Same-side recurrence of unilateral multiple evanescent white dot syndrome following the thermal laser photocoagulation for inflammatory macular neovascularization

Abstract

Purpose: We report the same side recurrence of multiple evanescent white dot syndrome (MEWDS) subsequent to 532 nm laser treatment for the macular neovascularization (MNV) associated with the first MEWDS episode.

Method: Retrospective case documentation with the multimodal imaging.

Result: A 24-year-old otherwise healthy woman who was diagnosed as having left MEWDS four years ago was re-examined for a visual disturbance of the duration of one month in the same eye. Fundus evaluation led us to the diagnosis of left extrafoveal inflammatory MNV. Surprisingly, she developed further visual deterioration a month following the uneventful 532 nm laser photocoagulation in her left eye. Fundus examination and multimodal imaging tests confirmed the recurrent MEWDS after full negative laboratory work-up. Visual acuity and fundus changes were improved with the help of a short course oral steroid therapy.

Conclusion: MEWDS can very rarely recur and thermal laser photocoagulation may be a possible triggering factor.

Keywords: choriodal neovascularization; fundus autofluorescence; laser photocoagulation; macular neovascularization; multifocal ERG; multiple evanescent white dot syndrome.

Figure 1. Color fundus (CF), fundus autofluorescence (FAF), and fluorescein angiography (FA) images of the patient at the time of initial MEWDS diagnosis in 2019. CF photo of the right eye (A) displayed no abnormality, while there were small whitish dots scattered around the optic disc and throughout the posterior pole (black arrows) in the left eye (D). Right FAF image (B) exhibited the normal appearance, whereas hyper-autofluorescent areas corresponding to the fundus alterations (black arrows) were observed in the left eye (E). FA displayed no changes in the right eye (C), whereas left eye showed hyperfluorescent lesions corresponding to the FAF alterations (F).

Figure 2. Left eye, January 2024. Color fundus (CF) photo (A) displaying the subretinal hemorrhage and macular edema (white arrow) at the superior perifoveal area. Fundus autofluorescence image (B) revealing the hypo/hyper-autofluorescent areas corresponding to the fundus alterations. Macular neovascularization (MNV) with subretinal fluid and subfoveal hyperreflective material (white arrow) was detected on optical coherence tomographic (OCT) section passing through the lesion (C). OCT angiography exhibiting the abnormal vascular network (white arrow) at the outer retinal layer consistent with a type 2 MNV (D). Fluorescein angiography (E) demonstrating the hyperfluorescence related to MNV with dye leakage (white arrow). CF image (F) showing the thermal laser photocoagulation treatment (black arrow) over the MNV area.

Figure 3. Left eye. Color fundus (CF), fundus autofluorescence (FAF), optical coherence tomographic (OCT), and fluorescein angiography (FA) images at the time of MEWDS recurrence. CF image (A) revealing the multiple white spots at the posterior pole (white arrows). FAF image (B) exhibiting some hyper-autofluorescent areas (white arrows) corresponding to the fundus alterations. FA delineating the hyperfluorescent lesions (white arrows) corresponding to the FAF alterations (C). OCT demonstrating the disruption of the ellipsoid zone and retinal pigment epithelium with subfoveal hyperreflective materials (D). FAF picture (E) indicating a prominent resolution of hyperautofluorescent lesions after two months of the treatment.