ANSWER TO "YOU MAKE THE DIAGNOSIS"

This patient in has multifocal choroiditis. Multifocal choroiditis is a disorder occurring primarily in middle-aged females. Its presentation is typically bilateral without any racial predilection. Etiology of this condition is unknown but there are associations with Epstein-Barr virus, sarcoidosis, syphilis, toxoplasmosis, and tuberculosis.

Patients typically present with a decrease in visual acuity in one or both eyes. Ocular findings include chorioretinal lesions with an overlying vitritis. These lesions range in size from 50 - 350um and number from several to several hundred aligned in streaks or linear clusters. Fresh lesions appear yellow to gray in color, while older lesions appear atrophic and punched-out. While the vitritis occurs in all patients, only 50% of patients will have an anterior uveitis. The anterior cellular reaction may range from 1+ to 3+ and the amount of keratic precipitates may range from non-granulomatous to granulomatous.

Other findings include peripapillary atrophy, mild disc edema/enlarged blind spot, macular or peripapillary choroidal neovascular membranes, cystoid macular edema, and subretinal fibrosis.

Additional tests would include Amsler grid, fluorescein angiography and/or indocyanine green angiography if any choroidal neovascular membrane is suspected or cystoid macular edema is present and an electroretinogram.

Differential diagnosis includes presumed ocular histoplasmosis syndrome (POHS), birdshot choroidopathy, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), serpiginous choroiditis, multiple evanescent white dot syndrome (MEWDS), diffuse unilateral subacute neuroretinitis (DUSN), sarcoidosis, Vogt-Koyanagi-Harada syndrome, sympathetic uveitis, punctate outer retinal toxoplasmosis, punctate inner choroidopathy (PIC) and myopic degeneration.

Treatment occurs on several levels, and is geared toward managing the ensuing inflammation. Systemic corticosteroids are used to reduce vitritis, edema and macular detachment during the active stages. Topical corticosteroid may also be needed to control and mitigate the anterior segment inflammation. Further, periocular corticosteroid injections to reduce anterior segment uveitis, vitritis, macular detachment, and edema may be warranted. Lastly, laser photocoagulation may be necessary to treat any associated choroidal neovascular membranes (CNVM). Ironically, laser photocoagulation of CNVM may cause an increase in choroidal inflammation, which in turn may initiate the growth of new CNVM.

Andrew Gurwood, OD, FAAO
ORS Founding Fellow

In a second phase 3 trial, 95% of patients taking Lucentis (ranibizumab, Novartis/Genentech) for the treatment of wet age-related macular degeneration either maintained or improved vision for 1 year, according to the drug’s developers. The ANCHOR (Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD) study is a phase 3, randomized, multi-center, double-masked, active-treatment controlled trial comparing two doses of Lucentis to photodynamic therapy in patients with predominantly classic wet AMD.

One-year results of the 2-year study show that 94% of patients treated with 0.3 mg and 96% of patients treated with Lucentis 0.5 mg maintained vision or improved vision. In comparison, 64% of those treated with Visudyne (verteporfin for injection, Novartis/QLT) in the trial maintained or improved vision at 1 year. Study data will continue to be analyzed through a second year, according to a press release from Novartis.

Early age-related macular degeneration was found to be common in a study in a U.S. Hispanic population, but the prevalence of late AMD in that population was lower than estimates for white people in the United States.

This finding from Proyecto VER (Vision and Eye Research), a population-based study of blindness and visual impairment in Hispanic people in Arizona, is published in the November issue of Archives of Ophthalmology. The overall prevalence of late AMD was 0.5%. The prevalence of late AMD was associated with age; 0.1% of participants in the 50- to 59-year age range had late AMD, increasing to 4.3% in those aged 80 years and older. Early AMD was also strongly associated with age. Twenty percent of patients in the 50- to 59-year age range had early AMD, and 54% of those aged 80 years and older.

Re-treatment with verteporfin photodynamic therapy at 2-month intervals did not show a significant benefit at 1 year compared with re-treatment every 3 months in patients with age-related macular degeneration, a study published in the December issue of Ophthalmology found.

Stephan Michels, MD, and colleagues conducted the prospective, randomized, multi-center clinical study, including 203 patients with predominantly classic choroidal neovascularization (CNV) secondary to AMD, to determine the value of early re-treatment with verteporfin PDT.

Baseline mean visual acuity was 20/100 -1 for both groups. Mean visual acuity was better in the early re-treatment group at all follow-up points, but the difference did not reach statistical significance. The re-treatment group trended toward better outcomes, with 61% losing less than three lines of vision at 12 months compared with 51.7% of the standard re-treatment group.

Juxtafoveal or subfoveal idiopathic choroidal neovascularization responds significantly better to combined photodynamic therapy and systemic steroid treatment than to PDT alone, according to a study by Alfonso Giovannini, MD, of Ancona University, Italy. In addition, steroids alone should be used in specific forms of extrafoveal lesion.

In a group of 20 patients with juxtafoveal or subfoveal lesions, the results of PDT alone and PDT plus systemic steroid treatment were compared. The mean age of patients was 29 years, ranging from 10 to 44 years. The median follow-up was 23 months.

Visual acuity after PDT alone was improved in only one patient, was stable in five and decreased in four cases. Lesion size was stable in four patients, reduced in two and increased in four cases, according to the study. In the group that was treated with a combination of PDT and systemic steroids, visual acuity was stable in five cases, improved in four cases and decreased in only one case. The CNV lesion size increased in one patient, while it was stable in four cases and reduced in five cases, according to the study.

Macular thickness is affected by genetics, a recent study in twins suggests. The differences in macular thickness between older, healthy identical and nonidentical twins "suggest an inherited basis of macular thickness," according to the study published in the January issue of Investigative Ophthalmology & Visual Science.

Matthew D. Chamberlain and colleagues at the Centre for Eye Research Australia performed a classic twin study to compare the correlation of macular thickness between monozygotic and dizygotic twins. They analyzed data from 109 white twin pairs who ranged in age from 50 to 80 years old and had no evidence of ocular disease. The correlation of retinal thickness was significantly greater between the identical twins than the fraternal twins in all macular regions. After adjusting for significant covariates and model fitting, there was a final heritability estimate of 85% in the foveal region, 81% in the inner macular region and 81% in the outer macular region, the authors said. They also found a significant negative correlation between outer macular thickness and axial length.

Two drugs for the treatment of type 2 diabetes have been reported to be associated with rare instances of macular edema, according to a letter from GlaxoSmithKline to physicians issued late last week. GlaxoSmithKline markets the drugs Avandia and Avandamet, both containing rosiglitazone, for the treatment of type 2 diabetes.

According to a Reuters news report, a Glaxo spokeswoman said the incidence of macular edema associated with these drugs was "extremely rare, affecting fewer than one in 10,000 patients" taking the drugs. To date, more than 6 million patients worldwide have taken either Avandia or Avandamet, according to the letter Glaxo sent to health care providers discussing the side effects.

"In the majority of these cases, the patients also reported concurrent peripheral edema," the letter said. "In some cases, the macular edema resolved or improved following discontinuation of therapy and in one case, macular edema resolved after dose reduction."