Enigma of serpiginous choroiditis

Choroidal hypopigmented lesions: A review

Choroidal hypopigmented lesions (CHLs) represent significant diagnostic and therapeutic challenges due to their diverse and complex etiologies, including neoplastic, infectious, and inflammatory origins. Accurately differentiating between benign lesions with good prognoses and malignant or life-threatening conditions is crucial in directing the appropriate management and avoiding unnecessary invasive interventions. We integrate the latest research and clinical guidelines on advanced multimodal imaging modalities, emphasizing their comparative diagnostic value across varied etiologies of CHLs. In contrast to prior studies, this review comprehensively evaluates the clinical implications of these techniques in accurately differentiating between benign from malignant choroidal lesions. Emphasis is placed on the role of advanced imaging modalities, including swept-source optical coherence tomography, B-scan ultrasound, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography, in enhancing diagnostic precision. These technologies have substantially increased the capability to distinguish between lesion types, improving diagnostic accuracy and giving more targeted therapeutic strategies.

Long-Term Outcomes of Adalimumab Treatment in Conventional Treatment-Resistant Serpiginous Choroiditis

BACKGROUND/OBJECTIVES

To investigate the long-term efficacy and safety of adalimumab(ADA) in the treatment of patients with serpiginous choroiditis (SC) refractory to conventional therapy through quantitative parameters.

SUBJECTS/METHODS

A retrospective analysis was conducted on patients diagnosed with SC clinically and through fundus autofluorescence(FAF). Patients receiving ADA treatment were included. Demographic and clinical characteristics of the patients, association with tuberculosis (TB) infection, number of immunosuppressive therapies, recurrences, best corrected visual acuity (BCVA) change, and ADA-related side effects were recorded. The progression rate before and after ADA was calculated based on the area involved by FAF.

RESULTS

Sixteen eyes of 8 patients (3 female/5 male) were enrolled to the study. The median (IQR) age was 53.5 (16.5) years. Diagnosis was SC in 4, ampiginous choroiditis in 3, and TB-related serpiginous-like choroiditis in 1 patient. Peripapillary involvement was present in 10 of 16 eyes. The area involved by FAF continued to progress under ADA treatment, however the progression rate was decreased (p = 0.143).The BCVA was preserved (p = 0.772). The number of systemic and local treatments decreased with ADA (p = 0.025 and 0.019, respectively). Additionally, the number of recurrences was reduced with ADA (p = 0.002). Median (IQR) follow-up was 45(28.75) months. Two patients experienced ADA-related side effects (pulmonary TBand rash).

CONCLUSIONS

Our findings suggest a promising role for ADA in halting the progression of SC and have implications for improving outcomes. Despite the evidence in the literature at the level of case reports, ADA can be used effectively with close monitoring for potential risks.

TREATMENT OF SERPIGINOUS CHOROIDITIS WITH SUBTENON TRIAMCINOLONE IN CONJUNCTION WITH SYSTEMIC STEROIDS: A CASE REPORT

PURPOSE

To report two cases of serpiginous choroiditis which were treated with subtenon triamcinolone in conjunction with systemic steroids to control acute and chronic disease progression. Increased success of disease remission has been postulated for subtenon triamcinolone therapy in conjunction with systemic steroids.

METHODS

Retrospective chart review of two serpiginous choroiditis patients who presented at an eye center. Both patients received subtenon triamcinolone and systemic steroids. Visual acuity and disease course are reported.

RESULTS

Both cases of serpiginous choroiditis received subtenon triamcinolone on presentation and were hospitalized for IV corticosteroids and systemic workup. The first patient had been on oral corticosteroids before presentation. Both patients reported same-day visual improvement after subtenon triamcinolone was administered.

CONCLUSION

These two case reports describe unique clinical scenarios in which subtenon triamcinolone was used in both the acute and chronic phases of serpiginous choroiditis. Local steroid therapy can be a useful adjunctive therapy when systemic steroids are delayed, contraindicated, or intolerable.

Monocular Tuberculosis-Related Serpiginous-Like Choroiditis with Acute Posterior Multifocal Placoid Pigment Epitheliopathy-Like Presentation in a Danish Patient

PURPOSE

To report a case of tuberculosis-related serpiginous-like choroiditis (TB-SLC) in Denmark in a patient with few risk factors.

METHODS

Single case report.

RESULTS

A 54-year-old Caucasian male with no relevant travel history presented with unilateral light placoid confluent elements in the macula of the right eye with a best-corrected visual acuity of 0.2 Snellen. The left eye was normal. Wide-field Fluorescein and Indocyanine green-angiography were performed, and findings were consistent with acute posterior multifocal placoid pigment epitheliopathy. Since the condition was considered sight-threatening, and the patient had no recognizable risk factors for tuberculosis (TB), he was prescribed 50 mg of oral prednisolone. Blood tests and an X-ray were ordered to exclude infectious causes. The first interferon-ỿ release assay (IGRA) test was inconclusive and a new test was ordered. Over the following weeks new white dots appeared in the retina. After the patient had been treated for seven weeks with prednisolone, the second IGRA came back positive, and he was diagnosed with TB-SLC. Upon repeated questioning two months after baseline, the patient remembered that ten years ago he had been in a workplace with 50 different nationalities, and seven years ago he had been in contact with a friend who was treated for latent TB, thus supporting relevant exposure.

CONCLUSION

TB-SLC may occur even in a patient with few recognizable risk factors and in a setting that is not TB endemic. It is imperative to continuously reassess differential diagnoses and initiate or repeat paraclinical testing in cases with atypical features.

Choroidal vasculitis as a biomarker of inflammation of the choroid. Indocyanine Green Angiography (ICGA) spearheading for diagnosis and follow-up, an imaging tutorial

BACKGROUND

Indocyanine green angiography (ICGA) is the gold standard to diagnose, evaluate and follow up choroidal inflammation. It allows clinicians to precisely determine the type and extension of choroidal vasculitis in the two main choroidal structures, the choriocapillaris and the choroidal stroma. The presence of choroidal vasculitis is often overlooked by the physician who often does not include ICGA in the investigation of posterior uveitis.

PURPOSE

To describe choroidal vasculitis by analysing its ICGA signs in order to investigate and follow choroiditis and determine the pathophysiological mechanisms of inflammation of choroidal vessels.

METHODS

The tutorial is presenting the normal findings in a non-inflamed choroid and the semiology of diverse choroidal vasculitis conditions, followed by practical illustrations using typical cases.

RESULTS

The two identified patterns of choroidal vasculitis corresponded on one side to choriocapillaritis appearing as areas of hypofluorescence depicting the involvement and extension of choriocapillaris inflammatory non-perfusion. The vasculitis of the choriocapillaris goes from limited and reversible when distal endcapillary vessels are involved such as in Multiple Evanescent White Dot Syndrome (MEWDS) to more severe involvement in Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE), Multifocal Choroiditis (MFC) or Serpiginous Choroiditis (SC) with more pronounced non-perfusion causing scars if not treated diligently. On the other side, stromal choroidal vasculitis is characterised by leaking hyperfluorescent vessels that appear fuzzy and at the origin of late diffuse choroidal hyperfluorescence.

CONCLUSION

Choroidal vasculitis is present in almost all patients with inflammatory choroidal involvement, occlusive in case of choriocapillaritis and leaky in stromal choroiditis causing vessel hyperfluorescence, fuzziness of the choroidal vessels and late diffuse stromal hyperfluorescence on ICGA. Systemic vasculitis entities produce occlusive vasculitis of large choroidal vessels.

Serpiginous Choroiditis After COVID-19 Infection

Purpose: To present the first case of macular serpiginous choroiditis after COVID-19 infection. Methods: A single case was analyzed. Results: A 28-year-old previously healthy man presented with severe unilateral vision loss in the left eye. A fundus examination showed severe atrophic pigmentary changes that corresponded with optical coherence tomography (OCT) findings of a rapidly progressing amoeboid-like lesion disrupting the ellipsoid zone and retinal pigment epithelium. Multimodal imaging, including fundus autofluorescence, OCT angiography, and indocyanine green angiography, was supportive of serpiginous choroiditis. After a comprehensive systemic workup, the diagnosis of macular serpiginous choroiditis was confirmed. No improvement was seen with high-dose steroids; therefore, an immunosuppressive regimen was initiated. Conclusions: An exaggerated choroidal inflammatory response may be triggered by a COVID-19 infection, although causation cannot be inferred. Retinal manifestations should be considered when assessing patients presenting with visual symptoms after COVID-19 infection.

Bilateral Relentless Placoid Chorioretinitis Following Pfizer-BioNTech COVID-19 Vaccination: Specific Antigenic Trigger or Nonspecific Immune Activation?

PURPOSE

To report bilateral relentless placoid chorioretinitis following Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine administration.

CASE REPORT

A 55-year-old Caucasian New Zealand-born woman presented with progressive left eye vision loss and bilateral photopsias and floaters occurring 10 days after receiving the Pfizer-BioNTech COVID-19 vaccination. She had a similar self-limiting episode of photopsias and floaters without vision loss 1 year prior after receiving the influenza vaccine. Snellen visual acuity (VA) was 20/25 in the right eye, and count fingers at 2 m in the left eye. Bilateral, active, creamy, plaque-like lesions were present at the level of the retinal pigment epithelium and choroid, suggestive of relentless placoid chorioretinitis. Commencement of 100 mg oral prednisolone and 3 g mycophenolate daily resulted in recovery of the foveal ellipsoid layer with VA of 20/25 in each eye after 8 weeks. Subsequent activations occurred following COVID-19 infection and respiratory infection.

CONCLUSION

This is the first reported case of relentless placoid chorioretinitis occurring as a potential side-effect of the Pfizer-BioNTech COVID-19 vaccine. Vaccination, and not infection, could be assumed to be the likely trigger. Subsequent flares following COVID-19 and a nonspecific respiratory infection during periods of inadequate immunosuppression suggest that a COVID-19 antigen or general immune activation could also be the trigger.

Rare Case of Tubercular Serpiginous-Like Choroiditis

Serpiginous choroiditis is a rare cause of posterior uveitis, included in the spectrum of white dot syndromes. It occurs as a result of an autoimmune process but could be associated with infections such as tuberculosis (TB) (serpiginous-like choroiditis). Tubercular serpiginous-like choroiditis is more commonly reported in Southeast Asian countries than in Western countries. We report a case of an Indian male in his late 30s with bilateral grey-yellowish subretinal infiltrates at the level of choroid with active scalloped edges having a positive TB-QuantiFERON Gold test (Cellestis Limited, Carnegie, Australia), who responded well to the treatment of intravenous methylprednisolone and systemic steroids (given initially to control the acute inflammation) while on anti-tubercular (anti-TB) therapy. The lesions finally completely healed on the anti-TB therapy.

Long-term follow-up of a bilateral acute posterior multifocal placoid pigment epitheliopathy following COVID-19 infection: a case report

BACKGROUND

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare inflammatory eye disorder that is characterized by the presence of multiple placoid lesions in the posterior pole of the eye. Relentless placoid chorioretinitis (RPC) is an inflammatory chorioretinopathy that combines clinical features of APMPPE and serpiginous chorioretinitis, which is a progressive condition with a high risk of visual disability. Patients with COVID-19 can develop various ocular manifestations, however, there have been limited reports of APMPPE and RPC associated with the infection. We report a case of a patient who developed APMPPE after a COVID-19 infection and subsequently progressed into RPC.

CASE PRESENTATION

A 17-year-old male presented with a one-week history of painless gradual visual loss in both eyes. Two months prior to the visual symptoms, the patient had a SARS CoV-2 infection, confirmed by polymerase chain reaction test. Clinical findings with fundoscopy, optical coherence tomography and fluorescein angiography were consistent with APMPPE. Due to the severely affected vision in both eyes, the patient was started on 50 mg oral prednisolone daily, after which vision began to improve rapidly. Two months after symptom onset during steroid taper, the impression of continued inflammatory activity and new lesions in the retinal periphery of both eyes suggested RPC. Adalimumab 40 mg every other week was initiated with 12.5 mg prednisolone daily followed by slow tapering. Vision improved and five months after the start of the adalimumab treatment, the steroid was discontinued and there were no signs of active inflammation. The patient has been followed for a total of 21 months since presentation, had full visual recovery and good tolerance of the immunosuppressive treatment.

CONCLUSION

COVID-19 might cause long-lasting activity of APMPPE. The scarcity of reports compared with the number of confirmed COVID-19 infections worldwide suggests a rare entity. The association of APMPPE with a variety of infections may suggest a common immunological aberrant response that might be triggered by various factors. Further examinations and case reports are needed to understand the role of biological therapy in the treatment of such cases.

Blue-Light Fundus Autofluorescence (BAF), an Essential Modality for the Evaluation of Inflammatory Diseases of the Photoreceptors: An Imaging Narrative

Our purpose is to describe blue-light fundus autofluorescence (BAF) features of inflammatory diseases of the outer retina characterised by photoreceptor damage. BAF from patients diagnosed with secondary and primary inflammatory photoreceptor damage were retrospectively analyzed and compared to other imaging modalities including fluorescein angiography (FA), indocyanine green angiography (ICGA), and spectral domain optical coherence tomography (SD-OCT). Multiple evanescent white dot syndrome (MEWDS), idiopathic multifocal choroiditis (MFC), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), serpiginous choroiditis (SC), and acute syphilitic posterior placoid chorioretinitis (ASPPC), all cases corresponding to secondary photoreceptor diseases caused by inflammatory choriocapillaris nonperfusion, were included and compared to primary photoreceptor disease entities, including acute zonal occult outer retinopathy (AZOOR) and cancer-associated retinopathy (CAR). Both groups showed increased BAFs of variable intensity. In severe cases of APMPPE and ASPPC, BAF also showed hypoautofluorescent areas. In group 1 (secondary diseases) BAF hyperautofluorescent areas were associated with colocalized ICGA hypofluorescent areas, indicating choriocapillaris nonperfusion; whereas in group 2 (primary diseases), no ICGA signs were detected. The associated colocalized areas of hypofluorescence on ICGA in the first group, which were absent in the second group, were crucial to allow the differentiation between primary (photoreceptoritis) and secondary (choriocapillaritis) photoreceptor diseases. BAF patterns in inflammatory diseases of the outer retina can give relevant information on the photoreceptor and RPE involvement, with ICGA being crucial to detect concurring choriocapillaris damage and differentiating the two pathologies.

[Acute posterior multifocal placoid pigment epitheliopathy, serpiginous choroiditis and related diseases]

Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) and serpiginous choroiditis are two diseases classified as "white spot syndromes." Both are inflammatory/autoimmune diseases with suspected primary involvement of the choriocapillaris. The former usually has an excellent prognosis, while the latter can rapidly induce legal blindness. Whereas these diseases are well defined and well known, other entities (such as persistent placoid maculopathy or ampiginous choroiditis) with features of both APMPPE and serpiginous choroiditis have been described more recently. This review aims to describe demographic characteristics and multimodal imaging features to help differentiate between these four diseases.

Multifocal Serpiginoid Choroiditis Due to Mycobacterium Mageritense following Laparoscopic Hysterectomy in an Immunocompetent Host

PURPOSE

To report nontubercular choroiditis, caused by Mycobacterium mageritense isolated using MALDI-TOF MS, following laparoscopic hysterectomy in an immunocompetent patient.

CASE REPORT

A 42-year-old female presented with gradual, painless diminution of vision in the right eye for six weeks. She had undergone laparoscopic hysterectomy two months back. BCVA was 2/60 OD. Clinical presentation and imaging all pointed to a diagnosis of serpiginous-like choroiditis. Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS) had led to isolation of Mycobacterium mageritense. Patient was treated with systemic antibiotics. At 3 months follow up, BCVA improved to 6/60; fundus showed healed choroiditis and chorioretinal thinning.

CONCLUSION

Atypical mycobacterial infections associated with laparoscopic surgeries can rarely lead to debilitating systemic bacteremia resulting in profound visual impairment. The importance of timely diagnosis using specific and sophisticated methods such as MALDI-TOF MS as well as maintaining aseptic precautions perioperatively during major surgeries cannot be overemphasized.

Interpreting posterior uveitis by integrating indocyanine green angiography, optical coherence tomography, and optical coherence tomography angiography data: A narrative review

Posterior uveitis is sight-threatening disease entity that can be caused by infectious and non-infectious entities. Vision loss in posterior uveitis can be following complications such as cystoid macular edema, epiretinal membrane, artery and vein occlusions, vasculitis, papillitis, choroidal neovascular membrane, retinal neovascularization, tractional retinal detachment, vitreous hemorrhage, glaucoma, cataract, among others. Diagnosis of posterior uveitic entities have been revolutionized following introduction of choroidal imaging with techniques such as indocyanine green angiography (ICGA), optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA). Med Line search and PubMed search was performed pertaining to causes of posterior uveitis, ICGA in posterior uveitis, OCT in posterior uveitis, OCTA in posterior uveitis, retinal and choroidal vascular changes in posterior uveitis, quantification of choriocapillaris lesion area in posterior uveitis, subfoveal choroidal thickness in posterior uveitis, quantification of choriocapillaris in posterior uveitis, vascular indices for quantification of choriocapillaris. This review article highlights various changes in the choroid and the quantification of choroid using various parameters in ICGA, OCT and OCTA.

BILATERAL SERPIGINOUS-LIKE CHORIORETINITIS ASSOCIATED WITH CILIOCHOROIDAL MELANOMA: A Clinicopathologic Correlation

PURPOSE

To report the clinicopathologic correlation of a case of bilateral serpiginous-like chorioretinitis (SLC) associated with unilateral ciliochoroidal melanoma.

METHODS

A 71-year-old white woman was diagnosed with progressive SLC in both eyes associated with ciliochoroidal melanoma in the right eye. Clinical findings and imaging before and after enucleation in the right eye were correlated to histologic and immunohistochemistry sections.

RESULTS

Examination and imaging identified a peripheral bilobed amelanotic lesion with low reflectivity on B-scan ultrasound with an associated exudative detachment in the right eye. Additionally, multiple areas of new SLC lesions in the macula and peripapillary region in the right eye and along the inferior arcade in the left eye were observed. Oncologic evaluation confirmed a Class 2, ciliochoroidal melanoma, and the eye was enucleated. Autoimmune and infectious laboratory evaluations for the etiology of the SLC lesions were negative. Histopathology of the enucleated eye confirmed the diagnosis of uveal melanoma with lymphocytic inflammation at the edges of the tumor itself and in the areas of discrete SLC lesions. Immunohistochemistry identified similar predominantly CD3 and CD8 T cells and fewer CD20 B cells in both regions.

CONCLUSION

Serpiginous-like chorioretinitis may present as a paraneoplastic, predominantly T-lymphocyte inflammation associated with intraocular tumor such as uveal melanoma.

Mechanisms, Pathophysiology and Current Immunomodulatory/Immunosuppressive Therapy of Non-Infectious and/or Immune-Mediated Choroiditis

Non-infectious choroiditis comprises immune-mediated diseases resulting from diverse pathophysiological mechanisms. These conditions are sub-divided into two main groups, (1) diseases of the choriocapillaris and (2) diseases of the choroidal stroma. The purpose of this study is to expose the pathophysiology of the most common diseases of both these groups and recommend the optimal immunomodulatory/immunosuppressive therapy of each analyzed condition based on literature data and data from our own centers. Material and Methods: Narrative review. In the group of choriocapillaritis entities or primary inflammatory choriocapillaropathies (PICCPs) including multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), idiopathic multifocal choroiditis (MFC) and serpiginous choroiditis (SC), as well as secondary choriocapillaritides including acute syphilitic posterior multifocal placoid chorioretinitis (ASPMPC) and tuberculosis-related SC (TB-SC), were analyzed. In the group of stromal choroidites, HLA-A29 birdshot retinochoroiditis (BRC) and Vogt-Koyanagi-Harada (VKH) disease were included. For each entity a literature search, in the PubMed database, on treatment was performed and analyzed and the therapeutic attitudes of our own centers were presented. Management of immune-mediated choroiditis implies vigorous immunosuppressive therapy given in a prompt and prolonged fashion in most of these entities.

The use of optical coherence tomography angiography in comparing choriocapillaris recovery between two treatment strategies for multifocal choroiditis: a pilot clinical trial

PURPOSE

To compare differences in choriocapillaris flow deficit (CC FD) in multifocal choroiditis (MFC) between two treatment arms using optical coherence tomography angiography (OCTA).

METHODS

In this prospective randomized clinical trial, patients were randomized to either Group 1 which received standard tapering dose of oral corticosteroids, or Group 2 which received additional dexamethasone implant (or intravitreal methotrexate). The patients were followed-up until 12 weeks using OCTA and other imaging tools. CC FD and visual acuity between the two groups were compared at each visit.

RESULTS

Twenty-five subjects (17 males; 25 eyes) were studied (11 eyes in Group 1). There were no differences between the visual acuity or CC FD (1.12 versus 1.08 mm²; p = 0.86) at baseline between the groups. However, patients in Group 2 achieved better visual acuity (0.32 ± 0.23 versus 0.15 ± 0.11; p = 0.025) and CC FD (0.54 versus 0.15 mm²; p = 0.008) at 12 weeks.

CONCLUSIONS

OCTA is a useful tool in monitoring the CC FD recovery after treatment in MFC. Patients receiving intravitreal corticosteroid/methotrexate in addition to systemic corticosteroid showed greater resolution of CC FD on OCTA compared to those receiving only oral corticosteroids.

Tuberculosis-related serpiginous choroiditis: aggressive therapy with dual concomitant combination of multiple anti-tubercular and multiple immunosuppressive agents is needed to halt the progression of the disease

Background/purpose

Serpiginous-like choroiditis is a rare immune-mediated sub-entity of tubercular uveitis with a usually deleterious outcome. Treatment is still controversial. The purpose in this case series is to indicate that only aggressive treatment comprising multiple anti-tubercular and multiple immunosuppressive agents seems to be able to halt the disease progression.

Methods

This retrospective case series included patients diagnosed with Interferon Gamma Release Assays (IGRA) -positive serpiginous choroiditis, seen at the Centre for Ophthalmic Specialized Care, Lausanne, Switzerland, treated with combined multiple antitubercular and immunosuppressive agents at presentation and having a sufficient follow-up. Disease history before referral, appraisal of disease, treatment modalities and follow-up were analyzed. Inclusion criteria were positive IGRA patients with serpiginous choroiditis with complete Spectral-Domain Optic coherence tomography (SD-OCT) and angiography images.

Results

From 2001 to 2020, 24 of 1525 new patients (0.26%) were diagnosed as serpiginous choroiditis. 10/24 were related to tuberculosis (positive IGRA and/or hyper-positive Mantoux test), 8/24 were IGRA negative and in 6 there was no information available. 4/10 tuberculosis related serpiginous patients fulfilled the inclusion criteria. Mean age was 39 ± 5.3 years. Snellen best corrected vision acuity (BCVA) at presentation in 3/4 where the macula was preserved was 0.96 ± 0.08. In 3/4 patients, treatment with multiple tuberculostatic therapy combined with multiple immunosuppressive agents, started at presentation or in the initial months after the first consultation, was shown to stop the progression of the disease, with a retained visual acuity of 1.0. One patient with macular involvement and a bilateral visual acuity of hand movements after 11 years of insufficient treatment, improved his visual acuity to 0.25 OD and 0.05 OS and presented a substantial visual field improvement that stabilized once multiple anti-tubercular and immunosuppressive therapy was introduced.

Conclusion

IGRA-positive serpiginous choroiditis (serpiginous-like choroiditis) could be halted by combined multiple tuberculostatic and multiple immunosuppressive agents, as seen in our study where 3/4 early treated patients had conserved central function and one late treated patient had recovered a substantial amount of visual field. In all 4 patients this treatment regimen halted the progression of the disease.

Clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis

Purpose:

To describe the clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis (MSC).

Methods:

Clinical records of 16 eyes (14 patients) with MSC presenting to a tertiary eye care institute between 2015 and 2019 were analyzed retrospectively.

Results:

Mean age of 14 patients presenting with MSC was 33 ± 13 yrs with 64% males and 36% females. Mean visual acuity of the eyes with MSC at presentation was 0.43 ± 0.46 (logMAR) improving to 0.16 ± 0.28 (logMAR) at final visit. Thirteen eyes (81.3%) had active lesion at presentation. Mantoux test was positive in seven patients (50%) and QuantiFERON TB gold test positive in 10 patients (71%). HRCT chest showed latent tuberculosis in seven patients (50%). All patients underwent multimodal imaging. All patients received oral steroids as treatment therapy; 11 patients also received immunosuppressives, nine patients received additional anti-tubercular therapy (ATT). Mean duration of follow-up for the patients was 18 ± 10 months. A total of eight (50%) eyes had recurrence of lesions after an average duration of 14 ± 14 (3-36) months and were restarted on the treatment as per the requirement. At final follow-up, all eyes showed a good response to treatment and had healed lesions. Comparing the final BCVA to the initial BCVA, 38% (n = 6) showed improvement, 56% (n = 9) remained stable, and 6% (n = 1) eyes worsened at the final follow-up.

Conclusion:

Clinical profile and presentation of MSC is similar to that of CSC, and combination treatment with intravenous methyl prednisolone (IVMP), steroids, immunosuppressives, and ATT can salvage vision. A high suspicion of associated tuberculosis in endemic regions should be kept in mind.

Serpiginous Choroiditis Complicated with Choroidal Neovascular Membrane Detected using Optical Coherence Tomography Angiography: A Case Series and Literature Review

Serpiginous choroiditis (SC) is a rare, chronic, recurrent, progressive disease of unknown origin. The inflammatory process of SC can disrupt Bruch’s membrane, allowing occasional choroidal vascular growth, leading to significant visual loss even in the healed stages of the disease. Optical coherence tomography angiography (OCTA) can help in the detection of choroidal neovascular membrane (CNV), leading to a definitive diagnosis and thereby guide the initiation of intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment. We report herein two cases of SC complicated with a CNV detected with OCTA and treated with a series of anti-VEGF injections.

Intravitreal Methotrexate

Intravitreal methotrexate (MTX) has been proven to be an effective treatment for various intraocular diseases. In this article, a comprehensive review was performed on intravitreal applications of methotrexate. Different aspects of the administration of intravitreal MTX for various clinical conditions such as intraocular tumors, proliferative vitreoretinopathy, diabetic retinopathy, age-related macular degeneration, and uveitis were reviewed and the adverse effects of intravitreal injection of MTX were discussed. The most common indications are intraocular lymphoma and uveitis. Other applications remain challenging and more studies are needed to establish the role of intravitreal MTX in the management of ocular diseases.

Choroidal Thickness in Multifocal Dendritic and Placoid Serpiginous-Like Choroiditis: A Comparative Study

BACKGROUND AND OBJECTIVE

To study spectral-domain optical coherence tomography (SD-OCT) characteristics in multifocal advanced dendritic serpiginous-like choroiditis (D-SLC) and placoid serpiginous-like choroiditis (P-SLC).

PATIENTS AND METHODS

Retrospective, comparative study. SD-OCT features were studied in both the groups. Area of involvement (AoI) due to SLC lesions was calculated, and cases with comparable AoI from both the groups were subclassified into Group A (subgroup D-SLC) and Group B (subgroup P-SLC). Central choroidal thickness (CT) was measured, and comparative analysis was performed.

RESULTS

Thirty-four eyes (15 D-SLC, 19 P-SLC) of 28 patients were studied. Mean AoI for Group A (n = 10) and for Group B (n = 12) was 197,066.50 units (range: 139,602 to 267,151 units) and 203,407.33 units (range: 148,156 to 285,048 units), respectively (P = .553). Mean central CT was 217.92 µm for DSLC and 152 µm for P-SLC (P = .01).

CONCLUSIONS

The choroid was significantly thinner at the resolution in P-SLC than in D-SLC form. P-SLC renders more choroidal destruction and may warrant aggressive treatment. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:438-442.].

Bilateral Ampiginous Choroiditis following Presumed SARS-CoV-2 Infection

Purpose

To report a case of bilateral ampiginous choroiditis following presumed SARS-CoV-2 infection. Case Description. A 25-year-old woman presented with metamorphopsia and a paracentral scotoma in her left eye. She endorsed night sweats, headache, and new-onset anosmia beginning 1 week before her visual symptoms. She also had multiple confirmed ill COVID-19 contacts at her workplace before the onset of her symptoms. Funduscopic examination and multimodal imaging revealed placoid lesions in the macula and midperiphery of both eyes consistent with ampiginous choroiditis. COVID-19 antibody testing returned positive for IgG, and an extensive systemic evaluation was otherwise unremarkable. She was treated with oral prednisone and azathioprine with stabilization of the retinal lesions and no progression of her symptoms.

Conclusions

Ampiginous choroiditis is an inflammatory chorioretinopathy with an unknown pathogenic mechanism that often necessitates early immunomodulatory therapy. This report suggests that SARS-CoV-2 infection may trigger chorioretinal inflammation in susceptible hosts.

A review of diseases of the retina for neurologists

Diseases of the retina are common and numerous, with causes ranging over inherited, inflammatory, vascular, infectious, neoplastic, traumatic, toxic, and idiopathic etiologies. A key issue in the diagnosis of retinal disease is the duration of symptoms, which can be acute, chronic, or acute presentations of chronic disease. Clinical examination with direct ophthalmoscopy or, even better, biomicroscopy with a slit lamp and condensing lens, is a key component of diagnosis, which can be enhanced through investigational methods such as fluorescein angiography, optical coherence tomography, or electroretinography. Consideration of the history, visual acuity and visual field, and fundoscopic findings is usually sufficient to determine whether patients need referral on an emergency, urgent, or routine basis. Emphasis is given to vascular disease, age-related macular degeneration, diabetic retinopathy, genetic eye disease, and retinal detachment.

LONGITUDINAL FOLLOW-UP OF TUBERCULAR SERPIGINOUS-LIKE CHOROIDITIS USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To analyze and describe serial follow-up of choriocapillaris alterations in tubercular serpiginouslike choroiditis (SLC) using optical coherence tomography angiography (OCTA) and to compare it with multimodal imaging.

METHODS

In this prospective cohort study, patients with active tubercular SLC underwent OCTA using Optovue RTVue XR Avanti and other imaging techniques including enhanced-depth imaging OCT (EDI-OCT) (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Serial imaging was performed for a total follow-up of 3 months. Choriocapillaris alterations at the site of lesions were analyzed on OCTA imaging, and their mean lesion areas were calculated.

RESULTS

Twenty-six eyes (26 patients; 20 males; mean age: 32.68 ± 10.56 years) were included. Fourteen eyes had active multifocal lesions (n = 39), whereas 12 eyes had active placoid lesions (n = 12). At baseline, OCTA showed hyporeflective flow deficit lesions corresponding to the hypofluorescent lesions on indocyanine green angiography in all eyes. In the multifocal type of SLC, the mean lesion area decreased in all eyes compared with baseline, and lesions with a lesion area less than 0.1 mm2 on OCTA showed near-complete resolution with minimal choriocapillaris atrophy. In comparison, all eyes with a placoid type of SLC showed no significant reduction in the lesion area and showed extensive choriocapillaris atrophy.

CONCLUSION

Optical coherence tomography angiography has the unique ability to demonstrate pathological flow impairment at the level of choriocapillaris in active tubercular SLC. Serial OCTA analysis reveals that large tubercular SLC lesions result in choriocapillaris atrophy as the lesions heal, whereas smaller multifocal lesions show resolution of choriocapillaris hypoperfusion with minimal atrophy.

Chlorambucil combination therapy in refractory serpiginous choroiditis: A cure?

Purpose

To find a remedy for serpiginous choroiditis refractory to oral prednisone and chlorambucil treatment.

Observations

Eight eyes of four patients (all female) with advanced macular involvement secondary to serpiginous choroiditis were included in the study. The average age of the patients was 45.2 years. One eye of each patient was legally blind and the lesion was close to the fovea in the other eye. All four patients failed oral prednisone and chlorambucil therapy. However, case 1 responded to chlorambucil treatment after intravitreal dexamethasone implant implantation and discontinuation of oral prednisone. Case 2 responded to chlorambucil therapy when oral prednisone was stopped in combination with infliximab therapy. Due to long follow-up period of more than four years, these two cases are considered to be cured. Case 3 and case 4 were not able to achieve remission with chlorambucil and immunomodulatory therapy. They refused intravitreal steroid implant due to side effects profile.

Conclusions and importance

The stability of WBC counts within toxic levels close to normal or lower limits of normal (3000–4500 cells/μl) during treatment with chlorambucil is an essential factor for the success of this therapy. A combination of dexamethasone intravitreal implant with chlorambucil therapy can be an effective and promising regimen in inducing and maintaining remission in refractory serpiginous choroiditis patients who fail a combination of systemic corticosteroid and chlorambucil therapy.

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Serpiginous choroiditis may be recurrent or refractory to chlorambucil in conjunction with systemic corticosteroids.

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The stability of WBC counts within lower limits of normal is an essential factor for the success of chlorambucil therapy.

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This can be achieved with dexamethasone intravitreal implant or systemic immunomodulatory without systemic corticosteroid therapy.

Swept source OCTA reveals a link between choriocapillaris blood flow and vision loss in a case of tubercular serpiginous-like choroiditis

Optical coherence tomography angiography (OCTA) is a non-invasive technique that is useful in the diagnosis and management of patients with posterior uveitis. Here we report the use of swept source OCTA (SS-OCTA) in a patient with tuberculosis (TB) associated serpiginous like choroiditis (TB-SLC) that made a full visual recovery following treatment with ATT, local and systemic corticosteroids, and systemic immune modulation. By comparing en face images of choriocapillaris (CC) blood flow before and after treatment, we conclude that the patient's visual recovery was associated with resolution of extensive CC flow deficits. This case highlights the utility of SS-OCTA in the multimodal evaluation of patients with choroidal inflammation, and the potential for good visual recovery in patients treated for TB-SLC.

Placoid lesions of the retina: progress in multimodal imaging and clinical perspective

Placoid lesions of the retina may be secondary to a wide spectrum of acquired inflammatory conditions that have been reported as single entities with different presentation and clinical course. These conditions include acute posterior multifocal placoid pigment epitheliopathy, persistent placoid maculopathy, serpiginous choroiditis, serpiginous-like choroiditis, relentless placoid chorioretinitis and acute syphilitic posterior placoid chorioretinitis. In this article, we will group these conditions under the name of 'placoids'. The recognition of the specific condition may be challenging in clinical practice, often resulting in diagnostic and therapeutic delay. Given the complex nature of placoids and their similarities, a systematic approach including differentiating between infectious and non-infectious aetiologies increases the chance of reaching the correct diagnosis. Detailed history and comprehensive clinical examination are the first steps to formulate a diagnostic hypothesis that should be corroborated by multimodal imaging and appropriate investigations. The advent of multimodal imaging has made it possible to extensively study placoids and revealed a constellation of specific findings that may help clinicians in the diagnostic process. The treatment of the conditions other than syphilis is complex and sometimes challenging. Our article is aimed at giving an overview of the individual entities associated with placoids and discussing the differential diagnosis. A practical and systematic approach is then proposed.