A 43-year-old married Syrian woman presented at the age of 40 with distortion of central vision in the right eye. Choroidal dystrophy was suspected in Damascus (Syria) ( and ). Rheumatology and infectious workup was negative (syphilis, tuberculosis, anti-double-stranded DNA, anti-single-stranded DNA, rheumatoid factor). CNV was also detected in the macular area in Dubai (United Arab Emirates) and intravitreal injections were advised. She subsequently received three monthly intravitreal ranibizumab injections in Barcelona (Spain) (). Past ocular history revealed myopia of 2.5 D as per patient recollection. She had undergone bilateral refractive surgery (excimer laser 5 years ago followed by laser in situ keratomileusis [LASIK] 3 years ago). Medical history was negative. There was a strong family history of myopia and no parental consanguinity. Fifteen months after initial right eye involvement, the patient expressed the same symptoms in the left eye, such as seeing broken lines and asymmetric faces. She was advised to undergo treatment for CNV in the macular region. She received one injection in Beirut (Lebanon), and subsequently, three monthly injections in Dubai to the left eye. She reported further worsening of vision after each injection. Consultation in London (UK) revealed a best-corrected visual acuity of 20/80 in the right eye and 20/30 in the left eye. Dilated fundoscopy revealed bilateral areas of vertically linear atrophy, more extensive in the right eye, without subretinal fluid or hemorrhage by optical coherence tomography. Fundus autofluorescence imaging revealed areas of reduced autofluorescence corresponding to these areas of atrophy. The reported clinical impression then was myopic chorioretinal degeneration versus lacquer crack-associated myopic degeneration. She was advised to have regular checkup without intravitreal injections as long as the macula stays dry. The patient was frustrated because of both inability to pinpoint a definite diagnosis and gradual decline in vision bilaterally. Nine months later, she initially presented to our clinic with 20/200 visual acuity. Fundoscopy revealed definite widening of the vertical macular choroidal rupture bilaterally (). Stippled changes in the retinal pigment epithelium were observed. Peau d’orange appearance was not present. The patient was emmetropic without keratoconus on corneal topography. Axial length measurement with the IOL Master (Carl Zeiss Meditec AG, Jena, Germany) was 27.35 mm in the right eye and 27.31 mm in the left eye. Keratometry readings were 38.6 D in the right eye and 38.2 D in the left eye. The skin of the neck had tiny pinkish papules suspicious for early goose flesh (). Two separate dermatology consultations and skin biopsies did not favor the diagnosis of pseudoxanthoma elasticum. Even further widening of the choroidal rupture occurred 9 months after presentation. Our working diagnosis was lacquer crack from high myopia (without pseudoxanthoma elasticum) () possibly initiated by LASIK and exacerbated by ocular rubbing and intravitreal injections (). The patient was instructed to avoid ocular rubbing, head-down position, and intravitreal injection (unless an exudative component was present) and to have prior paracentesis before any future intravitreal injections.
A 13-year-old boy presented with 5 months old injury to the left eye. Examination of the left eye showed iris sphincter tears with angle recession. A curvilinear stellate yellowish gray lesion was seen just nasal to the fovea with associated gray-white lesion at the fovea []. The right eye was normal.\nSSOCT showed hyper-reflective, disorganized tissue involving RPE/BM complex, ellipsoid layer, external limiting membrane (ELM), and outer nuclear layer. This presumed scar tissue also involved the choriocapillary layer and the Sattler's layer. The Haller's layer was only minimally involved []. Scar tissue was also seen extending on the surface of the RPE away from the presumed site of rupture. The yellowish gray lesion seen at the posterior pole seemed to correspond to the areas where OCT showed the hyper-reflective scar tissue. No evidence of a full thickness BM or choroidal discontinuity could be made out.\nOCT angiogram (OCTA) showed the inner retinal capillaries to be intact. The outer retinal capillary layer showed some decreased vascular marking in the area of the scar. At the level of the photoreceptor and RPE, there was a discontinuity in the tissue pattern corresponding to the scar. Surrounding this discontinuity, there were new vessels. At the level of the choriocapillaries besides discontinuity in the vascular pattern due to scar tissue, there seemed to be increased vascularity along the rupture site itself [].