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 [Fig. 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
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 [Fig. 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
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 [Fig. 3]. However, in the seventh month, sub-retinal fluid occurred [Fig. 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
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
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 [Fig. 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
Discussion
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
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