Serpiginous choroidopathy presenting as choroidal neovascularisation

Vascular abnormalities in uveitis

Inflammation can involve several ocular structures, including the sclera, retina, and uvea, and cause vascular changes in these tissues. Although retinal vasculitis is the most common finding associated with uveitis involving the posterior segment, other vascular abnormalities may be seen in the retina. These include capillary nonperfusion and ischemia, vascular occlusions, preretinal neovascularization, microaneurysms and macroaneurysms, and telangiectasia. Moreover, vasoproliferative tumors and subsequent coat-like response can develop secondary to uveitis. Fluorescein angiography is ideal for the investigation of retinal vascular leakage and neovascularization, while optical coherence tomography angiography can provide depth resolved images from the superficial and deep capillary plexus and can demonstrate vascular remodeling. Choroidal vascular abnormalities primarily develop in the choriocapillaris or in the choroidal stroma and can appear as flow void in optical coherence tomography angiography and filling defect and vascular leakage in indocyanine green angiography. Extensive choriocapillaris nonperfusion in the presence of choroidal inflammation can increase the risk of choroidal neovascular membrane development. Iris vascular changes may manifest as dilation of vessels in stroma due to inflammation or rubeosis that is usually from ischemia in retinal periphery secondary to chronic inflammation. More severe forms of scleral inflammation, such as necrotizing scleritis, are associated with vascular occlusion in the deep episcleral plexus, which can lead to necrosis of sclera layer and uveal exposure.

Enigma of serpiginous choroiditis

Serpiginous choroiditis (SC) is an asymmetrically bilateral inflammation of the choroid that leads to loss of choriocapillaris atrophy or loss of overlying retinal pigment epithelium. Over the last few decades, SC has passed through a long evolution of nomenclature, etiologies and morphological variations. Initially diagnosed in patients with tuberculosis and syphilis, SC was predominantly considered as autoimmune process. With the advancement of molecular diagnosis, a new aspect of infectious subtypes of SC has emerged out. The terminologies such as serpiginous-like choroiditis (SLC) and multifocal serpiginoid choroiditis are now used to denote the subtypes of SC which are associated with infectious etiologies especially tuberculosis. In a country endemic for tuberculosis such as India, it is very important to differentiate between classic SC and SLC before initiating aggressive immunomodulatory therapy. Also, management of paradoxical worsening of the clinical condition with antitubercular treatment is another challenge in SLC and ophthalmologists should be aware of such situations. With advent of newer imaging modalities, monitoring the patient with choroiditis and identification of complications such as choroidal neovascular membrane have become much easier. This article aims to review the existing literature on SC with a special emphasis on management of SC and SLC.

Simultaneous Single Dexamethasone Implant and Ranibizumab Injection in a Case with Active Serpiginous Choroiditis and Choroidal Neovascular Membrane

Intravitreal anti-vascular endothelial growth factor (VEGF) agents seem to be effective in choroidal neovascular membranes (CNV) in association with various entities of posterior uveitis. We herein report a 46-year-old woman who was treated with a simultaneous single intravitreal dexamethasone implant and ranibizumab administration for the treatment of unilateral extrafoveal CNV associated with an active serpiginous choroiditis. Simultaneously with the intravitreal therapy, oral mycophenolic acid (2 × 720 mg) was started, and oral cyclosporine (3 × 100 mg) was then added 2 months later. On the other hand, the fellow eye had been treated for subfoveal CNV but with an inactive disease 4 years previously and ended up with a final visual acuity of counting fingers despite treatment with a single session of photodynamic therapy and 3 subsequent intravitreal ranibizumab injections. Simultaneous administration of anti-VEGF agents and a dexamethasone implant can be a viable approach in eyes with CNV and active serpiginous choroiditis.

Pigmented paravenous retinochoroidal atrophy (Review)

Pigmented paravenous retinochoroidal atrophy (PPRCA) is an uncommon disease characterized by perivenous aggregations of pigment clumps associated with peripapillary and radial zones of retinochoroidal atrophy that are distributed along the retinal veins. Patients are usually asymptomatic and the disease process is non-progressive or slow and subtly progressive. It is commonly bilateral and symmetric. The cause of the condition may be unknown or idiopathic, although a dysgenetic, degenerative, hereditary etiology or even an inflammatory cause has been hypothesized. A non-inflammatory cause is referred to as primary, while inflammation-associated PPRCA is referred to as secondary or pseudo PPRCA. The present study reviewed and summarized the features of PPRCA.

Serpiginous choroiditis in a referral clinic in India: visual field changes and clinical correlates

PURPOSE

To report the visual field changes in patients with serpiginous choroiditis as seen in a referral clinic in India.

METHODS

A retrospective noncomparative case series was conducted. Twenty-nine eyes of 17 patients who were diagnosed with serpiginous choroiditis were included in the study. Clinical findings were recorded. Visual field was measured with a Humphrey visual field analyzer. Information obtained was entered into SPSS 17.0 and analyzed.

RESULTS

There was a male preponderance (8:2). Age at presentation ranged from 14 to 53 years. Eleven subjects (64.7%) had bilateral involvement at presentation. Mean visual acuity improved to 0.35 after treatment. Visual field changes were seen in 28 eyes and the mean deviation value was maintained after treatment (-8.5, 7.19 SD). Multiple foci of defects (usually central or paracentral scotoma co-existing with isolated field defects in the nasal or temporal field) were the commonest form of visual field defect detected.

CONCLUSION

Patients with serpiginous choroiditis had a stable visual field defects after 6 months of treatment. The need for visual field monitoring in these patients is underscored.

Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis

Serpiginous choroiditis (SC) is a posterior uveitis displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. The choroiditis involves the overlying retinal pigment epithelium, and the outer retina. This intraocular inflammation typically involves both eyes in otherwise healthy, middle-aged individuals with no familial or ethnic predilection. Pathogenesis is unclear; based on limited histopathologic studies, however, favorable response to immunosuppressive agents, and the absence of association with systemic or local infectious or noninfectious diseases, an organ-specific autoimmune inflammation seems likely to be the underlying process. Patients, particularly from tuberculosis-endemic regions, may present with fundus changes simulating SC, but show evidence of active tuberculosis and/or the presence of mycobacterial DNA in the aqueous humor. This has been referred to as serpiginous-like choroiditis, but we prefer the description multifocal serpiginoid choroiditis (MSC). We present the distinguishing features of SC and infectious multifocal serpiginoid choroiditis simulating SC. The distinction is crucial to avoid unnecessarily treating SC with antimicrobial agents. Advances in diagnostic and imaging modalities can help differentiate SC from MSC. Novel local and systemic treatment approaches improve the outcome and preserve vision in SC.

Clinical Features, Investigations, Management, and Prognosis of Serpiginous Choroiditis

Serpiginous choroiditis is an inflammatory form of posterior uveitis that affects the choroid, retinal pigment epithelium, and choriocapillaries. Known to be recurrent and progressive in nature, this bilateral disease can result in severe visual loss both during the active and healed stages. The age at onset is 40 to 50 years, but it can affect younger Indian population. It can be further classified into 3 types based on its clinical presentation, and they are, namely, peripapillary, macular, and ampiginous. Histological features further qualify the site of inflammation as evidenced by lymphocytic infiltration within the choroid and atrophy of choriocapillaries and retinal pigment epithelium. Despite a multitude of etiologies such as autoimmunity, infection, and degeneration, autoimmune causes remain the mainstay. Laboratory investigations can help rule out infections, whereas angiography can provide further insights into the progression of the disease. Newer investigations such as optical coherence tomography and fundus autofluorescence can help locate the lesion and identify the phase of the disease. Corticosteroids with immunosuppressives are the major management modality. Treatment of complications may require intravitreal injections, laser photocoagulation, or even vitreoretinal surgery.

Current approach in the diagnosis and management of posterior uveitis

Posterior uveitic entities are varied entities that are infective or non-infective in etiology. They can affect the adjacent structures such as the retina, vitreous, optic nerve head and retinal blood vessels. Thorough clinical evaluation gives a clue to the diagnosis while ancillary investigations and laboratory tests assist in confirming the diagnosis. Newer evolving techniques in the investigations and management have increased the diagnostic yield. In case of diagnostic dilemma, intraocular fluid evaluation for polymerase chain testing for the genome and antibody testing against the causative agent provide greater diagnostic ability.

Persistent Placoid Maculopathy

PURPOSE

To describe a previously unreported clinical entity superficially resembling macular serpiginous choroiditis but with a distinct presentation and clinical course.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Six patients, 50 to 68 years old, exhibiting this entity who were seen at 5 different centers from 1984 to 2006.

METHODS

Review of medical records.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (VA) and clinical and angiographic findings.

RESULTS

The lesions in our patients are similar to those of acute macular serpiginous choroiditis. Our patients had well-delineated whitish plaquelike lesions involving the macula and sparing the peripapillary areas of both eyes. In contrast to serpiginous choroiditis, VA remained good despite early involvement of the fovea until complications related to choroidal neovascularization or pigmentary mottling developed. Angiographic characteristics and the clinical course were also atypical. Fluorescein angiography revealed well-defined early hypofluorescent areas that partially filled in in the late phase. Indocyanine green angiography showed the hypofluorescence to be persistent. Unlike serpiginous choroiditis, the white macular lesions faded over a period of months to years, whereas the characteristic angiographic findings often persisted longer. Choroidal neovascularization developed in 11 of 12 eyes, with subsequent conversion to disciform macular scars in 9 of 12 eyes. Unlike serpiginous choroiditis, none of the eyes showed chorioretinal scar formation unless related to choroidal neovascularization.

CONCLUSION

Persistent placoid maculopathy has features resembling macular serpiginous choroiditis but differs in its clinical course and effect on VA. It appears to be a new entity. The majority of eyes develop choroidal neovascularization that results in loss of central vision.

Persistent placoid maculopathy: a new clinical entity

PURPOSE

To describe a previously unreported clinical entity superficially resembling macular serpiginous choroiditis but with a distinct presentation and clinical course.

METHODS

A retrospective review of the medical records of five patients, aged 50 to 68 years, exhibiting this entity seen at five different centers from 1999 to 2006.

RESULTS

The lesions in the patients in this study are in some respects similar to those of acute macular serpiginous choroiditis. The patients had well-delineated whitish plaque-like lesions involving the macula and sparing the peripapillary areas of both eyes. In contrast to serpiginous choroiditis, visual acuity remained good despite early involvement of the fovea until complications related to choroidal neovascularization (CNV) or pigmentary mottling developed. The angiographic characteristics and the clinical course were also atypical. Fluorescein angiography revealed well-defined early hypofluorescent areas, which partially filled-in in the late phase. Indocyanine green angiography showed the hypofluorescence to be persistent. Unlike serpiginous choroiditis, the white macular lesions faded over a period of months to years, but the characteristic angiographic findings often persisted longer. CNV developed in nine of 10 eyes with subsequent conversion to disciform macular scars in seven of 10 eyes. Unlike serpiginous choroiditis, none of the eyes showed chorioretinal scar formation unless related to CNV.

CONCLUSION

Persistent placoid maculopathy has features resembling macular serpiginous choroiditis but differs in its clinical course and effect on visual acuity. It appears to be a new entity. The majority of eyes develop CNV, which results in loss of central vision.

Photodynamic Therapy With Verteporfin for Juxtafoveal Choroidal Neovascularization in Serpiginous Choroiditis

The authors describe a patient who underwent successful photodynamic therapy with verteporfin for juxtafoveal choroidal neovascularization complicated by serpiginous choroiditis. A 41-year-old woman presented with decreased vision and metamorphopsia in her right eye, which was diagnosed as a recurrence of serpiginous choroiditis at the first visit. Within a month, visual acuity had diminished to 20/1000 despite immunosuppressive treatment. At that time, indocyanine green angiography and optical coherence tomography revealed choroidal neovascularization in the juxtafoveal area. Photodynamic therapy with verteporfin was administered twice, after which juxtafoveal choroidal neovascularization regressed and her visual acuity improved to 20/20.

Serpiginous Choroiditis

Serpiginous choroiditis is a rare, usually bilateral, chronic, progressive, recurrent inflammation of the choroid, retinal pigment epithelium, and choriocapillaris of unknown etiology. Based on clinical presentation, it can be classified into 1) peripapillary, 2) macular, and 3) ampiginous types. The clinical course, regardless of the presentation, is progressive with multiple recurrences leading to potentially significant visual loss. Visual outcome is directly related to the involvement of the para-fovea and fovea by the lesions or secondary choroidal neovascularization. The histological findings of the lesions are atrophy of the choriocapillaris, retinal pigment epithelium and photoreceptor cells, and moderate diffuse lymphocytic infiltrates throughout the choroid. Multiple etiologies including autoimmunity, infection, vasculopathy, and degeneration were proposed but none is well supported by clinical and laboratory evidence. Fluorescein and indocyanine green angiography have been useful in the assessment of the extent and the activity of lesions. Due to the insidious and progressive clinical course, an assessment of treatment outcomes needs long term follow-up. Currently, treatment with immunosuppressive and alkylating agents have shown possible efficacy in small case series. Larger clinical studies and interventional trials are required to further our understanding of the pathogenesis, etiology, and for the evaluation of treatment strategies.