This 69YO male presented with asymptomatic vision loss in his left eye. Vision was 20/30 OD and counting fingers OS.
A small central scar with fluid was present in the left macula (initial photo not shown). OCT scanning shows a shallowly elevated type 1 macular neovascularization with associated subretinal fluid. An intravitreal Avastin injection was given that day, and 1 month later, the fluid had improved. Vision was 20/400. A second intravitreal Avastin was given.
He was then lost to follow-up for about 6 months while he was out of state receiving intravitreal Eylea every 6 weeks. When he returned, his vision was 20/60 with shallow residual subretinal fluid. Optos color imaging shows central macular pigmentary changes with a gutter of inferior pigment loss. Fundus autofluorescence (FAF) more dramatically shows the hyper-FAF inferior gutter. Fluorescein angiography shows mild staining of the foveal MNV with an inferior gutter of window defects.
Due to an upcoming trip to Alaska and Canada, he requested trying photodynamic therapy (PDT) in an attempt to minimize the treatment burden. Several weeks after PDT, vision remained at 20/60, and the subretinal fluid showed slight improvement on OCT. We will see him again when he returns from his travels.
Learning Points:
Pachychoroid neovasculopathy is a recently described phenotype (see Pang and Freund, Retina 2015;35:1-9) found in the pachychoroid spectrum, which includes idiopathic central serous retinopathy (ICSC), pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, pachychoroid pigment epitheliopathy, peripapillary pachychoroid syndrome, and choroidal excavation.
These lesions are particularly common in patients with ICSC and often present as a flat, irregular RPE elevation on OCT without exudative complications. The absence of drusen in our patient’s fellow eye, the thickened choroid, and gutter all point to the diagnosis of pachychoroid neovasculopathy with prior ICSC.
See Cheung et al, Eye 2019;33:14-33 for a great pachychoroid disease review.
