Clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis

Abstract

Purpose: To describe the clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis (MSC).

Methods: Clinical records of 16 eyes (14 patients) with MSC presenting to a tertiary eye care institute between 2015 and 2019 were analyzed retrospectively.

Results: Mean age of 14 patients presenting with MSC was 33 ± 13 yrs with 64% males and 36% females. Mean visual acuity of the eyes with MSC at presentation was 0.43 ± 0.46 (logMAR) improving to 0.16 ± 0.28 (logMAR) at final visit. Thirteen eyes (81.3%) had active lesion at presentation. Mantoux test was positive in seven patients (50%) and QuantiFERON TB gold test positive in 10 patients (71%). HRCT chest showed latent tuberculosis in seven patients (50%). All patients underwent multimodal imaging. All patients received oral steroids as treatment therapy; 11 patients also received immunosuppressives, nine patients received additional anti-tubercular therapy (ATT). Mean duration of follow-up for the patients was 18 ± 10 months. A total of eight (50%) eyes had recurrence of lesions after an average duration of 14 ± 14 (3-36) months and were restarted on the treatment as per the requirement. At final follow-up, all eyes showed a good response to treatment and had healed lesions. Comparing the final BCVA to the initial BCVA, 38% (n = 6) showed improvement, 56% (n = 9) remained stable, and 6% (n = 1) eyes worsened at the final follow-up.

Conclusion: Clinical profile and presentation of MSC is similar to that of CSC, and combination treatment with intravenous methyl prednisolone (IVMP), steroids, immunosuppressives, and ATT can salvage vision. A high suspicion of associated tuberculosis in endemic regions should be kept in mind.

Keywords: Fundus fluroroscein angiography; Indocyanin green angiography; macular serpiginous choroiditis; multimodal imaging; optical coherence tomography angiography; serpiginous choroiditis; tuberculosis.

Figure 1

(a-c): Color fundus photograph of posterior pole of the right eye showing progressive resolution of lesions (a) (baseline), (b) (1 month) and (c) (3 months) on treatment, with active lesions ((a), black arrows) seen as yellowish lesions with fuzzy margins and retinal edema, with overlying vitreous haze; healing lesions (b) show more indistinct margins, and resolving retinal edema; and inactive lesions (c) showing remnant retinal pigment epithelial (RPE) atrophy with resolved retinal edema. (d-f): Corresponding Fundus autoflurescence (FAF) images of the same eye. Active lesions ((d) black arrows) showing a central hypo FAF with surrounding hyper FAF; healing lesions (e) show a linear hypo FAF surrounding central but reduced hyper FAF; and healed lesions (f) showing a uniform hypo FAF corresponding to the region of RPE atrophy

Figure 2

Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICG) images of the corresponding right eye images as in Fig. 1. FFA and ICG angiography done at presentation. (a) (FFA) and (b) (ICG) early phase angiography images of the same patient showing showing hypofluorescence of the lesion. (c) Late phase FFA showing hyperfluorescence of the lesions due to diffuse leakage from the lesions. Optic disc leakage is also seen in late phase. (d) Late phase ICG angiography continues to show hypoperfusion of choriocapillaris and choroidal vessels

Figure 3

OCT images taken at presentation (a), 1 month (b), 3 months (c). (a) showing the hyperreflective outer bands due to destruction of RPE, photoreceptor layers and outer retinal layers with loss of Ellipsoid Zone (green arrow), increased retinal thickness adjacent to fovea (orange arrow) due to activity. (b) and (c) Inactive lesions show reduced retinal edema at corresponding location, and relative preservation of Ellipsoid zone at macula (blue arrow). Also, RPE layer backscattering is seen more during the healing phase

Figure 4

Optical coherence tomography Angiography done at baseline (a, b, g, h), 1 month (c, d, i, j) and 3 months (e, f, k, l). OCTA shows decreased vascularity in choriocapillary ((a), orange arrows) and choroidal region ((g), yellow arrows) seen as dark areas. The dark areas seen in choriocapillaris reduced in area (c and e) and was replaced with irregular capillary-like network as the lesions showed improvement with treatment at subsequent visits

Figure 5

Right eye HVF using 30-2 protocol showed involvement of central visual field at presentation and showed improvement with treatment over the subsequent follow-ups