothelial growth factor (n = 2). Visual recovery occurred in only three cases of whom two were treated. Varying morphological recovery was found in six cases, associated with decrease in hyperautofluorescence on fundus autofluorescence.

CONCLUSION

Multifocal choroiditis/punctate inner choroidopathy can present with transient or permanent central photoreceptor attenuation/loss. This presentation is likely a variant of multifocal choroiditis/punctate inner choroidopathy with chorioretinal atrophy. Associated changes are best evaluated using multimodal imaging.

Idiopathic multifocal choroiditis with outer retinal or chorioretinal atrophy

PURPOSE

To report thirteen cases of idiopathic multifocal choroiditis with discrete chorioretinal lesions who were found to have zonal, multizonal, or diffuse outer retinal or chorioretinal atrophy.

METHODS

A retrospective observational case series using multimodal imaging including high-definition optical coherence tomography, fundus autofluorescence imaging, and fluorescein and indocyanine green angiography.

RESULTS

Twenty-one eyes in 13 patients with idiopathic multifocal choroiditis were found to have zonal, multizonal, or diffuse outer retinal or chorioretinal atrophy visualized using multimodal imaging. Thirteen eyes presented with diffuse disease, six eyes with multizonal, and two with zonal atrophy. Patterns of atrophy included zones surrounding the optic nerve, multiple geographic zones in the mid and far periphery, and a diffuse peripheral pattern with relative sparing of the central macula until later in the course of disease. Eleven of the 13 patients were treated with topical, periocular, or systemic corticosteroids, and 1 patient was also treated with systemic immunomodulatory treatment. The atrophic changes progressed over an average of 8 years of follow-up in 10 eyes despite therapy.

CONCLUSION

Idiopathic multifocal choroiditis can present with an uncommon pattern of zonal, multizonal, or diffuse outer retinal or chorioretinal atrophy as part of its clinical spectrum. The severity, extent, and progression of these atrophic changes are best appreciated using multimodal diagnostic imaging.

Changes in outer retinal microstructures during six month period in eyes with acute zonal occult outer retinopathy-complex

Purpose

To study the changes in the outer retinal microstructures during a six month period after the onset of acute zonal occult outer retinopathy (AZOOR)-complex by spectral-domain optical coherence tomography (SD-OCT).

Methods

Seventeen eyes of 17 patients with the AZOOR-complex were studied. The integrity of the external limiting membrane (ELM), ellipsoid zone (EZ; also called the inner/outer segment junction), and interdigitation zone (IDZ; also called the cone outer segment tips) were evaluated in the SD-OCT images obtained at the initial visit and at six months. The three highly reflective bands were divided into three types; continuous, discontinuous, and absent. The integrity of the outer nuclear layer (ONL) was also assessed.

Results

Among the three highly reflective bands, the IDZ was most altered at the initial visit and least recovered at six months. Fifteen of 17 eyes (88%) had a recovery of at least one of the three bands at six months in the retinal area where the ONL was intact, and these areas showed an improvement of visual field. Three eyes (18%) had retinal areas where the ONL was absent at the initial visit, and there was no recovery in both the retinal structures and visual fields in these areas.

Conclusions

Our results indicate that more than 85% eyes with AZOOR-complex show some recovery in the microstructures of the outer retina during a six month period if the ONL is intact. We conclude that SD-OCT is a useful method to monitor the changes of the outer retinal microstructure in eyes with the AZOOR-complex.

Ocular coherence tomographic and clinical characteristics in patients of punctuate inner choroidopathy associated with zonal outer retinopathy

PURPOSE

To describe the findings of optical coherence tomography and clinical characteristics in patients of zonal outer retinopathy associated with punctuate inner choroidopathy.

METHOD

Review of consecutive cases on fundus photographs, spectral domain ocular coherence tomography, fluorescein angiography, indocyanine green angiography, visual field, and electrophysiological studies of patients with punctate inner choroidopathy and associated zonal outer retinopathy.

RESULTS

This study involves 4 patients suffering visual field defect far beyond the area corresponding to punctate inner choroidopathy lesions. Findings in optical coherence tomography include attenuated signals of photoreceptor inner/outer segment areas corresponding to visual field defect, and increased choroidal thickness. After treatment with immunosuppressive agents, improvements are noted in all 4 patients.

CONCLUSION

Optical coherence tomography is helpful in the diagnosis of patients suffering zonal ocular outer retinopathy associated with punctate inner choroidopathy. All those patients responded well to immunosuppressive agents.

Successful treatment of an overlapping choriocapillaritis between multifocal choroiditis and acute zonal occult outer retinopathy (AZOOR) with adalimumab (Humira™)

To report a case of overlapping choriocapillaritis that initially presented as multifocal choroiditis (MFC) but later showed features compatible with acute zonal occult outer retinopathy (AZOOR) resistant to standard immunosuppression that responded only to adalimumad therapy. A 41-year-old patient presented with multiple small, discrete yellow-whitish spots in both eyes, compatible with MFC. A few weeks later, despite treatment with sub-Tenon and systemic corticosteroids, a choroidal neovascularization occurred in the right eye. The patient was treated with intravitreal anti-vascular endothelial growth factor. After 2 months, reduced visual acuity, photopsia and visual field defect in the left eye occurred. Spectral domain optical coherence tomography revealed photoreceptor outer segment defects common to all choriocapillaritis. The additional finding of an annular scotoma and a 360° ring on indocyanine green angiography led us to make the diagnosis of presumed AZOOR. Despite the combination of several immunosuppressive agents leading to temporary control of the disease, the patient experienced a further worsening. At that point, adalimumab was introduced, which led to an obvious improvement. This case supports the hypothesis that two different entities of the so-called AZOOR complex can be possible in the same eye, even asynchronously. In our case, anti-tumor necrosis factor alpha monoclonal antibody therapy represented a valid treatment option in a patient unresponsive to traditional immunosuppressive treatments.

Acute Zonal Occult Outer Retinopathy: Vision Loss in an Active Duty Soldier

Objective. To describe a case of acute zonal occult outer retinopathy (AZOOR) in an active duty patient.Methods. In this paper we studied fundus photographs, optical coherence tomograph, Humphrey visual field 30-2, fundus autofluorescence images, fluorescein angiograms, and electroretinography.Results. Exam findings on presentation: a 34-year-old American Indian female presented with bilateral photopsias, early RPE irregularity, and an early temporal visual field defect. Progression RPE damage and visual field defect along with ERG findings support final diagnosis of AZOOR.Conclusion. AZOOR may initially be identified as a broader category of disease called the “AZOOR complex of disorders”. Specific visual field defects, ERG results, and clinical exam findings will help distinguish AZOOR from other similar disorders.

[Multiple evanescent white dot syndrome and multiple sclerosis]

PURPOSE

To describe a patient who fulfilled the criteria for both clinically definite multiple evanescent white dot syndrome (MEWDS) and multiple sclerosis.

METHODS

We performed a complete ophthalmologic and neurological examination in a 30-year-old woman who was referred to our department for blurred vision in her left eye (LE) with photopsia.

RESULTS

Following a complete ophthalmologic examination, the patient was diagnosed with MEWDS and coincident multiple sclerosis. She underwent therapy with intravenous methylprednisolone (1000 mg/day) for three days, followed by oral prednisone (1 mg/kg per day) for 15 days. Most of the symptoms and signs apparently regressed within one month, despite a still abnormal OCT macular scan, probably due to atrophic post-inflammatory changes in the outer and photoreceptor layers (rods and cones).

CONCLUSION

This report, showing the clinical features of MEWDS associated with multiple sclerosis, strongly suggests common neuropathological and inflammatory mechanisms between MS and white dot syndromes.

Cup-shaped choroidal excavation detected by optical coherence tomography: a case report

PURPOSE

The purpose of this study was to report a case with a cup-shaped choroidal excavation in the fovea. This condition was detected only by optical coherence tomography (OCT) and seems to be rare.

METHOD

This was an observational case report.

RESULT

A 29-year-old man had a central scotoma in his right eye. Color photography showed a reddish lesion in the fovea of the right eye, which was shown as a window defect on fluorescein angiography. Tomography with time-domain OCT showed a retinal pigment epithelial and choroidal excavation corresponding to the reddish macular lesion in the right eye. By using spectral-domain OCT, the inner segment and outer segment junctions of photoreceptors line thickening was detected by tomography, and the retinal pigment epithelium line was observed in the area of choroidal excavation by segmentation analysis.

CONCLUSION

The reddish lesion on ophthalmoscope corresponded to the excavation lesion, detected in the fovea only by OCT; this indicates a new clinical availability of OCT in clinical diagnosis.

Acute zonal occult outer retinopathy: a case report

BACKGROUND

Acute zonal occult outer retinopathy (AZOOR) is a disorder of unknown etiology with a predilection for young women. AZOOR is characterized by an acute loss of one or more zones of outer retinal function with a corresponding loss of visual field in one or both eyes. Patients present with photopsia, variable funduscopic changes, and abnormal electroretinogram (ERG) findings. There are no proven treatments. Diagnosed cases have a reasonable prognosis because central vision is often spared.

CASE REPORT

A 24-year-old white woman presented with acute photopsia with clouded temporal vision in the right eye (O.D.). Initial evaluation found a slightly swollen nerve fiber layer with no other outstanding lesions O.D. Over a 7-week follow-up period, there was significant progression into the deep chorioretinal tissues O.D. with an anterior chamber response. At 3 months, an afferent pupillary defect (APD) developed with significant retinal pigment epithelium (RPE) changes. After extensive testing, the consulting retinal specialist identified AZOOR as the etiology. At 21 and 31 months, the process remained in remission. Although primary symptoms subsided, the dense inferior-temporal field defect remained O.D.

CONCLUSION

AZOOR is a rare condition with subtle and often vague signs and symptoms making diagnosis difficult. The course of AZOOR, its clinical presentations, hypothesis of etiology, differential diagnosis, workup, management, and prognosis are reviewed.

Morphological study of acute zonal occult outer retinopathy (AZOOR) by multiplanar optical coherence tomography

PURPOSE

We set out to determine whether morphological retinal changes occur in patients with acute zonal occult outer retinopathy (AZOOR).

METHODS

Five patients diagnosed with AZOOR were studied. They included two men and three women, with an age range of 23-51 years. Symptoms and findings were retrospectively and prospectively collected. The three-dimensional multiplanar optical coherence tomography (OCT) Ophthalmoscope was used to examine the morphology of the retina in patients who were examined between April 2000 to December 2004. Standardized full-field electroretinograms (ERGs) and multifocal ERGs (mfERGs) were recorded.

RESULTS

All the patients reported an acute onset of visual disturbances including a decrease of central vision and photopsia. The a- and b-waves of full-field ERGs were decreased, and the mfERGs in the central area were reduced. Ophthalmoscopic examination showed no obvious fundus abnormalities. OCT Ophthalmoscopic images of a cross-sectional plane revealed hyporeflection at the level of the photoreceptor layer in the macular region in three of five patients, and presence of one or two layers in which the inner/outer segment junction of the photoreceptor layer was absent in the other two patients. En-face, constant depth C-scans, which present the image parallel to the retina, revealed an abnormal, patchy hyper-reflection in the affected eyes of two patients and in the non-affected eye in one of these two patients.

CONCLUSIONS

The changes in OCT Ophthalmoscope B-scan images indicate morphological damage to the photoreceptors, which probably accounts for the functional alterations. The alterations in the C-scan image in the normal fellow eye of one patient suggest that morphological changes may precede symptomatic changes.

Photoreceptor outer segment abnormalities as a cause of blind spot enlargement in acute zonal occult outer retinopathy-complex diseases

PURPOSE

To investigate the correlation between visual field (VF) defects in diseases of the acute zonal occult outer retinopathy (AZOOR)-complex and their spectral-domain optical coherence tomographic (OCT) findings.

DESIGN

Observational case series.

METHODS

Patients with AZOOR, multiple evanescent white dot syndrome (MEWDS), and multifocal choroiditis and panuveitis (MCP) examined in a private practice retinal referral center had threshold VF testing and spectral-domain OCT examination performed using a device capable of obtaining a block of 128 B-scans in a 6 x 6-mm region centered on the optic nerve and macula. The areas of defects in the boundary between the inner segments (IS) and the outer segments (OS) of the photoreceptors, termed the IS/OS boundary, were compared with the VF defects measured.

RESULTS

There were 18 evaluable eyes among one patient with MEWDS, two with AZOOR, and seven with MCP. In the 14 eyes with blind spot enlargement [corrected] corresponding IS/OS boundary defects were found in the [corrected] peripapillary region, while no IS/OS boundary defects were found in the four [corrected] eyes without blind spot enlargement. IS/OS boundary defects were seen over chorioretinal scars and areas of neovascularization and no widespread defects were seen [corrected] elsewhere in the fundus. The IS/OS boundary defects showed improvement, as did the blind spot enlargement, spontaneously in the patient with MEWDS and after treatment with immunosuppression in the patients with AZOOR.

CONCLUSION

The spectral-domain OCT finding of IS/OS boundary defects, implicating photoreceptor OS perturbation, appears to explain the blind spot enlargement in patients with AZOOR-complex diseases. These defects are not necessarily permanent.

[White dot syndrome]

The white dot syndromes comprise a group of diseases with a suspected immunological background, which show no systemic manifestations. The characteristic inflammatory changes of the choroid and the retinal pigment epithelium are typically yellow-white foci beneath the retina. Diseases belonging to the white dot syndromes which will be discussed in this article are acute multifocal placoid pigment epitheliopathy (AMPPE), multiple evanescent white dot syndrome (MEWDS), birdshot retinochoroidopathy (BSRC), multifocal choroiditis with panuveitis (MFC/MCP), punctuate inner choroidopathy (PIC), acute zonal occult outer retinopathy (AZOOR) and serpiginous choroiditis, Neither the trigger mechanism nor the pathogenetic development is known with certainty for any of these diseases. Immunological reactions to previous viral infections coupled with a genetic predisposition seem to be a common denominator. Transitions between the individual diseases have also been described.

Fungal infection in patients with serpiginous choroiditis or acute zonal occult outer retinopathy

The etiologies of a number of retinopathies, including serpiginous choroiditis and acute zonal occult outer retinopathy (AZOOR), remain uncertain. Recently, we provided evidence that AZOOR is caused by Candida famata infection. The purpose of this article was to investigate the presence of fungal infection in five patients affected with serpiginous choroiditis and five patients with diagnosis of AZOOR. To assess the presence of fungal infection the presence of antibodies in human serum samples against C. famata, C. albicans, C. parapsilosis, C. glabrata and C. krusei was analyzed. In addition, quantitative PCR was carried out to detect fungal genomes in whole blood. Finally, the presence of fungal antigens in the serum samples of patients was investigated. Three AZOOR patients presented high antibody titers against Candida spp., while antibodies against Candida spp. were observed in serum samples from four patients with serpiginous choroiditis. Fungal genomes in peripheral blood were evidenced in serum samples from one AZOOR and four serpiginous choroiditis patients. Fungal antigens were also apparent in the serum of different patients. Our findings indicate that there was evidence of disseminated fungal infection in most patients examined.

Indocyanine green angiography in a case of punctate inner choroidopathy associated with acute zonal occult outer retinopathy

BACKGROUND

The etiology of punctate inner choroidopathy (PIC) and acute zonal occult outer retinopathy (AZOOR) are currently unknown, although both diseases are hypothesized to be part of the spectrum of a single disorder.

CASE

We report indocyanine green (ICG) angiographic findings in a 24-year-old woman in whom PIC was associated with AZOOR.

OBSERVATIONS

The patient had been diagnosed with bilateral PIC. She noticed a visual field defect in her right eye 8 months later, and a defect in her left eye 25 months later. Perimetry showed an arcuate scotoma (right eye) and a central scotoma (left eye), which could not be explained by funduscopy or late-phase fluorescein angiography. Multifocal electroretinography led to a diagnosis of bilateral AZOOR. ICG angiography demonstrated late multiple patchy hypofluorescent spots throughout the posterior pole in the right eye and geographic hypofluorescence in the macular region from initial to late phase in the left eye. However, these findings were not evident at the onset of PIC.

CONCLUSION

These angiographic results suggest that at the onset of AZOOR, choriocapillaris injuries had occurred in the areas corresponding to the scotomas.

Acute zonal occult outer retinopathy in the fellow eye 5 years after presentation of punctate inner choroidopathy

BACKGROUND

There has been argument about the relationship between posterior inner choroidopathy (PIC) and acute zonal occult outer retinopathy (AZOOR).

METHOD

Case study.

RESULTS

A 26-year-old woman was diagnosed as having PIC in the right eye in 1998. Multiple yellow-white lesions in the inner choroid and retina were found in the posterior pole of her right eye and were treated with corticosteroid therapy. In 2003, she was referred to us complaining of visual field defect in the left eye. By means of electroretinographic and static perimetric analyses, she was diagnosed as having AZOOR in the left eye.

CONCLUSION

This case presents indirect evidence that PIC and AZOOR may have some common etiologic or pathogenic background.

Isolation of Candida famata from a patient with acute zonal occult outer retinopathy

The etiology of a number of retinopathies, such as acute zonal occult outer retinopathy (AZOOR), remains undetermined. Candida famata was isolated from conjunctival exudates of a patient diagnosed with AZOOR. This yeast was very abundant, particularly in the more affected eye, while no other pathogens or fungal species were in evidence. Immunological tests revealed the presence of antigen-specific T lymphocytes by using C. famata as a challenge. Moreover, enzyme-linked immunosorbent assay analysis showed the presence of specific antibodies against this yeast in the patient's blood. Delayed hypersensitivity by use of a skin test was also positive. Finally, antifungal treatments led to improvements in several clinical symptoms, including funduscopic analysis. However, despite prolonged treatment with fluconazole and itraconazole, C. famata still appeared in the conjunctival exudates. The new antifungal voriconazole may represent a better choice for treatment.

Acute zonal occult outer retinopathy: towards a set of diagnostic criteria

BACKGROUND

Individuals with acute zonal occult outer retinopathy (AZOOR) present with initially progressive scotomata and photopsia. Characteristically, the extent of the visual field defect is unexplained by fundal examination, but there is marked retinal dysfunction evident electrophysiologically. It is the authors' experience that a group of patients exhibit characteristic clinical and electrophysiological abnormalities, which serve as criteria for a working diagnosis.

METHODS

A retrospective observational case series of 28 patients were identified with the clinical diagnosis of AZOOR who shared similar abnormal electrophysiology. Details of the history and ophthalmic findings were obtained from the case notes.

RESULTS

Electrophysiology demonstrated a consistent pattern of dysfunction both at the photoreceptor/retinal pigment epithelial complex but also at inner retinal levels, essentially comprising a delayed 30 Hz flicker ERG and a reduction in the EOG light rise.

CONCLUSION

This study determines diagnostic criteria applicable to a group of patients with AZOOR, typically those with classic symptomatology. Electrophysiological testing can help avoid lengthy, costly, and potentially invasive investigations, and the unnecessary use of immunosuppressive therapy.

Multifocal electroretinography in multifocal choroiditis and the multiple evanescent white dot syndrome

PURPOSE

To study and compare the findings on multifocal electroretinography (MERG) between multifocal choroiditis (MFC) and the multiple evanescent white dot syndrome (MEWDS).

SUBJECT AND METHODS

Patients were recruited prospectively from the Department of Ophthalmology & Visual Sciences at the University of Iowa Hospitals & Clinics. They were evaluated using Goldmann visual fields (GVF) and MERG. Patients were diagnosed as having either MFC or MEWDS based on their clinical findings before MERG testing.

RESULTS

Nineteen patients (23 eyes) were included in the study. Eleven patients were diagnosed with MFC and eight patients with MEWDS. Fourteen eyes with MFC and seven eyes with MEWDS were tested with MERG during the acute phase of their respective conditions. Fourteen patients (8 MFC and 6 MEWDS) were followed serially with MERG. Patients with MEWDS demonstrated focal depression corresponding to GVF defects with subsequent near total recovery of the MERG to baseline. Patients with MFC typically demonstrated diffuse loss of function over the entire test field. Focal scotomata, in addition to the diffuse depression, could be identified in 7 of 14 patients. Patients with MFC demonstrated only partial or no recovery of MERG following acute episodes, which was significantly different from the course followed by patients with MEWDS (P < 0.001, Fisher's exact test).

CONCLUSION

Multifocal electroretinography differentiates MFC from MEWDS. Patients with MFC have permanent damage to the retina with diffuse depression of MERG. Patients with MEWDS, however, typically demonstrate greater focal loss initially on MERG followed by nearly full recovery of first order retinal function.

Acute annular outer retinopathy: report of four cases

PURPOSE

To describe the clinical findings and course in four patients with acute annular outer retinopathy.

METHODS

Four patients were evaluated during the course of acute annular outer retinopathy, and the historical and clinical findings were retrospectively collected.

RESULTS

Four healthy patients developed the acute onset of visual field loss associated with a localized, white annular outer retinopathy. All patients were caucasian; two were women, aged 29 and 32 years, and two were men, aged 71 and 79 years. The mean follow-up was 3.9 years (range, 1 to 6 years). On presentation, four eyes had an irregular, incomplete, peripapillary, annular band of gray-white, deep retinal opacification with visual

CONCLUSIONS

These four cases of acute annular outer retinopathy expand our knowledge of this disorder. Acute annular outer retinopathy may be a distinct entity or it may represent a variant of acute zonal occult outer retinopathy retinopathy. As more cases are recognized, the characteristic features of the disease spectrum, the etiology, and treatment options may be better elucidated.

Current controversies in the white dot syndromes. Multifocal choroiditis, punctate inner choroidopathy, and the diffuse subretinal fibrosis syndrome

The white dot syndromes are inflammatory diseases of unknown etiology which share several clinical features. The presence or absence of visual field defects, abnormal electroretinograms, lesions on indocyanine green angiography, and specific antiretinal antibodies may give us clues to their pathogenesis. Careful prospective studies into these features may enable us to differentiate between these diseases and facilitate further research toward developing effective treatments.

Indocyanine green angiography of multifocal choroiditis

PURPOSE

The purpose of the study is to determine indocyanine green (ICG) angiographic characteristics of patients with multifocal choroiditis (MC) and to identify features that may assist in the differentiation of MC from other ocular inflammatory diseases.

METHODS

After complete ophthalmologic examination, fluorescein angiography and ICG angiography were performed in a series of 14 patients with MC. The ICG findings were then correlated with the clinical and fluorescein angiographic appearance of these patients to determine specific characteristics and distinguishing features of the entity. These findings then were compared with those of angiographic patterns observed in patients with ocular histoplasmosis syndrome to determine whether differentiating features could be identified.

RESULTS

Fourteen (50%) of the 28 eyes were found to have large hypofluorescent spots in the posterior pole on ICG angiography, which, in most cases, did not correspond to clinically or fluorescein angiographically detectable lesions. Seventeen (61%) had smaller hypofluorescent lesions (approximately 50 pm in size) in the posterior pole on the ICG study. In seven eyes exhibiting enlarged blind spots on visual field testing, ICG angiography showed confluent hypofluorescence surrounding the optic nerve. The ICG angiogram was found useful in evaluating the natural course in two patients with MC as well as a response to oral prednisone therapy in four others. The ICG angiographic findings differed from those seen in patients with ocular histoplasmosis.

CONCLUSIONS

Indocyanine green angiography can provide information that is not detectable by clinical or fluorescein angiographic examination in patients with MC. This information may prove useful in differentiating this condition from the ocular histoplasmosis syndrome, provide a better understanding of the natural course and progression of the disease, and provide a potential adjunct in the clinical evaluation of patients undergoing therapeutic regimens for active inflammatory lesions.

Indocyanine green angiography in a case of punctate inner choroidopathy

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Pattern of retinal dysfunction in acute zonal occult outer retinopathy

PURPOSE

To elucidate the pathophysiology of the diseases recently grouped under the name of acute zonal occult outer retinopathy (AZOOR).

METHODS

Twenty-four patients with the diagnosis of multiple evanescent white dot syndrome, acute idiopathic blind-spot enlargement syndrome, acute macular neuroretinopathy, multifocal choroiditis, or pseudo-presumed ocular histoplasmosis syndrome, or a combination of these diagnoses, were evaluated on one or more visits with full-field electroretinograms (ERGs) and kinetic and static perimetry. Sera and IgG fractions were tested using immunofluorescence on cryostat sections of fixed and unfixed human and rat retina.

RESULTS

Patients with AZOOR as a group showed abnormal results for all eight ERGs and two visual field parameters measured. Interocular asymmetry was a prominent feature of the patients' test results. Logistic regression indicated that interocular differences in ERG parameters significantly increased the efficacy of identifying patients with AZOOR beyond that of the parameter values alone. Visual field area correlated well with ERG a-wave amplitude. Serial visual function tests in a subset of patients showed that there could be short-term partial recovery or progressive loss of function. Autoantibodies to a specific retinal cell type were not detected.

CONCLUSIONS

All patients with AZOOR showed a pattern of visual dysfunction that was photoreceptor in origin, patchy in its distribution across the retina, and asymmetric in the two eyes. There was considerable variability in the severity and the natural history of retinal dysfunction in the patients studied. The full-field ERG was found to be a valuable adjunct in diagnosing AZOOR, especially when the expected interocular variation in measured parameters was known for control subjects. No evidence was obtained for autoantibodies to any retinal cell type in the patients with AZOOR who were tested.