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A 39-year-old woman with unilateral metamorphosias
Digital Journal of Ophthalmology 2011
Volume 17, Number 4
November 20, 2011
DOI: 10.5693/djo.03.2011.11.001
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Lígia Ribeiro | Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia, Portugal
Sidnei Barge | Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia, Portugal
Luís Silva | Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia, Portugal
Arnaldo Brandão | Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia, Portugal
Dália Meira | Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia, Portugal
Diagnosis and Discussion
Given the patient’s presentation with unilateral metamorphopsias, the lack of signs of ocular inflammation (iritis or vitritis), the presence of multifocal choroidal lesions only in the posterior pole and the angiographic evidence of an active choroidal neovascular membrane, the presumptive diagnosis of punctuate inner choroidopathy complicated by choroidal neovascular membrane was made.

Management of PIC-related choroidal neovascular membrane is a diagnostic and therapeutic challenge. In a minority of the cases, the choroidal neovascular membrane resolved spontaneously(3); however, the problem could worsen since the pathology is often bilateral and usually occurs in young active patients. Due to the rarity of these cases, our current understanding of PIC comes from relatively small case series, and there is a paucity of evidence on which to base the treatment strategies.

Multiple therapeutic strategies have been used, with varying success, including corticosteroids (8-10) interferon ß-1a,(11) subretinal surgery,(12) photodynamic therapy,(13) and, more recently, anti–vascular endothelial growth factor (anti-VEGF).(7,14-16)

Essex et al, in the largest series of patients diagnosed with PIC, reported a total of 153 eyes of 117 patients with PIC-related choroidal neovascular membranes; 26% of those eyes had a final visual acuity of less than 1/10.(2) The final outcome was similar in all groups with choroidal neovascular membrane, regardless of the treatment; however, in this series none of the patients were treated with anti-VEGF agents.

While clinical observations suggest that intravitreal anti-VEGF drugs are effective, the optimal number and frequency of intravitreal injections remains uncertain. Chan et al reported all 4 patients with PIC treated with 3 bevacizumab injections had visual improvement of at least 1 line.(14) According to a report by Kramer et al, a single injection of bevacizumab led to a rapid and lasting resolution of the choroidal neovascularization in a patient with PIC.(16) Menezo et al reported 9 of 10 patients having benefited from a mean of 1.9 injections of ranibizumab per eye.(7) Cornish et al reported 9 eyes with PIC-related choroidal neovascular membrane that responded to anti-VEGF treatment, with a mean of 2.34 injections per year.(17) In this series, there was a reduction of the subretinal fluid on OCT and a visual gain of 0.23 logMAR units.

In our patient, 2 injections of intravitreal ranibizumab resulted in complete and long-lasting visual and anatomic improvement in an eye with diagnosis of PIC-related choroidal neovascular membrane. The present case report supports the effectiveness of intravitreal antiangiogenic drugs as a primary treatment of PIC-related choroidal neovascular membrane; however, long-term follow-up is needed since there is a risk of recurrence of the choroidal neovascular membrane. Further prospective controlled studies and additional data are needed to establish the visual benefit, the long-term safety, and the optimal efficacy regimen of ranibizumab for PIC-related choroidal neovascular membrane.