Cutaneous vitiligo associated with choroidal hypopigmentation

Progressive choroidal thinning (leptochoroid) and fundus depigmentation associated with checkpoint inhibitors

Purpose

To report asymptomatic progressive fundus depigmentation and choroidal thinning in the absence of intraocular inflammation in a patient treated with checkpoint inhibitors.

Observations

A 69-year-old woman with metastatic cutaneous melanoma, treated with checkpoint inhibition (nivolumab, ipilimumab and pembrolizumab), developed asymptomatic progressive fundus depigmentation associated with choroidal thinning in both eyes over 26 months. Serial multimodal imaging was obtained over the study period including fundus photography, fundus autofluorescence and optical coherence tomography (OCT). Over 26 months, the central choroidal thickness decreased by 34% (from 270μm to 92μm, mean between both eyes). Concurrently, central retinal thickness remained stable (206μm to 214μm, mean between both eyes). There were no findings of intraocular inflammation, subretinal fluid or retinal pigment epithelium disturbance. The patient reported no visual symptoms and maintained a visual acuity of 20/25+ in the right eye and 20/30 in the left eye throughout the observation period. Concurrently, cutaneous vitiligo and poliosis, inclusive of her periorbital dermis and eyelashes also developed.

Conclusions and importance

Progressive fundus depigmentation and choroidal thinning can be observed with checkpoint inhibition in the absence of intraocular inflammation.

Pigmentary disorders of the eyes and skin

Oculocutaneous albinism, Menkes syndrome, tuberous sclerosis, neurofibromatosis type 1, dyskeratosis congenita, lentiginosis profusa syndrome, incontinentia pigmenti, and Waardenburg syndrome all are genodermatoses that have well established gene mutations affecting multiple biological pathways, including melanin synthesis, copper transport, cellular proliferation, telomerase function, apoptosis, and melanocyte biology. Onchocerciasis results from a systemic inflammatory response to a nematode infection. Hypomelanosis of Ito is caused by chromosomal mosaicism, which underlies its phenotypic heterogeneity. Incomplete migration of melanocytes to the epidermis and other organs is the underlying feature of nevus of Ota. Vogt-Koyangi-Harada and vitiligo have an autoimmune etiology; the former is associated with considerable multiorgan involvement, while the latter is predominantly skin-limited.

Choroidal vitiligo masquerading as large choroidal nevus: a report of four cases

PURPOSE

To describe 4 patients with choroidal vitiligo masquerading as large choroidal nevus.

DESIGN

Retrospective chart review.

PARTICIPANTS

Observational case series of 4 patients.

METHODS

Retrospective chart review.

MAIN OUTCOME MEASURES

Clinical features.

RESULTS

Four patients referred with the diagnosis of large choroidal nevus were found to have unilateral (n = 1) or bilateral (n = 3) extensive patchy choroidal depigmentation classified as choroidal vitiligo. There was no evidence of choroidal nevus, and the pigmented "lesion" proved to be normal choroidal pigment surrounded by a region of pigment absence (vitiligo). There was no evidence of ocular inflammation or related retinal or retinal pigment epithelial changes. The choroidal vitiligo was clinically flat and measured 12 to 24 mm diameter, involving the post-equatorial fundus in all cases. There were no related anterior segment abnormalities. Cutaneous vitiligo was present in all cases. There was no documented progression of the choroidal or cutaneous vitiligo over a maximum 2-year follow-up.

CONCLUSIONS

Choroidal vitiligo is an idiopathic benign process that can involve large segments of the posterior choroid, leaving only patches of residual choroidal pigment, simulating, in reverse, a large choroidal nevus.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.