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Euretina Meeting 2013 Hamburg Miles Stanford Medical Eye Unit St Thomas’ Hospital London

Serpiginous choroiditis. Euretina Meeting 2013 Hamburg Miles Stanford Medical Eye Unit St Thomas’ Hospital London. Serpiginous choroiditis. Rare Bilateral 40-60 years Mainly caucasian Slight preponderance for men. Serpiginous choroiditis - pathology. Little available

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Euretina Meeting 2013 Hamburg Miles Stanford Medical Eye Unit St Thomas’ Hospital London

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  1. Serpiginouschoroiditis Euretina Meeting 2013 Hamburg Miles Stanford Medical Eye Unit St Thomas’ Hospital London

  2. Serpiginous choroiditis • Rare • Bilateral • 40-60 years • Mainly caucasian • Slight preponderance for men

  3. Serpiginous choroiditis - pathology • Little available • Widespread atrophy of photoreceptors, RPE and choriocapillaris • Lymphocytic infiltration of the choroid • Secondary choroidal neovascularisation

  4. 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

  5. Serpiginous – progression over 6 months

  6. Serpiginous choroiditis – stepwise progression over 18 months

  7. Fluorescein angiography showing early masking and late staining on the edge of a old scar

  8. Serpiginous – FFA staining at the edge of an old scar. These changes may be more evident on ICG

  9. Serpiginous choroiditisdifferential diagnosis • APMPPE • Myopia • Choroidal ischaemia • Sarcoidosis • Toxoplasma • Tuberculosis/syphilis • Metastases/lymphoma • Retinochoroidal dystrophies

  10. Ampiginous choroiditis (mantoux 20mm, subsequently developed Eales’ disease)

  11. 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

  12. 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

  13. 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

  14. Serpiginous choroiditisInvestigations • FFA • ICG • OCT • Electrodiagnostics • Visual fields • Mantoux/IFN gamma

  15. 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

  16. Serpiginous choroiditisTreatment • 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

  17. 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

  18. 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

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