Multiple Intravitreal Ranibizumab Injections for Persistant Choroidal Neovascularization Associated with Presumed Ocular Histoplasmosis Syndrome

Abstract

Presumed ocular histoplasmosis syndrome (POHS) is a clinical entity that is characterized by small, round, discrete, macular or mid peripheral atrophic (punched out) chorioretinal lesions (histo spots), peripapillary scarring, choroidal neovascularization (CNV), and the absence of anterior uveitis and vitritis. Diagnosis of this disorder is based upon characteristic clinical findings and a positive histoplasmin skin test or residence in an endemic region for Histoplasma capsulatum. There is no active systemic disease during diagnosis of POHS. Disciform scarring and macular CNV secondary to POHS is a well-known complication which leads to loss of visual acuity or visual disturbance. Without therapy, the visual prognosis in these patients is unfavorable. Submacular surgery, radiation, steroids, photodynamic therapy, and most recently anti-vascular endothelial growth factor therapy are current therapeutic options for this condition. We report a case with persistent CNV secondary to POHS in a middle-aged woman with moderate myopia and the clinical course of treatment with multiple intravitreal ranibizumab (Lucentis^®, Novartis) injections.

Keywords: choroidal neovascularization; histoplasmosis; intravitreal injection; ranibizumab.

Figure 1. Tilted optic disc and tigroid fundus in the right eye

Figure 2. Lesions consistent with macular choroidal neovascularization and a few small, discrete mid-peripheral chorioretinal scars in the left eye

Figure 3. Fundus fluorescein angiography shows juxtafoveal leakage consistent with classic choroidal neovascularization in the left eye

Figure 4. Optical coherence tomography shows intraretinal and subretinal fluid due to choroidal neovascularization in the left eye

Figure 5. Optical coherence tomography shows the subretinal scar post-treatment