A case of bilateral multifocal

choroiditis

Bucharest Ophthalmology Emergency Hospital

Author: Alexandru Dieaconescu

Clinical symptoms
I will present a case of a 33 years female, who
came to hospital accusing in left eye:

- decrease visual acuity - photopia

- blurring of vision - blind spot

symptoms that appeared in only few days.

The patient has no significant personal or

heredocolateral pathology.
History
 The patient presented the same symptoms in the right
eye 3 weeks ago, and she was diagnosed with
multifocal choroiditis in right eye, based on clinical
exam, fundus aspect, OCT test and visual field.

 The patient followed a medication with systemic and

local steroids and antibiotics and the visual acuity
improved.

 After 3 weeks of good visual acuity the same

symptoms appeared under medication in the left eye
so she came to a new examination.
History
Optical coherence tomography on
RE

17.08.2009 Best corr. RE Visual acuity 1/24

The patient presented the Right Eye OCT made three weeks ago, before
treatment administration , that shows macular edema ( 637 um),
neurosensory detachement and multiple yellowish oval lesions
History
Right Eye Visual Field

We can see in right

eye a narrowed
visual field and a
central scotoma.
Clinical evaluation

 General examination:

- Cardiovascular system in normal limits:

Blood pressure= 100 /70 mm Hg
Pulse = 74
- Respiratory system in normal limits
- Normal neurological examination
- Normal gastroenterological exam
 Clinical evaluation

Ophthalmological examination :

Best corr. visual acuity : Right eye = 0,7 (after 3 weeks treatment)
Left eye = pmm

Slit lamp exam reveals a normal anterior pole.

The fundus examination shows multiple yellowish to gray round

and oval lesions that vary in size in both eyes, with right eye
peripapilar edema and LE normal optic disc.

Clinical evaluation with a 90-D aspheric lens reveals areas of

retinal thickening and macular edema in LE, and depigmentated
macular area in RE without edema.
OCT in RE at initially hospital presentation,
after 3 weeks treatment

After 3 weeks of systemic and local treatment we see the resolution

of macular edema with a macular thickness of 207 um compared with
637 um and an improved visual acuity ( 0,7 Compared with 1/24).
Optical coherence tomography on LE
at initially hospital presentation

07.09.2009
Best corr. Visual Acuity = pmm

OCT Shows macular edema ( 1073 um) and yellowish oval lesions .
LE fundus aspect at initially hospital
presentation

The fundus examination shows multiple yellowish to gray round

and oval lesions that vary in size, with normal optic disc.
Differential diagnosis

Clinical exam and ancillary tests reveals an inflammatory

disease, and the possible diagnosis are:

 Punctate inner choroidopathy

 Ocular histoplasmosis syndrome
 Sarcoidosis
 Vogt–Koyanagi–Harada syndrome
 Sympathetic uveitis
 Subretinal fibrosis and uveitis syndrome
 Serpiginous choroiditis
 Birdshot retinochoroidopathy
 Myopic degeneration maculopathy
Positive diagnostic
Based on symptoms, clinical examination, fundus
aspect and OCT, the main diagnosis is multifocal
choroiditis in both eyes.

This diagnosis is supported by:

- Sex and age: female in forth decade

- Symptoms
- Fundus clinical aspect ( multiple yellowish lesions, vary in
size )
- OCT and visual field aspect
Diagnosis
To exclude the possibility of a certain etiology for the
inflammation, the patient made some tests to identify the
etiology:
 Sarcoidosis - negative
 Toxoplasmosis – negative
 Citomegalovirus – IGG +, IGM –
 FR negative
 Lupus cell negative
 ANCA negative
This negative results support the main diagnosis – multifocal
choroiditis, which is an inflammatory disease with an obscure
etiology.
Systemic associations
 Multifocal choroiditis with panuveitis is a common
inflammatory disease with an obscure etiology.

 An association between multifocal choroiditis and

Epstein–Barr virus systemic infection has been
suggested.

 It has been suggested that Epstein–Barr virus triggers

an immune response that results in persistent
intraocular inflammation.
 The patient had an Epstein-Barr test
Treatment

 Systemic - steroids : Medrol -first week 2cp/day,
then 1,5 cp of 16 mg/day
- antibiotic : Lekoclar - 2cp/day one week

 Local - steroids : Maxitrol 4 times / day


Intravitreal Triamcinolone acetonide injection

. The patient visual acuity decreased in the left eye,

after she forgot to take her steroids doses for a few days
and the LE OCT showed an important macular edema ,
so we decided to do, beside the treatment above, an
intravitreal injection with triamcinolone acetonide.

 In left eye, for macular edema we do intravitreal

injection with triamcinolone acetonide, using 30G
needle, injecting the dose supero-temporal through
pars plana at 4 mm from limbus , under checking the
central retinal artery perfusion.
OCT in LE one day after
treatment
One day after the
intravitreal injection the
OCT still shows a
significant macular edema,
but decreasing ( 845 um
compared with 1073 um),
and we decided to make a
control clinical examination
and OCT test in a 2 weeks
to see the efficiency of this
treatment.
Best corr VA one day
after injection : 0,1
(compared with pmm)
Treatment efficiency – one week
administration
Treatment efficiency – one week
administration

 RE best corr VA = 0,9  LE best corr VA = 0,7

 Macular thickness = 206 um  Macular thickness = 186 um
Evolution
 Without treatment
The normal course of this disease is with recurrent
inflammatory episodes, inactive lesions with pigmented
borders and association of CNV (choroidal
neovascularization) and occasionally diffuse subretinal
fibrosis, determining an important decrease in visual
acuity.
 With treatment
Treatment with systemic and local steroids is effective
in at least 50% of cases, when administered early.
Prognosis
 Prognosis is variable because the disease has
a wide spectrum varying between those with few
lesions and short periods of activity to patients
with progressive scarring and visual loss due to
maculopathy or diffuse subretinal fibrosis.

 However because the medication was

administrated early the evolution of this case may
be favorably.
Particularity of the case
 The particularity of this case is that after the patient
forgot to take some steroids doses the visual acuity in
LE decreased under systemic medication, but one
triamcinolone acetonide intravitreal injection, and the
straight administration of the local and systemic
medication had a significant improvement of visual
acuity.

 The obscure etiology of the inflammatory lesions,

which according with clinical exam and OCT aspect
are suggestive for multifocal choroiditis .
Thank you!