History of Present Illness
A 39-year-old woman with no significant past medical history presents to the eye clinic for the first time complaining of blurred central vision right eye (OD), with photopsias and a central blind spot (scotoma) of 1 week duration.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/60 | 20/20 |
| Intraocular pressure (IOP) | 11 | 10 |
| Sclera/conjunctiva | Within normal limits (WNL) | WNL |
| Cornea | Clear | Clear |
| AC | No cell or flare | No cell or flare |
| Iris | WNL | WNL |
| Lens | Mild nuclear sclerosis | Mild nuclear sclerosis |
| Vitreous cavity | No cells | No cells |
| Retina/optic nerve | Normal optic nerve. Several punctate chorioretinal lesions within the arcades and paramacular ( Fig. 31.1 ) | Normal optic nerve. No punctate chorioretinal lesions within the arcades |
Questions to Ask
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Have you had any recent infection or systemic illness?
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Have you had an episode like this before in either eye?
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Are you near-sighted and have you had any corrective surgery for near-sightedness?
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Do you have metamorphopsia in your left eye (OS)?
She has no recent respiratory infection or systemic illness. She does not recall having an episode like this in either eye. She does not wear glasses because she had laser in situ keratomileusis (LASIK) surgery, but she was moderately myopic (−4.00) both eyes (OU). There is no distortion or metamorphopsia in either eye.
Assessment
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Multifocal punctate chorioretinal lesions, OD, with presumed focal chorioretinitis OD
Differential Diagnosis
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Punctate inner choroidopathy (PIC)
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Multifocal choroiditis with panuveitis (MFCPU)
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Multifocal choroiditis with subretinal fibrosis (MFC-subretinal fibrosis)
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Multiple evanescent white dot syndrome (MEWDS)
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Sarcoidosis
Working Diagnosis
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PIC, OU, with focal chorioretinitis OD
Testing
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The presentation of punctate chorioretinal scars, ≤{1/4} of disc diameter in size, within the vascular arcades and without vitritis or anterior chamber (AC) inflammation is diagnostic of PIC. Confirmatory tests such as spectral domain optical coherence tomography (SD-OCT) and fluorescein angiography (FA) should be performed to rule out the presence of a choroidal neovascularization (CNV) complex within the macula and to identify the presence of chorioretinitis, OD. Fundus autofluorescence (FAF) can also be helpful in documenting the progression of the disease, as hypofluorescent spots are an indicator of RPE death or absence, whereas hyperfluorescent spots are an indicator of increased lipofuscin.
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FAF ( Fig. 31.2 )
