This 52YO male has been followed by us for many years for ocular histoplasmosis (OHS). Decades earlier, he received thermal laser from an outside practice for macular neovascularization (MNV) in his right eye. When recently seen for his yearly examination, vision was 20/20 OD, and he remained completely visually asymptomatic.
Triton color imaging shows a variably pigmented inferotemporal macular laser scar just sparing the foveal center. Swept-source OCT through this scar shows internal limiting membrane draping, variable outer- and mid-retinal atrophy, variable RPE loss, and more centrally a complete foveal cavitation with draping of the featureless neurosensory retina onto bare sclera.
Learning Points:
Thermal laser photocoagulation was the only treatment for MNV prior to the introduction of photodynamic therapy (PDT) in 2000 and anti-VEGF therapy in 2005. Unlike age-related MNV, which had an extremely high failure rate due to persistent/recurrent lesions, treating OHS-related lesions was often a one-and-done. The Macular Photocoagulation Study found that 74% of extrafoveal OHS MNV were without recurrences at year 5 (Arch Ophthalmology 1991;109:1109-1114). It is always amazing to us how few patients, including this patient, ever complained of a laser-induced scotoma, even when treatment extended close to the macular center.
We currently rarely perform thermal laser for extrafoveal MNV and prefer either PRN anti-VEGF monotherapy or combined anti-VEGF with PDT.
