Transcript Serpiginous choroiditis

Serpiginous choroiditis
Euretina Meeting 2013
Hamburg
Miles Stanford
Medical Eye Unit
St Thomas’ Hospital
London
Serpiginous choroiditis
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Rare
Bilateral
40-60 years
Mainly caucasian
Slight preponderance for men
Serpiginous choroiditis - pathology
• Little available
• Widespread atrophy of photoreceptors, RPE
and choriocapillaris
• Lymphocytic infiltration of the choroid
• Secondary choroidal neovascularisation
Serpiginous choroiditis – clinical
features
• Unilateral decrease in central vision,
metamorphopsia or scotoma
• Little anterior segment reaction
• Lesions classically peripapillary and then
spread outwards
• Disease progression is stepwise and
asymmetric
• Eventually permanent scar and subretinal
fibrosis
Serpiginous – progression over 6 months
Serpiginous choroiditis – stepwise progression
over 18 months
Fluorescein angiography showing early
masking and late staining on the edge of a old
scar
Serpiginous – FFA staining at the edge of an
old scar. These changes may be more evident
on ICG
Serpiginous choroiditis
differential diagnosis
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APMPPE
Myopia
Choroidal ischaemia
Sarcoidosis
Toxoplasma
Tuberculosis/syphilis
Metastases/lymphoma
Retinochoroidal dystrophies
Ampiginous choroiditis (mantoux 20mm, subsequently
developed Eales’ disease)
Serpiginous-like choroiditis and TB
• Presumed uveitis due to TB: All patients with 1 year
follow up, exclusion of other infections, +ve
Mantoux, no recurrence after full anti TB treatment
• 26/192 (15%) patients with presumed TB-related
posterior uveitis had serpiginous like choroiditis (OR
26; 95% CI 7.4-91.4)
• Sensitivity 14%: specificity 98%: positive predictive
value 56%
• Not a good sign for screening but makes diagnosis
90% certain if positive
Gupta A et al Am J Ophthalmol 2010 149:562
Serpiginous-like choroiditis and TB
• 11/21 (52%) patients tested +ve with
Quantiferon compared to 9% HC and 13%
uveitis controls
• 3/11 improved with specific anti-TB treatment
• ?directly due to bacteria or allergic response
Mackensen F et al Am J Ophthalmol 2008 146;761
Serpiginous-like choroiditis and TB
• Comparison of 5 patients with serpiginous like
(SLC) and classical serpiginous (SC)
• Patients with SLC were:
- most likely to have come from a country
where TB endemic
- To have unilateral multifocal disease with
significant vitritis
- to have a positive PPD
- to respond to tuberculostatic therapy
Arch Ophthalmol 2010 128: 853
Serpiginous choroiditis
Investigations
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FFA
ICG
OCT
Electrodiagnostics
Visual fields
Mantoux/IFN gamma
Serpiginous choroiditis - complications
• CNVM occurs in 15-35%
• Usually arises from the edge of a scar but may
be peripapillary
• Serous retinal or RPE detachments
• Subretinal fibrosis
• Rarely, CMO or NVs
Serpiginous choroiditis
Treatment
• Goals of therapy are to control active lesions
rapidly and to prevent further recurrences and
progression
• Steroids – oral or pulsed
• Other immunosuppressives
• Infliximab
• Treatment for secondary neovascularisation
Serpiginous choroiditis - prognosis
• Very few long term studies
• Chronic, progressive disease in a stepwise
manner
• Active lesions usually resolve over 3-6 months
but may take longer
• Extrafoveal lesions may not give rise to
symptoms and so pass unrecognised
Serpiginous choroiditis - Conclusions
• Rare, progressive disease of the middle-aged
• Must exclude TB especially if patient from
endemic area
• Treat with standard immunosuppressives to
control active lesions and prevent progression
• Potential for secondary CNVM