This 52 YO female presented to the clinic with vision of counting fingers OD and 20/25 OS. She reported that her vision had decreased 3 weeks earlier.
Color imaging shows a somewhat pigmented macular neovascularization (MNV) with associated subretinal blood.
Swept-source OCT shows a hyperreflective, laminated type 2 (located above the RPE) MNV. Overlying fibrinous-appearing subretinal fluid vs a bacillary layer detachment is seen.
Optos fluorescein angiography, magnified to show the macular details, show a leaking, hyperfluorescent MNV with adjacent blockage from the subretinal hemorrhage.
Ultrawidefield Optos imaging shows the extent of the bilateral peripheral multifocal chorioretinal scarring. Anti-VEGF therapy was started.
Learning Points:
Ocular histoplasmosis is caused by the Histoplasmosis capsulatum fungus, which is commonly found in soil contaminated by bird or bat droppings.
It is seen worldwide, but in the United States is most often seen in the Ohio-Mississippi River valley. Most people in endemic areas inhale the organism’s spores early in life, with only a few percent developing asymptomatic chorioretinal scars.
A small percentage of these will develop MNV later in life. Treatment is similar to wet AMD, with anti-VEGF therapy usually being the first-line therapy. Unlike AMD, these patients often do not require ongoing injections. Photodynamic therapy can help minimize the treatment burden, and thermal laser is still a good option for more peripheral macular lesions.
