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PHOTO ESSAY
Year : 2020  |  Volume : 68  |  Issue : 9  |  Page : 1948-1950

Unusual presentation of multiple evanescent white dot syndrome and importance of optical coherence tomography angiography to diagnose choroidal neovascularization under inflammed choriocapillaris


Department of Ophthalmology, Ankara University School of Medicine, Ankara, Turkey

Date of Submission24-Apr-2020
Date of Acceptance25-Jun-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Dr. Sibel Demirel
Mamak Street, Vehbi Koc Eye Hospital, Dikimevi, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1115_20

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  Abstract 


Keywords: Choriocapillaritis, choroidal neovascularization, indocyanine green angiography, multiple evanescent white dot syndrome, optical coherence tomography angiography


How to cite this article:
Demirel S, Yalçındağ N, Yanık ÷, Temel E, Batıoğlu F, Özmert E. Unusual presentation of multiple evanescent white dot syndrome and importance of optical coherence tomography angiography to diagnose choroidal neovascularization under inflammed choriocapillaris. Indian J Ophthalmol 2020;68:1948-50

How to cite this URL:
Demirel S, Yalçındağ N, Yanık ÷, Temel E, Batıoğlu F, Özmert E. Unusual presentation of multiple evanescent white dot syndrome and importance of optical coherence tomography angiography to diagnose choroidal neovascularization under inflammed choriocapillaris. Indian J Ophthalmol [serial online] 2020 [cited 2020 Sep 28];68:1948-50. Available from: http://www.ijo.in/text.asp?2020/68/9/1948/292508



Multiple evanescent white dot syndrome (MEWDS) may be complicated with choroidal neovascularization (CNV) or simultaneous white dot diseases.[1],[2] Here, we presented a case of MEWDS with an unusual pigment epithelial detachment (PED) with hyperreflective material.

A 22-year old male presented with decreased vision in his left eye. Best corrected visual acuity was 20/20 in the right and 20/100 in the left with a myopic refraction of -2.50 D. He did not describe any viral prodrome. Funduscopic examination showed parafoveal yellowish lesions [Figure 1].
Figure 1: Multimodal fundus images: (a) Color photograph showed parafoveally located yellowish lesions (arrows). (b) FAF revealed hypoautofluorescent lesions surrounded by hyperautofluorescent rings (arrows). (c) Early FA showed faint hyperfluorescence (arrow heads). (d) Early ICGA showed hypocyanescence (arrrow heads). (e) Late FA revealed increase in hyperfluorescence due to staining (circles). (f) Late ICGA revealed numerous hypocyanescent dots (arrows) located around the main lesions (circles). (g) OCT detected subretinal hyperreflective material (arrow). (h) OCTA visualized the type 1 CNVs

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Fluorescein angiography (FA) revealed hyperfluorescence due to staining of these yellowish lesions. Indocyanine green angiography (ICGA) revealed hypocyanescent spots located around the main lesions. The main lesions, which were hyperfluorescent on FA, seemed mostly hypocyanescent as seen in choriocapillaritis. Therefore, we thought the diagnosis was MEWDS and its related punctate inner choroidopathy/multifocal choroiditis. SD-OCT showed subfoveal PED and hyperreflective material. Optical coherence tomography angiography (OCTA) showed the presence of type 1 CNVs under macular lesions, although there was no sign of CNV on ICGA. The choroid had increased thickness compared with the fellow eye [Figure 2].
Figure 2: Enhanced depth imaging mode OCT: (a) Right central choroidal thickness was 323 μm. (b) Left central choroidal thickness was 352 μm. Left eye had pachyvessels and higher choroidal thickness than the right one

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Since there was not any sign of CNV activity, the patient did not receive therapy. In the second month, visual acuity improved to 20/20. SD-OCT showed regressed lesion under PED [Figure 3]. However, in the seventh month, sub-retinal fluid occurred [Figure 4]. Therefore, one intravitreal injection of 0.5 mg/0.05 ml ranibizumab was performed.
Figure 3: At the 2nd month of follow up, SD-OCT (a) showed decrease in the size of the PED (black arrow). However, OCTA (b) showed that CNV lesion was approximately at the same size with previous lesion

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Figure 4: At the 7th month of follow up, SD-OCT (a) showed occurrence of subretinal fluid (asterisk). OCTA (b) revealed an increase in the size of the CNV

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At the last visit, when the choriocapillaritis regressed, late phase ICGA showed that one of two CNV lesions (inferotemporally located one) began to become apparent [Figure 5].
Figure 5: Multimodal images of the left eye at the last visit, 10 months after the single intravitreal injection. Late phase of combined image of dye angiography; FA (a) showed hyperfluorescence compatible with the staining of the lesions (dashed circles). On ICGA (b), the superonasal lesion was still hypocyanescent (arrow) but inferotemporally located lesion (arrow head) began to become slightly hypercyanescent indicating a CNV under regressed choriocapillaritis. SD-OCT (c) showed PED (black arrow) and OCTA (d) revealed the existence of two type 1 CNV lesions

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  Discussion Top


MEWDS cases may show atypical presentation with PED.[3] Presence of dense inflammatory material or deposition may produce masking effect causing misinterpretation of conventional images. At this point, OCTA may be a complementary diagnostic tool for inflammatory CNV.[4]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fernandez-Barrientos Y, Diaz-Valle D, Mendez-Fernandez R, Benitez-Del-Castillo JM. [Possible recurrent multiple evanescent white dot syndrome and chroroidal neovascularization]. Arch Soc Esp Oftalmol 2007;82:587-90.  Back to cited text no. 1
    
2.
Kuznetcova T, Jeannin B, Herbort CP. A case of overlapping choriocapillaritis syndromes: Multimodal imaging appraisal. J Ophthalmic Vis Res 2012;7:67-75.  Back to cited text no. 2
  [Full text]  
3.
Barile GR, Harmon SA. Multiple evanescent white dot syndrome with central visual loss. Retin Cases Brief Rep 2017;11(Suppl 1):S219-S25.  Back to cited text no. 3
    
4.
Levison AL, Baynes KM, Lowder CY, Kaiser PK, Srivastava SK. Choroidal neovascularisation on optical coherence tomography angiography in punctate inner choroidopathy and multifocal choroiditis. Br J Ophthalmol 2017;101:616-22.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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