Grand Rounds Jinghua Chen, MD, PhD October 21,

Grand Rounds Jinghua Chen, MD, PhD October 21,

Grand Rounds Jinghua Chen, MD, PhD October 21, 2016 Department of Ophthalmology and Visual Sciences History CC: 29 yo young male complained of sudden blurred vision in right eye. HPI: This is a 29 yo young male from Peru who came to

US two months ago to study. Two nights ago he stayed very late to study for an exam. He noticed that he could only see periphery with right eye, central vision was very blurry. Past Medical History POH: Refractive error OU

PMH: Right knee joint pain Allergy: NKDA FH: None contributory Medication:

None Exam OD BCVA: OS 20/30+2

20/30+1 +4.75+1.50X090 +4.00+2.25X085 Pupils: 42 4 2 IOP: 15 16 EOM:

Full OU CVF: Central scotoma OD>OS Anterior segment: normal Vitreous: 0.5 cells in anterior vitreous Initial Exam

AF Foundus Photo FA and ICG OD 16 20 FA and ICG OD

60 235 FA and ICG OS 43

250 OCT What Could It Be? Multiple evanescent white dot syndrome (MEWDS) Differential diagnosis of white dot syndrome Multifocal choroiditis without pan uveitis

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) Punctate inner choroidopathy (PIC) Birdshot chorioretinopathy Acta Ophthalmol. Scand. 2000: 78: 348353 What Now?

No insurance Oral Prednisone (20 mg po tid) x 3 days To return in 1 week for follow up. If symptoms don't resolve- medical work up Chest imaging

Serological testing Two Weeks Later Vision 20/20 OD and 20/30 OS OCT White Dot Syndromes (WDS) Multiple evanescent white dot syndrome Multifocal choroiditis and panuveitis ( MCP )

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) Birdshot chorioretinopathy Punctate inner choroidopathy (PIC) MULTIFOCAL CHOROIDITIS AND PANUVEITIS ( MCP ) Myopic females (30s to 50s),bilateral Vitritis mild to moderate

Chorioretinal lesions At the level of the RPE and choriocapillaris From 50 to 350 m Lesions become atrophic with varying degrees of pigmentation and scarring Vision out come Cystoid macular edema (10-20%) CNVM in 25-39% of pts

Multiple Evanescent White Dot Syndrome (MEWDS) First described by Jampol L. M in 1984 Young, healthy women in the second to fourth decades of life Symptoms: a viral prodrome unilateral, acute painless vision loss

an enlarged physiologic blind spot shimmering photopsias Multiple Evanescent White Dot Syndrome (MEWDS) Multiple white spots at the level of the RPE or deep retina 100 and 200 m in size Posterior pole

An orange-yellow fovea with granularity Vitreous inflammation, optic disc edema. Multiple Evanescent White Dot Syndrome (MEWDS) FA reveals early punctate hyperfluorescence in a wreath-like pattern and late staining

OCT: Discontinuities in inner segmentouter segment junction Immune-mediated vascular inflammation that affects various retinal layers, including the choroid, RPE and photoreceptors.2,5 Early identification MEWDS is generally benign APMPPE may be associated with systemic vasculitis.

MCP has a chronic recurrent course responsive to anti-inflammatory therapy. PIC a significant risk of choroidal neovascular membrane formation References 1.

BSCS 2014-2015 Book 12, Retina and Vitreous: 185-193 2. 3. BCSC 2014-2015 Book 9, Intraocular Inflammation and Uveitis 147-172 Jampol LM, Sieving PA, Pugh D, et al. Multiple evanescent white dot syndrome. I. Clinical findings. Arch Ophthalmol 1984;102:671-4. Aaberg TM, Campo RV, Joffe L. Recurrences and bilaterality in the multiple evanescent white-dot syndrome. Am

J Ophthalmol 1985;100:29-37. Mamalis N, Daily MJ. Multiple evanescent white dot syndrome. A report of eight cases. Ophthalmology 1987;94:1209-12. Dreyer R, Gass JDM. Multifocal choroiditis and panuveitis: A syndrome that mimics ocular histoplasmosis. Arch Ophthalmol. Vol 102, Dec 1984:1776-1784. Dunlop A, Cree I, Hague S, Luthert P, Lightman S. Multifocal choroiditis: Clinicopathologic correlation. Arch Ophthalmol. 1998; 116:801-803 4.

5. 6. 7. 8. 9. Fung AT, Pal S, Yannuzzi NA, Christos P, Cooney M, Slakter JS, Klancnik JM Jr, Freund KB, Cunningham ET Jr, Yannuzzi LA.Retina. 2014 Jan;34(1):98-107.Multifocal choroiditis without panuveitis: clinical characteristics and progression.

Dunlop A, Cree I, Hague S, Luthert P, Lightman S. Multifocal choroiditis: Clinicopathologic correlation. Arch Ophthalmol. 1998; 116:801-803.) 10. Thorne J, Wittenberg S, Jabs D, Peters G, Reed T, Kedhar S, Dunn J. Multifocal choroiditis with panuveitis:Incidence of ocular complications and loss of visual acuity. Ophthalmology 2006;113:2310-2316. 11. Fine HF, Zhitomirsky I, Freund KB, Barile GR, Shirkey BL, Samson CM, Yannuzzi LA. Bevacizumab (avastin) and ranibizumab (lucentis) for choroidal neovascularization in multifocal choroiditis. Retina 2009 Jan:29(1) :8-12. Thank you!

MEWDS Original Description Department of Ophthalmology and Visual Sciences Multiple Evanescent White Dot Syndrome (MEWDS)

Who usually presents with MEWDS? Women, 14-47 Is the disease unilateral or bilateral?

Unilateral Can the disease be recurrent? Yes, but rarely What is the visual prognosis? Excellent, with recovery in 1-2 months

Which of the following is not associated with MEWDS acute macular neuroretinopathy, Lyme disease, enlarged blind spot? Lyme disease

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