Indocyanine green angiography in a case of punctate inner choroidopathy

Punctate inner choroidopathy: A review of the current diagnostic and therapeutic approaches

Punctate inner choroidopathy (PIC) is an uncommon idiopathic inflammatory condition characterized by multifocal chorioretinopathy that primarily affects young adults, with a predilection for myopic females. Clinically, it manifests as small, yellowish-white lesions in the inner choroid and outer retina, often associated with inflammatory changes. Accurate diagnosis remains a challenge due to its resemblance to other posterior uveitic entities, necessitating an astute clinical eye and advanced imaging techniques for differentiation. Multimodal imaging plays a crucial role by offering valuable insights, as it enables the visualization of various abnormalities related to uveitis. The pathogenesis of PIC is still a subject of debate, with a complex interplay of genetic, immunological, and environmental factors proposed. Managing PIC presents multiple challenges for clinicians. Firstly, variable disease severity within and among patients requires diverse treatments, from observation to aggressive immunosuppression and/or anti-VEGF therapy. Secondly, treatment must distinguish between primary causes of vision loss. New or worsening PIC lesions suggest active inflammation, while new neovascular membranes may indicate secondary neovascular processes. Thirdly, deciding on maintenance therapy is complex, balancing PIC prognosis variability against immunosuppression risks. Some patients have long periods of inactivity and remission, while others face sudden, vision-threatening episodes during quiescent phases. Through a systematic review of the literature, this paper sheds light on the current understanding of PIC, its challenges, and the prospects for future research. By synthesizing existing knowledge, it aims to aid clinicians in accurate diagnosis and guide treatment decisions for improved visual outcomes in individuals affected by PIC.

Classification Criteria for Punctate Inner Choroiditis

PURPOSE

The purpose of this study was to determine classification criteria for punctate inner choroiditis (PIC).

DESIGN

Machine learning of cases with PIC and 8 other posterior uveitides.

METHODS

Cases of posterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis by using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the posterior uveitides. The resulting criteria were evaluated in the validation set.

RESULTS

A total of 1,068 cases of posterior uveitides, including 144 cases of PIC, were evaluated by machine learning. Key criteria for PIC included: 1) "punctate"-appearing choroidal spots <250 µm in diameter; 2) absent to minimal anterior chamber and vitreous inflammation; and 3) involvement of the posterior pole with or without mid-periphery. Overall accuracy for posterior uveitides was 93.9% in the training set and 98.0% (95% confidence interval: 94.3-99.3) in the validation set. The misclassification rates for PIC were 15% in the training set and 9% in the validation set.

CONCLUSIONS

The criteria for PIC had a reasonably low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.

Choriocapillaris: Fundamentals and advancements

The choriocapillaris is the innermost structure of the choroid that directly nourishes the retinal pigment epithelium and photoreceptors. This article provides an overview of its hemovasculogenesis development to achieve its final architecture as a lobular vasculature, and also summarizes the current histological and molecular knowledge about choriocapillaris and its dysfunction. After describing the existing state-of-the-art tools to image the choriocapillaris, we report the findings in the choriocapillaris encountered in the most frequent retinochoroidal diseases including vascular diseases, inflammatory diseases, myopia, pachychoroid disease spectrum disorders, and glaucoma. The final section focuses on the development of imaging technology to optimize visualization of the choriocapillaris as well as current treatments of retinochoroidal disorders that specifically target the choriocapillaris. We conclude the article with pertinent unanswered questions and future directions in research for the choriocapillaris.

Characteristics of punctate inner choroidopathy complicated by choroidal neovascularisation on Multispectral Imaging in comparison with other imaging modalities

PURPOSE

To describe the characteristics seen on multispectral imaging (MSI) in patients with punctate inner choroidopathy (PIC) and choroidal neovascularisation (CNV) and compare the findings with current standard multimodal imaging techniques.

METHODS

This is a retrospective observational case series of 10 patients with PIC complicated by CNV that underwent multimodal retinal imaging examinations.

RESULTS

Twelve eyes of 10 patients were included. CNV was identified in 11 of the 12 eyes (91.7%) by MSI with nodular or trunk-like hyperreflectance on retinal oxy/deoxyhemoglobin map. MSI revealed choroidal vasculature around CNV in 91.7% eyes and pathological changes including retinal pigment epithelial atrophy and melanin disruption of punctate lesions in all eyes.

CONCLUSION

MSI helps in noninvasively detecting CNV in PIC patients and observing associated changes in choroidal vasculature. This imaging technique is also a promising tool for better tracking pathological changes of PIC lesions complementary to current standard multimodal imaging modalities.

Indocyanine Green Angiographic Findings in a Case of Punctate Inner Choroidopathy

Purpose

To report indocyanine green angiographic findings in a case of punctate inner choroidopathy.

Methods

Fundoscopy, fluorescein angiography and indocyanine green angiography were carried out on a 23-year-old woman who presented with features typical of punctate inner choroidopathy.

Results

Fundoscopy showed multiple small yellow lesions in the retinal pigment epithelium and inner choroid in both eyes and a subfoveal choroidal neovascular membrane in the left eye. The lesions showed early hyperfluorescence with mild leakage in the late phases of the fluorescein angiogram. On indocyanine green angiography, the lesions demonstrated obvious hypofluorescence in the early, mid and late phases.

Conclusions

The fluorescein and indocyanine green angiographic findings indicate that punctate inner choroidopathy affects the choriocapillaris as well as the retinal pigment epithelium and photoreceptors. However, it is still not known whether the primary pathology is in the retinal pigment epithelium, the photoreceptors or the choriocapillaris.

Optical Coherence Tomography Angiography for Detecting Choroidal Neovascularization Secondary to Punctate Inner Choroidopathy

Punctate inner choroidopathy (PIC) is a relatively uncommon inflammatory multifocal chorioretinopathy that predominantly affects young, myopic women. Subfoveal choroidal neovascularization (CNV) often leads to rapid loss of sight. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) remain the existing gold standards for CNV diagnosis. However, these methods are invasive and time-consuming. Recently, optical coherence tomography angiography (OCTA) has been used more frequently as an adjunct to FA/ICGA. In this report, a 38-year-old woman with PIC and idiopathic CNV presented with blurred vision despite 18/20 visual acuity. FA revealed positive staining and possible leakage, but did not provide clear evidence of CNV. OCTA detected abnormal flow in the outer retina, corresponding to type 2 CNV, that decreased following intravitreal anti-vascular endothelial growth factor (VEGF) therapy. Furthermore, OCTA could show remodeling of the choroidal capillaries after the treatment. OCTA may be helpful in the detection, follow-up, and evaluation of therapeutic strategies to treat CNV secondary to PIC. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1157-1161.].

Punctate inner choroidopathy: A review

Punctate inner choroidopathy (PIC), an idiopathic inflammatory multifocal chorioretinopathy that predominantly affects young myopic women, appears to be relatively rare, but there are limited data to support accurate estimates of prevalence, and it is likely that the condition is underdiagnosed. The etiological relationship between PIC and other conditions within the "white dot syndromes" group remains uncertain. We, like others, would suggest that PIC and multifocal choroiditis with panuveitis represent a single disease process that is modified by host factors (including host immunoregulation) to cause the range of clinical phenotypes seen. The impact of PIC on the patient is highly variable, with outcome ranging from complete spontaneous recovery to bilateral severe sight loss. Detection and monitoring have been greatly facilitated by modern scanning techniques, especially optical coherence tomography and autofluorescence imaging and may be enhanced by coregistration of sequential images to detect change over time. Depending on the course of disease and nature of complications, appropriate treatment may range from observation to systemic immunosuppression and antiangiogenic therapies. PIC is a challenging condition where treatment has to be tailored to the patient's individual circumstances, the extent of disease, and the risk of progression.

Increased macular choroidal blood flow velocity and decreased choroidal thickness with regression of punctate inner choroidopathy

Background

Changes in choroidal circulation hemodynamics during the course of punctate inner choroidopathy (PIC) remain unknown. The aim of this study was to quantitatively evaluate changes in choroidal blood flow velocity by using laser speckle flowgraphy (LSFG) in patients with PIC.

Case presentation

This PIC patient was initially treated with systemic corticosteroids for 4 months. LSFG measurements were taken 10 consecutive times before treatment and at 1, 3, 12, 20 and 23 months after the initiation of therapy. The mean blur rate (MBR), a quantitative index of relative blood flow velocity, was calculated using LSFG in three regions: Circles 1, 2 and 3 were set at the fovea, a lesion site, and an area of normal-appearing retina, respectively.

The PIC lesions scarred after treatment along with improvements in visual function and outer retinal morphology. When the changing rate of macular flow over the 12-month follow-up period was compared with the MBR before treatment (100%), an increase of 16–37%, 24–49% and 15–18% was detected in Circles 1, 2 and 3, respectively. At the time of PIC recurrence after 20 months, the MBR decreased temporarily but subsequently increased after retreatment with systemic corticosteroids. This trend was accompanied by a decrease in choroidal thickness at the lesion site after retreatment.

Conclusions

Macular choroidal blood flow velocity increased and choroidal thickness decreased concurrently with regression of PIC. The present findings suggest that inflammation-related impairments in choroidal circulation may relate to the pathogenesis of PIC, extending over a wider area in the posterior pole than the PIC lesions per se.

Redefining multifocal choroiditis and panuveitis and punctate inner choroidopathy through multimodal imaging

PURPOSE

To evaluate the characteristics of multifocal choroiditis and panuveitis (MCP) and punctate inner choroidopathy (PIC) using multimodal imaging.

METHODS

This is a retrospective, consecutive, observational case series of 38 eyes of 22 patients. Each eye of patients with multiple yellow-white idiopathic inflammatory lesions in the fundus was classified as having MCP or PIC using standard diagnostic criteria in a masked fashion. The features of these eyes as determined from color fundus photography, spectral-domain optical coherence tomography, fundus autofluorescence, and angiography were compared across diagnostic categories. The main outcome measures were the features of both MCP and PIC as evidenced by multimodal imaging.

RESULTS

Of the 38 eyes, 23 eyes had MCP, 15 had PIC; and 7 patients had a discordant pairing of one diagnosis in 1 eye with the other diagnosis in the fellow eye. Acute lesions appeared as nodular collections under the retinal pigment epithelium. These solid retinal pigment epithelium detachments appeared to rupture leading to inflammatory infiltration of the subretinal space and outer retina, often with a widespread loss of the outer retinal architecture beyond the confines of the inflammatory exudate. Treatment with corticosteroids caused a rapid regression of this material with a slower resolution of the abnormalities of the outer retinal architecture. The pattern of inflammatory involvement seen by multimodal imaging did not vary between PIC and MCP. No consistent abnormalities were seen in the choroid in either condition, although there was slight thickening of the choroid underlying some acute lesions.

CONCLUSION

Despite the names of these diseases, the principle sites involved appears to be the subretinal pigment epithelium and outer retinal spaces. Because both MCP and PIC target the same essential structures in the same phenotypic manner and, when active, are treated the same way, there seems to be limited clinical utility in trying to differentiate them. Based on multimodal imaging results, a reappraisal of pathogenic features and naming conventions of these diseases seems indicated.

Punctate inner choroidopathy: a systematic review

This article reviews clinically relevant data regarding punctate inner choroidopathy, mainly the various treatment options. Punctate inner choroidopathy is an uncommon, inflammatory, multifocal chorioretinopathy affecting mostly young myopic women. It is characterized by the presence of multiple, small, well-defined, yellow-white fundus lesions, in the absence of intraocular inflammation. We describe etiology, clinical findings and ancillary tests that help in the diagnosis and detection of complications. Treatment options that have been used to manage patients with PIC and CNV include immunosuppressants, corticoids, laser photocoagulation, photodynamic therapy, intravitreal anti-VEGF agents and submacular surgery.

Spectral-domain optical coherence tomographic findings at each stage of punctate inner choroidopathy

PURPOSE

To describe the natural course of punctate inner choroidopathy (PIC) using spectral-domain optical coherence tomography (SD-OCT).

DESIGN

Prospective observational case series.

PARTICIPANTS

Forty-two consecutive patients (60 eyes) with PIC with at least 3 months of follow-up.

METHODS

Serial SD-OCT images were obtained from both eyes of each participant at each visit.

MAIN OUTCOME MEASURES

The morphologic characteristics of each stage of PIC lesions observed by SD-OCT.

RESULTS

Continued stage progression of PIC lesions was observed in 27 eyes (45%), among which choroidal thickness changes were observed in 8 eyes (30%). Stage I lesion showed a normal appearance or slight irregularities in the outer nuclear layer. Stage II lesion appeared as a focal elevation of the retinal pigment epithelium (RPE) with corresponding disruption of the inner and outer segments of the photoreceptor interface. Stage III lesion broke through the RPE, forming a hump-shaped chorioretinal nodule with moderate reflectivity beneath the outer plexiform layer (OPL), generally with subsequent disruption of Bruch's membrane. Nodules occasionally invaded the inner retina, causing segmental retinal phlebitis in 2 eyes. Stage IV lesion regressed in a retrograde manner with tissue loss from the photoreceptor layer and inner choroid, finally leaving a V-shaped hernia of the OPL and inner retina into the choroid. Stage V lesion gradually eliminated the photoreceptors around the lesion; this process was accompanied by RPE proliferation at multiple levels, which reduced retinal herniation. Parafoveal stage V lesions caused late occult macular atrophy in 4 eyes. Choroidal thickness increased throughout the active phase and reached a peak at stage III; this parameter then significantly decreased at stage IV and gradually reached a minimum that was lower than the initial value at stage I.

CONCLUSIONS

Punctate inner choroidopathy is a chorioretinitis rather than an inner choroidopathy. Spectral-domain OCT characterized a 5-stage evolution of PIC lesions: choroidal infiltration, formation of sub-RPE nodules, and then chorioretinal nodules, regression, and retinal herniation.

Characterization of macular lesions in punctate inner choroidopathy with spectral domain optical coherence tomography

PURPOSE

Punctate inner choroidopathy (PIC) is an ocular inflammatory disease. Spectral domain optical coherence tomography (SD-OCT) allows detailed visualization of retinal and choroidal structures. We aimed to describe the retinal changes on SD-OCT associated with PIC lesions localized in the macula.

METHODS

Retrospective case series: PIC lesions not associated with choroidal neovascularization (CNV) and captured by macular SD-OCT scans were identified and characterized.

RESULTS

Twenty-seven PIC lesions from seven patients (eight eyes) were identified and classified into four categories according to disease activity and temporal changes. Among clinically inactive patients, two main patterns were noted on OCT: (1) retinal pigment epithelium (RPE) elevation with sub-RPE hyper-reflective signals and (2) localized disruption of outer retinal layers with choroid and Bruch's membrane (BM) generally spared. Clinically active patients demonstrated lesions with intact BM with RPE elevation that fluctuated with disease activity and sub-RPE hyper-reflective signals. Photoreceptor-associated bands on SD-OCT (PRs) were not visible during active disease, but returned to normal visibility when lesions were clinically stable. Seven lesions in patients without clinically detected activity demonstrated alteration of RPE elevation.

CONCLUSION

SD-OCT can provide detailed structural characteristics of PIC lesions. RPE elevation is noted in many lesions while BM and choroid are spared. Photoreceptor-associated bands on SD-OCT appear compressed during clinically active stages and are visible during stabilization. OCT may provide information on activity not detected clinically.

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.

Punctate inner choroidopathy: resolution after oral steroid treatment and review of the literature

CASE REPORT

A case of punctate inner choroidopathy (PIC) that resolved after oral steroid treatment is described. The 25-year-old female patient presented with reduced visual acuity of several days duration. Results of fundus examination, fluorescein angiography, and indocyanine green angiography were consistent with PIC with a small choroidal neovascularization lesion nasal to the fovea. Visual acuity improved significantly after several days on oral steroid treatment.

COMMENTS

Although spontaneous resolution of the lesions can occur without any treatment, oral steroids in PIC may help achieve improved vision more rapidly. The clinical manifestations, differential diagnosis, and therapeutic modalities of this rare entity are discussed.

Indocyanine green angiographic findings in idiopathic choroidal neovascularisation

PURPOSE

The authors report the cases of two patients affected with idiopathic choroidal neovascularisation studied with combined fluorescein angiography and indocyanine green (ICG) angiography. In particular the presence of choroidal abnormalities at ICG angiography which could not be detected by fluorescein angiography was studied.

METHODS

Both patients underwent a complete systemic and ocular assessment. Fluorescein angiography and ICG angiography were performed in a routine fashion at the time of presentation in both cases and after 14 months in the second patient.

RESULTS

Results of the systemic investigations were unremarkable. A distinct dark rim surrounding the choroidal neovascular net was evident until the late phases of ICG angiography despite the presence of subretinal blood. Dilated choroidal vessels were observed beneath the neovascular membrane in both cases. In the first patient a hyperfluorescent area beyond the primary lesion was detected in the affected eye and a distinct leaking subfoveal choroidal venous vessel was found in the fellow eye. The second patient never showed other angiographic alterations either in the affected or in the fellow eye.

CONCLUSIONS

ICG angiography has proved to be useful, both to better define and follow up the true extent of the pigment halo (healing response) around the neovascular membrane when subretinal blood and dye leakage at fluorescein angiography prevent its full appreciation, and to rule out other causes of choroidal neovascularisation in young healthy adults associated with either choroidal inflammatory focal lesions or choroidal vascular dynamic or inflammatory alterations.

Choroidal abnormalities in birdshot chorioretinopathy: an indocyanine green angiography study

Birdshot chorioretinopathy is a rare inflammatory disorder with an insidious onset that can slowly progress to severe visual loss. The pathogenesis is unknown. This study used indocyanine green (ICG) angiography to investigate the degree of choroidal vascular involvement with progression of disease and to determine the nature of the birdshot lesions. Seven patients with birdshot chorioretinopathy had ICG angiography performed with a scanning laser ophthalmoscope at various stages of clinical disease. Results were compared with fluorescein fundal angiography (FFA). All large choroidal vessels appeared normal. The birdshot lesions were demonstrated with ICG but not with FFA and were represented by dark areas on ICG angiography. Typically these areas were bordered by large or medium-sized choroidal vessels and their appearance suggested small choroidal vessel hypoperfusion. In disease of recent onset, some lesions masked fluorescence from large underlying choroidal vessels possibly due to inflammatory choroidal infiltrates. In long-standing disease, the choroidal angioarchitecture was relatively normal within the birdshot lesions. This study of birdshot chorioretinopathy demonstrates abnormalities in the small choroidal vessels within the birdshot lesions. ICG angiography detects the birdshot lesions more readily than FFA and may be of benefit in assessing disease activity.